Coding Guideline interpretation/DRG selection

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in CDI Talk Archive
Hi,

Coding guidelines can be applied so loosely. If a Pt came in with cp, worked up and found ascites. Paracentesis was done 6650 ml of fluid was removed. Pt stayed in for 5 days and cp was noncardiac. In the notes, the attending noted that the CP - ruled out. No further evaluation at this time. Not cardiac in nature, likely related to gastritis/reflux associated with significant ascites/ESLD. Final dx was noncardiac chest pain on d/s. Eventhough we queried for the cause of the cp concurrently, the coders coded the principle as cp. Our auditors also coded the principle as cp using symptom followed by contrasting/comparative diagnoses. But this is not a and/or situation. Can anyone explain/help us, we picked another DRG.

Confused!
Carla H

Comments

  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Carla
    Weird. I would have gone with the "after study" determination..and not used the chest pain! It is all so vague and loose and just depends on "who" is coding! :)

    Juli Bovard RN CDS
    Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    719-4390 (work)
    786-2677 (cell)
    "No Limit to Better......"
  • kmckaigkmckaig
    edited May 2016
    I agree that it looks like the after study dx would be correct. However, I know our coders are sticklers for having "the link" spelled out on the dcs. ie. "Chest pain, non-cardiac, due to gastritis/reflux due to ascites and ESLD."
    Hope this helps.


    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org
  • ddouthitddouthit
    Carla,

    Coding is definately not black and white so I can only speak from my coding perspective if this chart were to come across my desk to code. I would one have interpreted the / (forward slash )as and/or therefore the guideline of two or more contrasting/comparative diagnosis would apply. We have had issues with the use of / in audits. Auditors using recognize as and/or.

    Great job querying concurrently and trying to clarify.

    Dorie Douthit RHIT, CCS
  • robert.hodges2robert.hodges2
    edited May 2016
    That's why we have a "slash use" query here to help clarify cases where a slash is used between diagnoses. Unfortunately we do use it a lot.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
  • ddouthitddouthit
    Robert, What a great idea! We have provided physician education regarding "Please don't use slashes" and we have seen improvement.

    Dorie RHIT,CCS
  • robert.hodges2robert.hodges2
    edited May 2016
    We do that too. Frequent reminders not to use them, and then follow up with the query. Kind of like the "no urosepsis" which is at the top of almost every one of my newsletters.

    Robert
     
    VA Core Values:  Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
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    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
  • vdavis2vdavis2
    edited May 2016
    From a nurse perspective, I see this as gastritis/reflux being the general understood medical term for GERD b/c we always combine gastritis and reflux to mean one thing... then I think the MD is saying that the GERD is caused by the significant ascites from the ESLD (causing pressure build up to leads to that chronic "leak" of stomach acid which then causes chest pain.) I also don't think this is compare and contrasting situation... b/c of the above. It is more the due to... due to...due to situation. MD's think they are being more thorough by documenting the underlying cause of everything. I would have had a CDS take this back to the MD before it was coded for clarification and education in person.

    We don’t have issues with the "slashes" .... we get: "CP-atypical vs reflux." The 'vs' thing is a constant battle! (and atypical... atypical compared to what???)
  • vdavis2vdavis2
    edited May 2016
    @Robert- I love your quote by the way... I may have to borrow it from you and Mark Twain!
  • paxnerospaxneros
    edited May 2016
    I think that's a great idea!

    NBrunson, RHIA, CCDS
  • cmorellcmorell
    edited May 2016
    Coders are amazing and I don't know how they learn to sift through all of nuances of coding clinics, interpretations, new rules etc.
    So, I have nothing but absolute respect for them.
    BUT, As a CDI I often wonder why they chose a particular DRG.
    I have tried to make an algorithm to no avail.
    So, when I started out, I found this CDI Serenity Prayer on ACDIS I am sure...so I think I should share it because it has helped me out plenty of times. :)

    CDI Serenity Prayer

    God grant me the serenity
    to accept the things I cannot change,
    the foresight to know which coder will review which chart
    and the wisdom to remember what each coder feels is necessary/unnecessary.


    Charlie Morell
  • paxnerospaxneros
    edited May 2016
    That's pretty nice Charlie!!

    NBrunson
  • tpeytontpeyton
    edited May 2016
    Charlie -
    Awesome post...thanks for the serenity prayer!

    Tracy M Peyton RN, CCDS
    Case Management
    Bradford Regional Medical Center
    Upper Allegany Health Systems
    116 Interstate Parkway
    Bradford, PA 16701
    814-558-0406
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    I think the issue is documentation, not improper coding.


    The original post states: "Final dx was noncardiac chest pain on d/s, probably due to gastritis/reflux." We can read the body of the record and attempt to interpret the meaning of the physician, but the posting states the MD documented a FINAL DX of CP and also that the MD listed contrasting diagnoses after this Sign/Symptom.

    Bearing in mind the coder is compelled to report the chart's final Dx, it seems they properly applied the coding rule below and reported the PDX as the CP followed by contrasting conditions.

    E.
    A symptom(s) followed by contrasting/comparative diagnoses
    When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.
  • ssalinasssalinas
    edited May 2016
    The thing is, coders do not choose a particular DRG. They choose a
    principal diagnosis, (hopefully by following coding guidelines), code
    all appropriate and reportable secondary diagnoses and procedures. The
    DRG is assigned based on these. There are times when the DRG assigned
    does not seem appropriate but, if I have followed the rules and
    guidelines, it is still the correct DRG.

    As with most things, perception and interpretation play a part in the
    selections as does knowledge and skill. Hopefully knowledge and skill
    wins out the majority of the time.

    Sharon Salinas, CCS
    Extension 3336
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