What would you use as Principal in this case?

vdavis2

Pt admitted with "BRBPR several times starting yesterday." Hgb 11.2. Colonoscopy not performed this admit, but results 9/11 showed "ileocecal valve ulcer which was cauterized." EGD report from that date stated "gastritis and duodenal erosions." Daily progress notes state: "Rectal Bleed: differential diagnosis includes diverticular vs hemorrhoids, less likely colitis. D/C summary states: "Rectal Bleed: possible diverticular vs hemorrhoids vs old ulcer in the colon." Treatments were conservative and pt didn't have any further blood in stool. Hgb final was 9.5 and noted to have chronic anemia. (Demand ischemia was the cc on this case.)

We have debate amongst our team..
1) Is this a "vs" comparative/contrasting diagnosis situation in whihc you have to use the "symptom"?
2) Should Pdx be Rectal Bleed, Diverticulosis with hemorrohage, Unspecified hemorrhoids with complication, etc?
3) Is this a case where the rectal bleed is a component of the combination codes, so you could sequence either as Pdx since both POA?
4) If you do optimize and use the DRG 393 are you putting the case at more risk for audit since the admission was for bleeding hemorrhoids?

Let me know your thoughts!!!
VICKI
vdavis2@armc.com

robert.hodges2

My feeling is you have to use option 1 since the provider doesn't give a single likely or probable cause. It is definitely a query opportunity if you haven't already done so, and I suspect you have.

I will defer to the coding experts here for the correct answer.

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
 
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sharon.cole

I would query that one, otherwise you would have to use the symptom as PDX.

Sharon Cole, RN, CCDS
Providence Health Center
Case Management Dept
254.751.4256
srcole@phn-waco.org

tiffany_susan

With this info it would code to the symptom ....... needs a query to
clarify
Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System
phone: 570-887-6094
fax: 570-887-5152
email: tiffany_susan@guthrie.org
"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

vdavis2

I am also worried about using DRG 393 using code 4558 Hemorrhoids with complication as a Pdx with an MCC of diverticulosis with hemorrhage. Does anyone share the same concern that an auditor might take away the mcc since the hemorrhage is used twice to gain a higher weighed DRG? (This is a heavier weighted DRG and a GI Bleed which are both high risk for RAC audit.)

evanspx@sutterhealth.org

The rectal hemorrhage is a component of the CODES for both the
diverticulosis as well as the bleeding hemorrhoids. It is not coded
separately as the rectal hemorrhage is reported with both codes
562.12 and code 455.8 , and the codes are:

562.12 - Diverticulosis with hemorrhage
569.82 - Ulcer Intestine
455.8 - Bleeding Hemorrhoids


Sequencing either the Ulcer of the intestine (569.82) or the Bleeding
Hemorrhoids (455.8) as the Principal yields MS-DRG 393 with a R.W. of
1.6750

I would not be concerned with the subsequent MS-DRG as the coding
describes the final MD assessment of the discharge conditions.



Paul Evans, RHIA, CCS, CCS-P

Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org

vdavis2

Thanks everyone! This case has stimulated great discussion to say the least! I love the cases that are not just black and white-the ones that really push us to use all of our resources and skills! This record will be a case study that we will use for CDI and physician education! Have a great week!

Thanks again,
VICKI