Pseudohyperkalemia in CLL

What diagnosis code would be appropriate in this case? The patient presented with hyperkalemia and also had CLL with an extremely elevated WBC. Nephrology diagnosed pseudohyperkalemia . Apparently this is a rare condition with extreme leulocytosis presumably casued by cell lysis with release of intracellular K+. There is no index entry for pseudohyperkalemia. Would the PDx be CLL or hyperkalemia? The condition is a manifestation of CLL and the hyperkalemia is not true hyperkalemia. 

Cathy Seluke

Comments

  • edited July 2018
    This is not official advice.   I personally do not consider hyperkalemia from hemolysis to fall in the same category as pseudohyponatremia in a pt with DKA or DI or SIADH or on mannitol etc.

    The difference in real practice, is that hyperkalemia from hemolysis can precipitate lethal cardiac conduction disorders (among other things) and is often an emergency situation which merits intervention and elevation to a higher level care nursing unit.

    For these reasons, it seems to me that hyperkalemia would still be reportable when it was subsequent to cell lysis.   It may be the MD is simply trying to distinguish a cell lysis induced hyperkalemia from other forms, but was not necessarily stating it is not a separately clinically significant event?  Of course, the "significance" will depend on just how high the level went in the blood and what if any action was actually needed to remedy the situation.

    I am curious to hear what others think.

    Since ICD indexing seems to heavily favor sequencing etiology before manifestation (much more so than ICD 9) I would be inclined to sequence the CLL first.    Be aware however that certain auditors may point out that it was the acute manifestation (the elevated K) which resulted in the decision to admit and cite hyperkalemia as the PDX under a strict interpretation of the UHDDS definition of the pdx (which ICD 10 indexing often seems NOT to follow).


  • In agreement w/ Allen's comments.  Selection of PDX would depend upon the focus of the treatment, with recognition to Allen's points on that matter.  What was investigated and treated? 

    Is this a patient with KNOWN CLL or was the CLL diagnosed during this encounter with the hyperkalemia  being one indicator of the CLL?  Or, was the CLL established, and presentation was with the electrolyte issues, which were the focus of treatment?

     If 'only' the hyperkalemia w/ a known CLL,  I'd argue that the hyperkalemia would be the PDX as long as no staging or intervention directed toward the CLL.  Also interested to hear from any others?


    Paul Evans

    CCDS

  • Thanks for your input, Paul and Alan. I don't think I made myself clear in the original post, however. The hyperkalemia was not true hyperkalemia; the patient's serum K+ was actually probably low. The hyperkalemia existed only in the tube used to draw the blood. So, the patient was actually admitted to rule out serum hyperkalemia. Since the presumptive diagnosis responsible for admitting the patient was ruled out, I don't think it can be used as principal diagnosis. The patient did have known CLL. 
  • Consider   Z03.89 - Observation for suspected condition, rule out.   MS-DRG =  951. 

    As a side note, one would wonder why the patient was not placed in observation status rather than full admission?  However, given that the Chronic LL is not being addressed in any way, nor is there any other acute condition of concern,  the Z code seems most appropriate,  It has been my observation that many coding teams are reluctant to assign this code; however, I can't think of any thing more appropriate.

    There are three observation Z code categories. They are for usein very limited circumstances when a person is being observed for a suspected condition that is ruled out. The observation codes are not for use if an injury or illness or any signs or  symptoms related to the suspected condition are present. In  such cases the gnosis/symptom code is used with the corresponding external cause code.
    Ref: 2018 Official guidelines...sorry for font...problems with posting this message

    Paul Evans,

    RHIA, CCDS

  • Paul, that seems like the best choice. I did not know that code existed. Actually today I have another case with a patient admitted with a positive blood culture (1 of 2 bottles with GPC in clusters) and an implanted pacemaker/defibrillator. The blood cultures ended up growing a skin contaminant, so bacteremia (1st choice for PDx)  was ruled out. I think Z03.89 would fit in this situation as well. 

    I thought the same thing about the pseudohyperkalemia patient (observation status), but he was pretty debilitated and sick from his cancer. 
  • Cathy:  The "Z" code is a code of last choice, in a manner of speaking.  "Cancer" cases, due to the coding rules and documentation, can be difficult to code.  It may be that the coding team found a viable condition qualifying as the principal diagnosis given you state he is debilitated?   I'd mention that use of the Z code has lessened as facilities have perhaps employed observation status appropriately for such cases?  Just my thought.


    PE

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