November 4, 2022

Top Questions from the Coding and Documentation Challenges for High Volume Diagnoses Webinar

Looking for more information about the Coding and Documentation Challenges for High Volume Diagnoses? BESLER’s Coding Analyst Supervisor Kristen Eglintine answers your questions from the recent webinar.

To watch the related Coding Updates from Coding and Documentation Challenges for High Volume Diagnoses Webinar, click HERE.

When a patient is non-compliant with dialysis and comes to the hospital because fluid overload, will the principal diagnosis be E8779 followed by N186 and Z9115?
Yes, that is correct
Doesn’t Coding Clinic allow for exacerbation heart failure due to fluid overload secondary to dialysis noncompliance?
The provider would have to determine if the fluid overload is due to the CHF, of cardiogenic origin, or due to the noncompliance with the dialysis. If the fluid overload is due to dialysis noncompliance it would be coded and could be the principal diagnosis. If the fluid overload is due to a CHF exacerbation, it is not coded separately. For the CHF exacerbation to be coded, the physician should specify if there was cardiac decompensation.
With the sepsis slides – “link positive cultures to the infection” – if documentation states UTI culture grew E. coli, would we assign the code for E.coli or does documentation have to state UTI due to E.coli?

ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2014 Pages: 15-16 Effective with discharges: March 31, 2014, states that The Official Coding Guideline Section III.B., states: “Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added.” Therefore, internal guidelines should not replace physician documentation.
I was wondering how we should code a case where the providers are documenting severe sepsis and giving a calculated SOFA score? With sepsis three guidelines having sepsis and sepsis with septic shock as the standard and the diagnosis of severe sepsis from sepsis 2 being phased out, should we just capture the diagnosis of sepsis?

As you have stated, the ongoing issue is that the definition of sepsis is changing between Sepsis-2 and Sepsis-3 criteria. CMS is still using the Sepsis-2 criteria for the SEP-1 bundle. Coders must assign the ICD-10-CM code for the term that is documented by the physician. ICD-10-CM still reflects Sepsis-2 criteria. In this case the code for severe sepsis is appropriate to use as it was documented.

If only the term sepsis was documented, The Official Coding Guidelines, C.1.d.1(iii) states, “If a patient has sepsis and associated acute organ dysfunction or multiple organ dysfunction (MOD), follow the instructions for coding severe sepsis. Based on the documentation of organ failure, which is used in the SOFA criteria, severe sepsis could be coded even if the term itself is not documented. This issue should be discussed with your providers, so they understand the current constraints on the coding/CDI staff and what information their documentation should reflect.