Performance Activity and Quality Division Clinical Coding Advisory Group WA Audit Cases for Discussion April 2014 Clinical Coding Advisory Group WA CASE: 1 AUDIT CASES Adm: 12/04/2013 April 2014 Sep: 15/04/2013 A 26 year old woman is admitted via oncology where she was a booked day patient for chemo: rituximab infusion, for Hodgkin’s lymphoma. During the infusion, she developed hypotension and sore throat. The infusion was continued but at a slower rate. BP responded to IVF bolus. Progress notes: rehydrated overnight, K+ 2.8- replaced antibiotics for chest infection. on general exam angioma upper limb noted, for surgical review as outpatient- no further action now. Discharge Summary: Hypotension. (? Drug reaction) Chest infection Hodgkin’s ORIGINAL PRINCIPAL DIAGNOSIS Additional Diagnoses I95.9 J22. C81.9 M9650/3 E87.6 D18.01 M9120/0 AUDIT C81.9 M9650/3. I95.9 J22 E87.6 PRINCIPAL PROCEDURE 96199-00 96199-00 DRG Version 6.0 ORIGINAL F75B AUDIT R61B Oth Circulatry System Dx+Smcc Lymphma &N-Acute Leukaemia-Ccc NEP: $5394.58 NEP: $8102.44 (NEP = National Efficient Price).  Intended day admission for rituximab (chemo): Z511. However, overnight stay is required. Z511 cannot be assigned for a non-same day outcome . Therefore Z511 (admit for chemo, same day), gives way to the underlying cancer (C819) as principal diagnosis (ACS 0044). This is now a multiday stay but still principally occasioned by the need for chemo and therefore for treatment of malignancy (C819). Department of Health WA Performance Activity & Quality Division 2 Clinical Coding Advisory Group WA AUDIT CASES April 2014 Case 1 continued:  The hypotension (I959) is a complication arising (condition onset flag = 1). Medication as the cause is speculative and never confirmed.  Noted incidentally is an angioma upper limb (D1801). All care and follow up is to be on an outpatient basis. Conditions noted on routine assessment are not coded unless they require increased clinical care/monitoring during this episode (ACS 0002, Q&A June 2011, Q&A June 2013).  ‘K+ 2.8 – replaced’ is never diagnosed formally as ‘potassium depletion’ or ‘hypokalaemia’ but the abnormal reading is taken from the notes, confirmed as abnormally low on biochemistry , AND then meets ACS 0002 by being treated under doctor’s orders (for replacement)(see Coding Matters 16.2; September 2009)**. ** Some clinical coders have been concerned by the fact that this national advice, in its response to a broader question, focuses only upon the scenario where there is a ‘down arrow’ (K+↓). Some have been reluctant to apply the advice to scenarios where there are numbers (2.8) but no arrow. To be provided with the number upfront, in lieu of an arrow, simply advances the coder one step in the same logical process. K+↓ - find the patient’s actual result K+ 2.8 - you have the patient’s actual result cross check against normal range cross check against normal range Assigning a code (E876) will ultimately depend, of course, on the condition meeting ACS 0002 criteria. Department of Health WA Performance Activity & Quality Division 3 Clinical Coding Advisory Group WA CASE: 2 AUDIT CASES Adm:23/06/2013 April 2014 Sep: 23/06/2013 An 88 year old man is admitted via ED, following a mechanical fall at his nursing home: no obvious injuries. He is admitted for observations from 1000 – 1500 (transferred to Short Stay Unit at 1230, with observations continuing until discharge at 1500). He is discharged well, back to nursing home. Discharge Summary: Fall ORIGINAL PRINCIPAL DIAGNOSIS R29.6 AUDIT Z04.3 Additional Diagnoses W19 Y92.14 U73.9 PRINCIPAL PROCEDURE DRG Version 6.x ORIGINAL B81B AUDIT X64B Other Dsrd Of Nervous Sys-Cscc Oth Inj, Pois &Tox Eff Dx-Cscc NEP: NEP: $715.91 $3305.02  This is an admission following one isolated fall.  There is no mention of 'tendency to fall', 'repeated falls', 'recurrent falls', or any of the essential modifiers required to assign: R296 (tendency to fall).  There are no injuries. The patient has a brief admission for observations (Z043), following an accidental fall. Note: Z04.3 never applies where patients are treated/investigated for injuries or pain. For example, ‘hip pain’ which is, after study, linked by the clinician to the traumatic event, is coded to non-specific injury of that site: (eg ‘ Fall- hip pain ’ : Department of Health WA code S79.9 - injury hip). Performance Activity & Quality Division 4 Clinical Coding Advisory Group WA AUDIT CASES April 2014 CASE: 3 Adm: 12/08/2013 Sep: 13/08/2013 84 year old woman: admitted via ED with fast AF Discharged this morning after an admission 7/8/13 – 12/8/13, she was originally admitted 7/8/13 with a provisional diagnosis of pneumonia. Chest x-ray (CXR) at that time showed clear lung fields. Final diagnosis on discharge summary for that episode is: LRTI Now presents with rapid AF and crackles on chest auscultation. Progress notes 13/8/13: lobar pneumonia. CXR: not done this episode. AF resolved and discharged. Discharge Summary: 1) FAST AF 2) LRTI ORIGINAL PRINCIPAL DIAGNOSIS Additional Diagnoses I48.9 J18.9 AUDIT I48.9 J22 PRINCIPAL PROCEDURE DRG Version 6.0 ORIGINAL F76A AUDIT F76B Arrhy, Card & Cond Disdr +Cscc Arrhy, Card & Cond Disdr -Cscc NEP: $1920.81 NEP: $3149.58  Pneumonia (J189) is not confirmed. See ACS 1004: “The only definitive way to diagnose pneumonia is by chest x-ray”…….. Chest x-ray (CXR)was not performed and the previous chest x ray (7/8 – 12/8) did not establish pneumonia.  Nevertheless pneumonia could have subsequently developed. ACS 1004 allows a clinical diagnosis of pneumonia to stand without x-ray evidence. But note the pre-condition for this: “when only pneumonia is documented……….” There has to be consistency in the clinical diagnosis. In this case pneumonia is not the ONLY diagnosis. There is pneumonia, and LRTI. Critically, the latter is the final diagnosis after study.  There may be a tendency to think that whenever pneumonia is mentioned, even as a provisional diagnosis, that ‘ LRTI’ is purely imprecision on the part of the clinician. In fact, ‘LRTI’ can reflect a genuine change in diagnosis after study ; (particularly study of chest x-rays, the patient’s presentation and subsequent clinical course). A final diagnosis of LRTI should not be discounted in favour of a provisional diagnosis of pneumonia without CXR confirmation. Even where the latter is present, the case should be queried to confirm and correct the discharge summary diagnosis. Department of Health WA Performance Activity & Quality Division 5 Clinical Coding Advisory Group WA CASE: 4 AUDIT CASES Adm: 17/08/2013 April 2014 Sep: 17/08/2013 63 year old man for booked elective colonoscopy Nursing notes: T2DM Discharge Summary: (computer-generated endoscopy report): indication: malignant sigmoid polyp for tattooing anaesthetic: sedation IV midazolam extent: terminal ileum Findings: large sigmoid polyp (noted on previous sigmoidoscopy): tattooed. Further polyps in ascending descending, transverse colon – snared and retrieved. Diverticular disease noted in sigmoid and descending colon. Histopath: conclusion: tubular adenomas: ascending, transverse, and descending colon. ORIGINAL AUDIT PRINCIPAL DIAGNOSIS D12.2 C18.7 Additional Diagnoses M8000/3 D12.4 D12.3 D12.2 M8211/0 E11.9 D12.4 D12.3 M8211/0 K57.30 E11.9 PRINCIPAL PROC: 32093-00 32093-00 Other Procedures 32090-02 32090-02 92515-99 92515-99 DRG Version 6.0 Department of Health WA ORIGINAL G48C Colonscopy, Sd AUDIT G48C Colonoscopy Sd NEP: $1590.27 NEP: $1590.27 Performance Activity & Quality Division 6 Clinical Coding Advisory Group WA AUDIT CASES April 2014 Case 4 continued: No DRG change, but important coding issues remain: The case is exempt from ACS 0046 –same day endoscopy. The following scenarios are not subject to ACS 0046:  follow up  screening and  endoscopies to investigate a known condition or  presentation with problems relating to a known condition. The condition chiefly occasioning this day endoscopy is a known condition (malignant sigmoid polyp: C187) and the endoscopy is booked to further attend to that condition (for tattooing).  Normal rules apply.  The malignancy meets ACS 0001.  All other conditions are assigned only where they meet ACS 0002.  In this case there are extra diagnostic procedures (polypectomy) for the tubular adenomas (D122, D124, D123). ACS 0002 criteria are met.  The diverticular disease (K5730) meets no ACS 0002 criteria. Department of Health WA Performance Activity & Quality Division 7