Q&A: Appropriately reporting pulmonary edema, CHF, and sepsis
Q: We’ve been having a CDI discussion in regards to the following scenario:
The physician documents acute pulmonary edema secondary to debility, congestive heart failure (CHF), and sepsis. The Excludes 1 note in the Tabular Index precludes coding the pulmonary edema (J81.0) with heart failure I50.1. According to the exception, however, since pulmonary edema is being documented as both cardiogenic and non-cardiogenic, is it correct to code also the J81.0 in addition to I50.1?
A: This is a fascinating question. From a clinical perspective it would be appropriate to report both conditions, however, you cannot do so until the documentation clearly demonstrates that the pulmonary edema is multifactorial (i.e., contributed to equally by sepsis and CHF rather than just CHF).
Coding Clinic fourth quarter 2016 page 118 state it this way:
“An exception to the Excludes 1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes 1 note are related or not, query the provider. For example, code F45.8, Other somatoform disorders, has an Excludes 1 note for ‘sleep related teeth grinding (G47.63),’ because ’teeth grinding’ is an inclusion term under F45.8. Only one of these two codes should be assigned for teeth grinding. However psychogenic dysmenorrhea is also an inclusion term under F45.8, and a patient could have both this condition and sleep-related teeth grinding. In this case, the two conditions are clearly unrelated to each other, and so it would be appropriate to report F45.8 and G47.63 together.”
Coding Clinic, Fourth Quarter 2015 pg. 40 has this to say:
“There are circumstances that have been identified where some conditions included in Excludes1 notes should be allowed to both be coded, and thus might be more appropriate for an Excludes 2 note. However, due to the partial code freeze, no changes to Excludes notes or revisions to the Official Guidelines for Coding and Reporting can be made until October 1, 2016. The new guidance concerning Excludes 1 notes is intended to allow conditions to be reported together when appropriate even though they may currently be subject to an Excludes 1 note.
And, Coding Clinic Fourth Quarter 2015 pg. 40 offers this as an example:
“If the two conditions are not related to one another, it is permissible to report both codes despite the presence of an Excludes 1 note. For example, the Excludes 1 note at code range R40-R46, states that symptoms and signs constituting part of a pattern of mental disorder (F01-F99) cannot be assigned with the R40-R46 codes. However, if dizziness (R42) is not a component of the mental health condition (e.g., dizziness is unrelated to bipolar disorder), then separate codes may be assigned for both dizziness and the mental disorder.”
In other words, dizziness can be caused by other medical problems and shouldn’t always be assumed to be a mental issue—something that seems rather obvious.
Furthermore, some of the existing Excludes 1 notes have been discovered to just be completely wrong:
“As of October 1, 2016, the Excludes 1 note under category F02 prohibiting assignment of dementia with Parkinsonism (G31.83) has been deleted.”
In other words, the book had previously been set up so that you couldn’t code dementia with Lewy bodies or Parkinsonism with a code for dementia in diseases classified elsewhere as a separate diagnosis. This was later addressed in 4th Quarter 2016 pg. 141 that yes, you can report G31.83 Dementia with Lewy Bodies and F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance together even though they had previously been Excludes 1 listed. To further illustrate how the index is needing to be corrected, the index also directed you to turn Parkinson’s disease (G20) into Parkinsonism (G81.83) and yet they included Parkinsonism as an inclusion term under G20. Queries to the AHA received responses categorizing such events as simple “inconsistencies in the indexing,” possibly to be fixed later.
However, in the example of the multifactorial pulmonary edema a query is in order. Although the diagnostic statement, “acute pulmonary edema secondary to debility, CHF, and sepsis,” appears to confirm that pulmonary edema is not simply a manifestation of CHF, it would not be acceptable to most coders or auditors without a little more provider documentation explicitly stating that the acute pulmonary edema in this patient is also caused by sepsis.
To further support an acute diagnosis like this, one would also expect to see additional respiratory compromise documented in the chart as a result of the acute pulmonary edema. One would also expect to find standard treatment such as a moderate to large IV push dose of Bumex or Lasix—unless those medications are otherwise contra-indicated and if they were contraindicated—in which case, you’d need an explanation as to why.
Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.