Q&A: Coding false primary diagnoses

Q: I have two questions on how to code diagnosed conditions that were later determined to be non-existent:

• In one case, a patient was initially treated for bacteremia due to a positive blood culture lasting two to three days. However, it was later determined that the culture was contaminated, so the IV antibiotics were stopped, and the patient was discharged. Nevertheless, should bacteremia still be coded since resources were used to treat it?
• In a second case, a patient presented with complaints of nausea, vomiting, diarrhea, and cloudy urine—they were diagnosed with pyelonephritis. The treatment continued for two days; however, in the discharge summary, the physician noted that the patient possessed minimal genitourinary symptoms. Given the borderline urinalysis with 6-10 white blood cells (WBC), negative leukocyte esterase, and negative nitrites, there wasn’t a compelling case for pyelonephritis. Therefore, the IV antibiotics were stopped. The primary diagnosis was changed to viral gastroenteritis, but do I still code for pyelonephritis?

A: For your first case, since the cultures were contaminated and the treatment stopped, the discharge documentation should note that the initial “concern for bacteremia” was ruled out. If this was not documented, you should send a query to determine if the condition was in fact ruled out. If the documentation did rule out the bacteremia, then, despite the fact that it was treated, you would not be able to code the condition.

In response to your second question, there is also an opportunity for clarifying the pyelonephritis. The provider’s documentation—i.e., borderline urinalysis with 6-10 WBC, negative leukocyte esterase, and negative nitrites—further clarification if the condition was possibly present but resolved after treatment, ruled out, etc.

Editor’s note: Nicole Nodal-Rodriguez, MSN, RN, CCDS, CDI education specialist at HCPro, answered this question. Contact her at Nicole.Nodal-Rodriguez@hcpro.com.