Q&A: PE versus DVT as a principal diagnosis

Q: I have a patient whose chief complaint was shortness of breath (SOB) and, after studies, the patient was found to have moderate to large B/L pulmonary embolism (PE) and extensive B/L lower extremity deep vein thrombosis (DVT). The coding staff is using the PE as the principal diagnosis because they say it was the reason for the admission. I am a nurse, not a coder, and figured, since both conditions were present on admission, we could use the higher DRG—my DRG is 2099 (DVT and PE as the MCC). The coders’ DRG is 176 (PE) and no MCC. Which is correct for this scenario?

A: I understand and can see your point of view. As a nurse, myself I can follow your logic. But we need to remember that we cannot assume anything. The assignment of principal diagnosis and secondary or other conditions—provided they meet the Uniform Hospital Discharge Data Set (UHDDS) definitions for principal and secondary diagnoses—should solely be based on the provider’s documentation. So, when in doubt our best advice would be to query the provider. This way, we remove all doubt when final coding the chart.

How did the provider document these conditions in the chart? Did they state in their documentation that the PE was related and/or caused by the DVT? What was the physician’s stated reason for the admission? If the reason the person was admitted was the PE as stated by the provider, then the PE’s would be the principal diagnosis. But, if the reason the person was admitted was in fact the DVT, then that would be the principal diagnosis.

The Official Guidelines for Coding and Reporting states:

“In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.”

I have looked up both conditions in my code book and see no sequencing guidance listed under either diagnosis, unless related to an abortion, or ectopic or molar pregnancy.

I would want to make sure that the physician attributed the PE to the DVT of the lower extremity, and not another source, such as renal. I would also look into the patient’s respiratory status at the time of admission. Is there a chance that this patient was in acute respiratory failure? As nurses, we tend to assume that the SOB is related to what we consider to be the obvious diagnosis, such as pneumonia, congestive heart failure, or PE without asking the provider. You want to make sure that we are not missing indicators of another diagnosis, such as acute respiratory failure or acute cor pulmonale.

The only information provided in your question is the chief complaint of SOB. Were there any other indicators that were present on admission, that would have you lean towards the PE or DVT as your principal diagnosis? There is no rule that states because a condition is caused by another condition, such as the DVT causing the PE, that it will automatically make the condition of cause (the DVT) your principal diagnosis. We can’t assume and should defer to the person legally accountable for making that decisions, which would be the provider.

Also look at this person’s past surgical history. Could the DVTs be related to a previous procedure? If they are related to past treatment, it would change this scenario to a possible complication code based on physician documentation.

My best advice is: when in doubt query the provider. This will remove any one person’s interpretation of the medical record documentation. I truly wish I could give you absolute advice in this circumstance but, it really would depend on the totality of the documentation within the medical record by the provider.

Editor’s Note: Sharme Brodie, RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.