Q&A: When to query for pleural effusion etiology

Q: We recently had a patient with a pleural effusion who came to the hospital for shortness of breath. The patient had a bronchoscopy, left video-assisted thoracoscopy, evacuation of pleural effusion, pleural biopsies, and talc pleurodesis, but the work up revealed no known cause for the effusion, leaving only a history of congestive heart failure (CHF) and a history of Crohn’s disease.

The rheumatologist was consulted and the pathology report revealed chronic inflammatory cells. The physician stated an unknown etiology for the pleural effusion in the discharge summary.

The coders are now asking us to get the documentation that the pleural effusion is not related to the diastolic CHF. Is this more of a coding query or a CDI query? Should we query at all?

A: I am not sure if I can give you a definite answer, but, let’s look at the various concerns this scenario raises.

First, understand the coders’ motivation—a pleural effusion is considered integral to heart failure, and would not be coded separately if related to heart failure, so likely he or she is  trying to identify the etiology of the pleural effusion. Since the heart failure is not identified as being an acute exacerbation, the effusion is likely not related. A query to establish the etiology could help the coder better identify the principal diagnosis:

• Is there an acute heart failure?
• A malignancy?
• An infection?

If no possible etiology can be identified, then the pleural effusion is the principal diagnosis and DRG assignment would be to the DRG grouping of 186, 187 or 188. The provider could also identify a probable etiology if the etiology is uncertain, allowing for a more specific DRG to be assigned.

Determining whether this query would be issued by the coding or CDI team really depends on the query policies in your organization. Where I worked previously, there was no differentiation of a coding or CDI query. If a query needed to be asked, whoever identified the need asked the question. The coders mainly handled retrospective queries and the CDI specialists mainly handled concurrent queries. But, we worked together to ensure the record was complete. Many organizations have very clear lines dividing the query practice between the two teams.

In the case described, I do think the question should be asked to ensure capture of what is true to the patient’s story. I would ask the query but would ask the provider to identify the etiology of the pleural effusion (to include any possible/probables). I would also give an option for unknown etiology. The answer to this question will determine the DRG assignment.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.