How Do You Look in an Orange Jumpsuit?
Avoid Sequencing Oversights for Profit

Every so often, I come across some coding issues that recall other coding issues and – BAM – an article!  I found this situation within the last few weeks and it deserves some discussion.

A baby is brought into the hospital with weight loss.  Can’t keep anything down.  The Pediatrician and the mom worked for weeks on dietary modifications, size of feeding, various changes in formula – stop the breast milk – try soy products – feed small amounts frequently – feed large amounts a few times a day – add a little farina to thicken the feeding.  Nothing.  The weight went down as the baby became more malnourished and, eventually, the baby became sleepy and weak and dehydrated.  Admitted to the hospital for workup.  IV fluids were administered and parenteral nutrition started to give the baby some caloric intake.  Pediatric GI studies showed a significant sliding hiatal hernia and the baby underwent Nissen fundoplication.  Success!  Feeds were retained, the patient started gaining weight, all was well and the baby was discharged.  The chart was evaluated by the coders and dehydration 276.51 and malnutrition 263.9 were assigned as the first two diagnoses with hiatal hernia 750.6 with gastroesophageal reflux 530.81 as subsequent diagnostic information.  We came up with DRG 982, Extensive O.R. Procedure Unrelated to Principal Diagnosis with CC.  Cool one might think!  We know this one is a good paying DRG (RW = 3.5417).  It MUST be right.  After all, that’s what brought the patient into the hospital – right?

WRONGGGG!

The malnutrition and the dehydration were symptoms of something going on.  They were manifestations of a disease process.  After workup, it was found that there was a hiatal hernia with significant esophageal reflux and THAT was the diagnosis after workup – that is the principal diagnosis.  Resequencing the diagnoses properly, then, the DRG assignment is now 327 Stomach. Esophageal and Duodenal Procedures with CC (RW – 3.2941).  Sure it’s less – but that’s what it is.  If you consider the co-principal diagnosis argument and the fact that you can sequence either first, the concepts apply:

1. Co principal diagnoses are equally serious and equally treated.  In our case, one was treated with an IV and fluids and calories – the other with a trip to the OR – this is equal?
2. The definition of principal diagnosis – you do not sequence a symptom of the diagnostic entity first (unless sequencing guidance prevails, such as only treating the symptom or sequencing of acute respiratory failure and its cause, etc.)

This case recalls another situation that I’ve seen many times in many places.  An elderly lady was shopping at WalMart, got weak and dizzy and almost passed out, but fell against the Charmin display, knocking over the stacks of toilet paper.  An assistant manager called 911 and the EMS personnel arrived, applied oxygen, took her vital signs (tachycardia – rate of 124/minute, slight tachypnea – breathing at 22 respirations a minute, blood pressure slightly low at 98/60).  They transported her to your hospital where she was admitted to the Emergency Department.  EKG monitor showed some old ST-T wave changes, oxygen saturation was 88% on room air, vital signs were consistent with what the transport folks had found.  The physician in the ED thought she appeared pale and ordered a CBC and orthostatic vital signs to be taken.  Indeed, it was found that she had a rise in pulse rate and a slight drop in blood pressure in hanging from lying supine to sitting, from sitting to standing and she became dizzy again.  The physician wrote “orthostatic hypotension.”  The CBC came back with a hemoglobin of 6.8 and hematocrit of 22.  The cells were hypochromic (pale) and microcytic (small).  Immediately, the ED physician ordered a stool for hemoccult and had the patient admitted with diagnoses of:

            Near syncope
            Orthostatic hypotension
            Anemia

Workup proceeded in the hospital with upper gastrointestinal endoscopy and colonoscopy and, lo and behold, a relatively large, fungating, bloody sessile mass was found in the cecum with no signs of disease in the liver on liver scan.  The patient was prepped for surgery, given a few units of packed cells to bump the hemoglobin and underwent an uneventful lap assisted right hemicolectomy.  She was advanced in diet and discharged.  Pathology showed adenocarcinoma of the cecum with no positive nodes in the mesentery.

The record got to the coders.  Hmmmm.  Such a conundrum. We have syncope 780.2, orthostatic hypotension 458.0 and anemia 285.9.  Then we add the right hemicolectomy and – WOW – DRG 264 Other OR Procedures for Circulatory Disorders with the syncope as principal (RW = 2.4840), same with the orthostatic hypotension first, but then there’s DRG 982 Extensive OR Procedure Unrelated to Admitting Diagnosis (3.5417) when we sequence the anemia first and follow that with the 154.0 for the cancer.  That must be it!

WRONGGGGG again.

This is yet another case in which the patient’s presentation represented symptoms of the disease process which, after work up, turned out to be the malignant neoplasm of the colon – and it was chronic blood loss from that malignancy that caused the patient’s anemia which caused the syncopal episode.  The DRG assigned should be 331 Major small and Large Bowel Procedures without MCC or CC (unless you can find one somewhere else) with a relative weight of 1.8415.  Why?  Because that’s the way it is.

Finally, selection of the proper procedure code can sometimes get one into trouble.  As we all know, because I wrote about it in the recent past, there is a new code for the conversion of a PEG (percutaneous endoscopic gastrostomy) feeding tube to a transgastric PEJ (percutaneous endoscopic jejunostomy) feeding tube.  It had been, prior to October 1, 2008, that this description led to the assignment of an ICD-9-CM procedure code which made the procedure a major operating room procedure and led to the 981, 982 and 983 DRGs (formerly 468).  Now, with the recognition that an anastomosis must be done endoscopically to justify a major OR procedure, the code for the conversion of a PEG to a PEJ is no longer a procedure that affects DRG assignment.  READ THE OPERATIVE NOTE.  If an anastomosis is done, then ICD code 44.32 is justified and the procedure code affects the DRG.  But, even if the physician uses the phrase or abbreviation inappropriately for conversion of a PEG to a PEJ and calls it a PEGJ when no anastomosis was done, 46.32, a non-OR procedure is warranted – and that does NOT affect the DRG assignment.

You see – you have to consider truth, justice and the American way and assign codes properly and according to the rules, even though there may be a financial incentive to “misinterpret” for the benefit of the bottom line.  That’s where folks get into trouble

Now, you be careful out there.