Provident has been engaged in ongoing DRG audits since ICD-10 was implemented in October 2015. We have identified potential DRG audit target areas related to our audit work, changes to the ICD-10 codeset, and Coding Clinic updates. We will be posting cases regularly in our newsletter. Please see this edition’s case study below:
79-year-old female was transferred to emergency department after she was unable to get out of bed with tremors, shaking and was completely non-verbal. CT of the brain showed a large acute hemorrhagic bleed involving the right middle cerebral artery measuring up to 8.5 cm resulting in approximately 0.9 cm midline shift.
Per H&P, patient noted to have suffered a devastating intracranial hemorrhage with midline shift mass effect, and cerebral edema, family wishes for palliative care. Patient was a DNR (do not resuscitate) and expired the following day.
Audit Considerations & Strategies
- The coder originally did not assign a code for the cerebral edema because it was not treated (e.g. high-dose steroids (Decadron), diuretics (Mannitol), intubation, transfer to the ICU, etc.)
- Typically, we agree that there should be clear evidence of monitoring and/or treatment to assign a code however, the exception to this advice would be for cases where comfort care is ordered and the patient expires soon after where further treatment and monitoring may not be an option
- Even though the cerebral edema was not treated, it was evaluated and could have contributed to the decision for comfort care only
- Coders should also ensure the cerebral edema is clinically relevant/significant before capturing (e.g. cerebral with mass effect or with mid-line shift)
- If cerebral edema is noted as “mild” or “without mass effect”, we recommend either querying to clarify the clinical relevance or not coding the condition at all
- If cerebral edema is present with “mass effect” or when there is “midline-shift” potentially causing “brain compression (MCC)” or “brain herniation” (also an MCC) we recommend coding the condition
- We recommend capturing conditions that were present and evaluated that are not only treated but meet the UHDDS requirement that conditions are “clinically evaluated” to ensure that the severity and complexity of a patient encounter is accurately reflected
- Not reporting conditions that were present and clinically evaluated will adversely affect risk profiles for hospitals and physicians. It is common for risk management departments to routinely review mortality cases to ensure all conditions that contributed to a patient’s death are coded and reported when meeting UHDDS guidelines
- Coding is utilized not only for reimbursement purposes, but also to ensure accurate tracking and reporting of diseases; not coding clinically significant conditions that were present and evaluated and contribute to mortality would adversely affect disease data capture and reporting
- Intracerebral Hemorrhage (ICH) with Vasogenic Edema, Coding Clinic – 1st Quarter 2010 Page 8
- Gliobastoma with Vasogenic Edema, Coding Clinic – 3rd Quarter 2009 Page 8
- ICD-10-CM Official Guidelines for Coding and Reporting (Effective Oct 1, 2017), Section III. Reporting Additional Diagnosis: For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. The UHDDS item #11-b defines Other Diagnoses as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.