Situation:

Lynn Salois, RHIT, CCS, CDIP, Director of Coding

On the evening following total hip replacement surgery, the patient is found to be confused and disoriented. The progress notes indicate the patient’s mental status changes are secondary to pain medication, which will be reduced. The PCA pump is removed resulting in the patient’s mental status returning to baseline.

Do any of the diagnostic statements require further specification for code assignment? Is a query warranted?

Here are my thoughts…

• The mental status changes are identified as confusion and disorientation due to pain meds. The acuity of the confusion is not identified, therefore, from the main term confusion in the ICD-9 Alphabetic Index; the coder is directed to see also State, confusional. There is a sub-term acute drug-induced under the main term State, confusional, acute in the ICD-9 Alphabetic index.
• Code 292.81(cc) acute confusion drug induced may not be assigned without querying the physician for specification of the confusion acuity. The appropriate confusion code assignment without documented acuity is 298.9 Psychosis NOS (no cc).
• Present case studies similar to this one as part of the hospital’s medical staff education to emphasize the importance of documenting acuity in relationship to severity of illness reflection, reimbursement and quality reporting.

What are your thoughts?