A sixty-two year old patient is seen in the emergency room complaining of rectal bleeding. His HCT is 24 and his platelet count is 38,000. The admitting diagnosis is GI bleed. Makes sense.
However, per the history and physical, the patient has a history of a bleeding arteriovenous malformation and myelodysplastic syndrome with recurring thrombocytopenia. During the admission of this one day stay, the patient receives platelet and packed cells transfusions, two units each.
Considering a Principal Diagnosis
The final diagnoses per discharge summary are lower GI bleeding due to arteriovenous malformation, acute blood loss anemia, and advanced transfusion dependent myelodysplastic syndrome.
What Principal Diagnosis should be assigned for the above case scenario?
- Consider the definition of Principal Diagnosis – that condition after study to be chiefly responsible for occasioning the admission.
- Consider the treatment rendered to the patient during the hospitalization.
- Consider coding conventions and Coding Clinic Guidelines.
- Consider the complete documentation provided within the medical record.
The coding challenge here is that all three final diagnoses potentially meet the definition of Principal Diagnosis.
Take it All into Account
Some might be tempted to code the bleeding AV malformation as the Principal Diagnosis since this is the etiology of the anemia and the rectal bleed. However, no treatment or work-up was done regarding the AV malformation.
Some might consider the myelodysplastic syndrome as Principal Diagnosis. However, this is a chronic condition and not the acute reason/manifestation for occasioning the admission.
Coding Clinic guidelines regarding to two or more conditions each potentially meeting the definition of Principal Diagnosis state that either may be sequenced first unless the circumstances of the admission, the therapy provided, diagnostic workup indicate otherwise. In this case, the focus of treatment was directly specifically to the anemia and the thrombocytopenia given the transfusions and monitoring of hematologic lab values.
Always take into consideration the full circumstances of the patient’s admission and the treatment rendered in conjunction with Coding Clinic guidelines when assigning the Principal Diagnosis. Assess the entire record. Don’t take at face value the Principal Diagnosis on the discharge summary without taking into consideration the above factors. Reference Coding Clinics 2Q 2002, p. 64-65 and 1Q 2002, p. 3
What would you do?