MRA Thought of the Day: Secondary Diagnoses Matter! Check Your Grouper

Cathie Wilde, RHIA, CCS, Vice President of Coding Services Cathie Wilde, RHIA, CCS, Vice President of Coding Services

It is important that your coding staff identify and code all pertinent secondary diagnoses that meet additional diagnoses criteria (as outlined by Coding Clinic, 4Q 2008, p. 305-306). In this month’s case, the identification of another secondary diagnosis meant an extra $22,000 in hospital revenue.More than Just Another Code Coders should never presume that a valid secondary code makes no difference, given other significant conditions of the patient. Also, be aware of the variations in the different grouper software (Medicare vs. BC APR for example). Here’s why… A fifty-two year old male presented to the ER with several issues – nausea, vomiting and diarrhea, acute renal failure, hyponatremia, suspected UTI and acute respiratory failure. The patient had:

  • BUN of 33
  • Creatinine of 2.5 for which patient was given IV fluids
  • Ultrasound done to rule out obstructive uropathy
  • Renal consult
  • Monitoring of lab values and holding of patient’s Lisinopril

The patient was hypoxic with saturation of 87% on room air and a respiratory rate of 22. Work up for the respiratory failure determined that patient had atelectasis with underlying newly diagnosed COPD and he was placed on supplemental oxygen and received incentive spirometry. The discharge summary was lacking at the time of coding. But based on the documentation present for this Blue Cross/BlueShield account, the case was coded to acute renal failure (584.9) as the Principal Diagnosis followed by codes for acute respiratory failure (518.81), UTI (599.0), gastroenteritis (558.9), hyponatremia (276.1), atelectasis (518.0), COPD (496,) and diabetes (250.00). The case was assigned to DRG 460 with severity of illness (SOI) of 3. One interesting note in this case is that the hospital has a policy in place that requires a secondary coding review once the discharge summary has been completed. It was this policy that resulted in a substantial increase in payment for this case. Here’s how:

  • In the body of the discharge summary, it was noted that the patient had metabolic acidosis during the hospitalization which caused the secondary reviewer to delve further into the documentation within the chart.
  • The reviewer found that metabolic acidosis was indeed documented briefly on several MD progress notes but was not coded.
  • Since the patient already had a MCC condition coded (518.81) along with several CCs, the reviewer didn’t think adding code 276.2 for the acidosis would change the DRG but decided to add the code for completeness sake.
  • To her surprise the addition of 276.2 changed the SOI for this DRG to 4 under the Blue Cross / Blue Shield grouper and increased the overall payment by almost $22,000!

Our advice, consider secondary reviews of accounts initially coded without discharge summaries. And check your groupers. All pertinent secondary diagnoses that meet additional diagnoses criteria should be coded. Your revenue could benefit. What would you do?

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