MS DRG Case of the Month: Answer to Case #5

Optimal DRG: 180 Respiratory Neoplasm with MCC

Here there is room for disagreement on the principal diagnosis.  With so much cancer riddling this poor patient’s body, it was tempting to go for something with a higher case weight.  But remember: the truth is always right.

Principal Diagnosis

The H&P documents metastatic endometrial cancer.  Metastases to both liver and lungs are documented on admission, along with ascites and pleural effusions.  The GI consultant documents probable malignant ascites.  The pulmonary consultant documents probable malignant pleural effusion.  The primary and metastases to both liver and lungs were present on admission.  Metastases to both liver and lungs required assessment, so both conditions are eligible for selection as principal diagnosis.  Coding guidelines state that the circumstances of admission always determine the principal diagnosis.  In this case, the patient presented with difficulty breathing and tachypnea.  While ascites could have contributed to the patient's difficulty breathing, the GI consultant did not recommend any treatment other than observation for the patient's ascites.  The pulmonary consultant performed a thoracentesis, after which the patient's respiratory rate normalized from 28 on admission to 18.  The circumstances of admission and the response to thoracentesis support a principal diagnosis of Malignant pleural effusion (518.81) over liver metastases (197.7) or the primary uterine malignancy (179).  Sequencing either Malignant pleural effusion (518.81) or Secondary malignant neoplasm of lung (197.0) as principal diagnosis will result in DRG 181 Respiratory Neoplasms with CC.

Secondary Diagnoses

The H&P / Review of Systems document the patient to require total assistance for all ADLs, bed mobility, and transfers, and to be non-ambulatory.  The H&P / Physical exam documents unable to assess neurologic status, minimal extremity movement noted, no purposeful movement, flexion contractures of the knees, and a Stage II pressure sore on the sacrum.  The Progress Notes / Nursing document patient incontinent of bowel and bladder, cleansed after incontinence, fed meal, follows no commands, no functional use of arms or legs, unable to assist with care.  ICD-9 listing Functional quadriplegia (780.72) includes "Complete immobility due to severe physical disability or frailty."  Coding Clinic Fourth Quarter 2008 states that functional quadriplegia is the inability to move due to another condition (e.g. dementia, severe3 contractures, arthritis, etc.), and that the individual does not have the mental ability to ambulate and functionally is the same as a paralyzed person.  .  Attending physicians are slowly starting to document "Functional quadriplegia" on lists of admitting and discharge diagnoses.  Few of us have ever seen such documentation, so a query is almost always needed. Please see FairCode templates for Functional Quadriplegia under General Queries on the FairCode website.   Adding Functional quadriplegia (780.72) as a secondary diagnosis will result in DRG 180 Respiratory Neoplasms with MCC.

Procedure

The surgeon sent off tissue from debridement to pathology.  The coder coded a skin biopsy. Should a query be sent for possible excisional debridement?  Probably not.  Coding Clinic Third Quarter 2009 states that Versajet is non-excisional debridement.   Coding Clinic Second Quarter 1995 advises that inadvertent resection of the parathyroid gland is not coded as a surgical procedure when the resection of the parathyroid gland was not intentional. Bits of lung tissue included in a transbronchoscopic bronchial biopsy do not justify adding a lung biopsy code when the lung tissue was included in material from an intended bronchial biopsy, according to Coding Clinic Second Quarter 2009.  Bits of skin sent to pathology without documentation of the intent to biopsy the skin probably will not support either a biopsy procedure code or a query for excisional debridement in a patient who underwent Versajet debridement of a skin ulcer.  The procedure best supported in this case is Non-excisional debridement of wound (86.28).