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Q&A: Including diagnosis from consult notes

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Q: How would the following be viewed if it was included in a cardiology consult note:

“Mr. X has paroxysmal atrial fibrillation. He had a recurrence last night which was asymptomatic. We think this happens all the time at home. This is not a pacing post-conditioning (PPC). He is back in normal sinus rhythm (NSR). I would restart his warfarin if Dr. Y will allow. Goal International Normalized Ratio (INR) is 2-3.”

A: Because code assignment can be based on documentation of other physicians (e.g., consultants, residents, or anesthesiologists) that note meets criteria for a secondary diagnosis and doesn’t conflict with the attending physician. I can see where this case could be tricky, since it looks like the condition did not require further evaluation or diagnostic testing, and did not increase nursing care or increase the length of stay. However, the cardiologist did want to restart the patient’s warfarin and if that occurred during this admission, then it would be treatment and make it a reportable condition. This could be a vulnerable claim if the physician does not document the atrial fibrillation in the discharge summary, with the need for continued follow up-care regarding the warfarin and/or if the paroxysmal atrial fibrillation is the only CC.

Editor’s Note: Sharme Brodie RN, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, CDI education specialist and CDI Boot Camp instructor for HCPro in Danvers, Massachusetts, answered this question. For information, contact her at For information regarding CDI Boot Camps offered by HCPro, visit

Q&A: Clinical definitions and core measure capture

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Q: How have you handled situations when specialty physicians and hospitalists do not agree with diagnoses impacting core measures?

A: It becomes difficult because the clinical definitions of some disease processes are a little bit tricky. In specific scenarios such as acute myocardial infarction (AMI) and congestive heart failure (CHF), we’ve brought together a team of coding, quality, case management, and the physician groups involved to develop specific clinical definitions everyone can agree on. That cut down a lot of the back and forth that we’ve had along the way.
The coders got stuck in the middle of it. Coders don’t feel comfortable going up to a physician and saying, “Okay, Doctor Jones documented this as a STEMI, but you’re saying it’s not. You’re saying it’s not even an AMI.” That situation puts the coders and CDI staff in a very difficult position. We’re not the physician who’s ultimately responsible for the diagnosis of the patient, but we’re trying to dig through all the information.
We tried to select the most widely accepted clinical definition of CHF, because we don’t want to pick the most obscure definition that’s out there and narrow the field down to the point where we’re going to look odd when you compare us to other hospitals. By having an agreement about what that clinical picture is for a patient, a clinical definition for a diagnosis really sets the groundwork so that you don’t have all those conflicts back and forth in the chart.
It’s not a perfect world. We still have some cases that have to be clarified, but the nice thing you don’t have it happening all the time. You can follow the coding guidelines about the attending physician being ultimately responsible for the diagnoses of the patient and you can go back to that attending physician using the agreed upon clinical definitions.
Editor’s Note: Heather Taillon, RHIA, manager of corporate coding support services at Franciscan Alliance in Greenwood, Indiana, answered this question. This answer was originally published on JustCoding and is provided based on the limited information submitted to JustCoding.

Q&A: Sequencing a diagnosis when the phrase ‘versus’ is used

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Have a question that is troubling you and your team? Ask us!

Q: Is it okay to code a diagnosis if the physician documents two diagnoses using the phrase “versus” between them? For example, the patient arrives with abdominal pain and the physician orders labs and other tests but they all come back normal. In the discharge note, the physician documents “abdominal pain, gastroenteritis versus irritable bowel syndrome (IBS).”

When I first started as a CDI specialist I was told we could not use diagnosis when “versus” was stated, and that we had to query for clarification.

A: Always refer back to the ICD-9-CM (ICD-10-CM/PCS) Official Guidelines for Coding and Reporting if you are unsure of how to sequence or apply codes. Guidelines applicable to your situation are located in Section II, Selection of Principal Diagnosis.

The first guideline states:

“In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.”

However, let’s review another guideline from the same section which states:

“When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as secondary diagnoses.”

In the situation described, the physician documented a symptom, abdominal pain, followed by two contrasting diagnoses, gastroenteritis and IBS in the discharge summary. The principal diagnosis is the abdominal pain and secondary diagnoses are the gastroenteritis and the IBS.

If there is no symptom diagnosis documented–for example the physician documents NSTEMI versus GERD–the coder would assign a code for each, sequencing the principal according to the circumstances of the admission (as it tells us to in the Guidelines). Typically, however, the physician will have identified either the presence of the NSTEMI or the GERD, based on enzymes, and other testing.


Q&A: Identifying the MS-DRG for unreleated surgical procedures

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Q: Could you please explain unrelated surgical procedure DRGs? For example, a patient with a principal diagnosis of pneumonia whose surgical procedure transurethral resection of the prostate (TURP), MS-DRG 168. Also can you explain how we can differentiate between extensive operating room (OR) procedure and non-extensive OR procedure.

A: Many CDI specialists with a clinical background are what I like to call, encoder dependent. What I mean by that is we’ve been trained to “code” using an encoder and create our working MS-DRGs based on “grouper” software. It is often helpful to understand how to manually assign a MS-DRG. The basics steps for assigning a MS-DRG are as follows:

  1. Identify all the applicable diagnoses in the health record
  2. Identify the principal diagnosis (the condition after study to be chiefly responsible for occasioning the admission)
  3. Determine its associated ICD code (we currently use ICD-9-CM, but we’ll eventually use ICD-10-CM)
  4. Identify the base/medical DRG noting its Major Diagnostic Category/body system
  5. Identify any/all procedures

This is where it can get a little tricky. The UHDDS (Uniform Hospital Discharge Data set) defines the principal procedure as

  • One that was performed for definitive treatment, rather than one performed for diagnostic or exploratory purposes, or was necessary to take care of a complication
  • If there appear to be two procedures that are principal, then the one most related to the principal diagnosis should be selected as the principal procedure

If there was a procedure performed take the following steps:

  1. Determine the associated procedure codes (currently based on ICD-9-CM Vol. 3 codes and soon to be ICD-10-PCS) and determine if the procedure code associated with the principal procedure as listed in the DRG Expert?
  2. If the code isn’t in the DRG Expert index of procedures, it is for one of two reasons: Either it is not a “reimbursable” procedure (i.e., one that will affect the MS-DRG assignment) or is it a major OR procedure
  3. If there isn’t a procedure or it doesn’t impact DRG assignment, does the medical DRG allow for movement i.e., can patients be put into different groups based on the presence or absence of a complicating condition (CC) or major complicating condition (MCC)
  4. If so, check to see if any of the remaining diagnoses, which are now considered “secondary diagnoses” are CCs or MCCs
  5. Finalize the working DRG
  6. If the procedure code is in the same MDC/body system as the principal diagnosis assign the new surgical MS-DRG (this is the most common scenario and is often referred to as a “match”)
  7. If the procedure code is not in the same MDC/body system a different process is used to assign the surgical MS-DRG

The MS-DRG system is based on the assumption that if there is a “reimbursable” medical intervention/procedure that the case/claim will remain in the same body system (MDC) as the principal diagnosis will apply. However, there are occasions when the principal procedure is not related to the principal diagnoses because it is associated with a different MDC/body system as in the example you describe, which will require you to take some additional steps, including:

  1. Turn to the start of “DRGs Associated with All MDCs.”
  2. Scan the procedure codes listed under DRG 984 Prostatic O.R. Procedure Unrelated to PDX to try to locate the applicable procedure code.  These are codes that range from 60.0 to 60.99 within ICD-9-CM Vol. 3. If the applicable code is found under DRG 984 then the case will fall within a DRG referred to as a “triplet” where either a CC or a MCC can “move” the DRG. Check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses resulting in a final DRG between 986 and 984

Your example of a principal diagnosis of pneumonia (respiratory system MDC) with a procedure of a TURP will fall into one of these DRGs because the TURP is not a procedure located within the respiratory MDC/body system, but is classified as a prostate procedure and found under DRG 984. Your final MS-DRG assignment will depend on the presence or absence of secondary diagnose classified as a CC or MCC.

If the procedure code is not found under DRG 984, scan the procedure codes listed under DRG 987 Nonextensive O.R. Procedure Unrelated to PDX to try to locate the applicable procedure code. These codes span several pages within the DRG Expert. If the applicable code is found under DRG 987 then the case will fall within a DRG referred to as a “triplet” where either a CC or a MCC can “move” the DRG. Check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses resulting in a final DRG between 987 and 989.

If the procedure code is not found under DRG 984 or DRG 987 and it was not associated with a page when referencing a procedure index or if it was found, it was in a different MDC/body system than the PDX then the assumption is the case/claim belongs in DRGs 981-983. This final step requires a leap of faith since it is based on a process of elimination where this is the “last resort” for DRG assignment. These DRGs are heavily scrutinized by external auditors as assignment within these DRGs can erroneously inflate reimbursement if the case was improperly assigned. As above, this is a DRG is a “triplet” where either a CC or a MCC can “move” the DRG. So check the remaining diagnoses codes to see if any are classified as a CC or MCC and finalize the working DRG based on the value of the applicable secondary diagnoses.

Editor’s Note: Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, CDI Education Director for HCPro Inc., answered this question. Contact her at For information regarding CDI Boot Camps offered by HCPro visit

Q&A: Querying for CHF for systolic/diastolic specificity

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Q: After reviewing Coding Clinic for ICD-9-CM, First Quarter 2014, p. 6, regarding heart failure and preserved or reduced ejection fraction the coding department began querying for a direct link between congestive heart failure (CHF) and the systolic/diastolic dysfunction that is often times noted in the medical record, but not directly linked to the CHF diagnosis.

For example, CHF is documented in the history of present illness as the reason for admission. The attending consults cardiology and cardiology’s progress note states severe systolic dysfunction. Our coders are now directed to query for the type of CHF and not just acuity in this example. Also going forward, if documentation in the electronic health record states acute CHF on line 1 and systolic dysfunction is on line 4, coding will query for systolic CHF.

Our coding department did submit a related question on this matter to AHA Coding Clinic for ICD-9-CM Editorial Board but they are no longer accepting questions related to ICD-9-CM since they have already transitioned to ICD-10-CM/PCS advice.

So we were hoping that you might have some advice as to whether such queries were actually necessary or whether the coders can go ahead and code for the type without a query.

A: There is no need to query when the chars states the type of dysfunction(systolic, diastolic, or combined) concurrently with a diagnosis of CHF, according to Coding Clinic for ICD-9-CM, First Quarter 2009, p. 8. If CHF is documented by a clinician in notes, history of present illness, consult, etc., and ‘systolic dysfunction’, as one example, is written in a similar fashion during the same episode of care, we do not query for linkage.

Editor’s Note: Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity at Sutter West Bay, in  San Francisco, answered this question in the ACDIS discussion forum CDI Talk.

Q&A:Work with physicians to iron out clinical indicators for clarifying COPD

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Have a question that is troubling you and your team? Ask us!

Q: We have a problem getting our physicians to understand what we are querying for (chronic respiratory failure) when a patient is on home oxygen continuously with documented supplementary oxygen (SpO2) of <90% or arterial blood gas (ABG) with hypoxemia documented. They tell us Chronic Obstructive Pulmonary Disease (COPD) is chronic respiratory failure by definition. Can you help us clarify this or give us some tips on how to educate our physicians?

A: I see two pieces of education as needed in this situation. First, we need to establish the diagnostic criteria for chronic respiratory failure. Many physicians do consider COPD as chronic respiratory failure. But not every patient with COPD requires continuous oxygen support. Some require oxygen at night only, others only as needed, and others do not require oxygen at all.

If your organization has not developed an agreed upon definition of both acute and chronic respiratory failure maybe now is the time to do so. Work with your pulmonologist to define these terms with examples of the clinical indicators needed to make the diagnosis. These clinical indicators would then be the standards the CDI specialists and coders would use to determine if a query is needed as well. Once you have an agreed upon criteria, you can use it as part of your physician education.

Examples of diagnostic criteria for chronic respiratory might include:

  • Persistent decrease in respiratory function
  • Chronic continuous home oxygen
  • Chronic hypercarbia due to respiratory condition (i.e. pCo2>40)
  • Use of chronic steroids for underlying lung pathology
  • Polycythemia

Secondly, physicians need to understand wording such as “end stage lung disease,” “severe lung disease,” or use of the GOLD staging for COPD does not lead to a code assignment that reflects chronic respiratory failure. Using the clinical indicators such as those above, discuss with the physicians that not every person with COPD meets such criteria. Some are more severe than others, and as mentioned above not all require oxygen. Not all require chronic steroid use.

A patient with chronic respiratory failure has a higher severity of illness (SOI) and risk of mortality (ROM). These patients have a much lower threshold to enter acute respiratory failure. They can decompensate very quickly. The physicians may not understand why the wording of chronic respiratory failure is so important.

We need to ensure the physicians understand how important it is to capture the SOI/ROM that accurately reflects their patients’ conditions. This will affect both the quality measures assigned to the organization and to the physicians.

I hope this information helps. Please let me know if you need further assistance and also if you discover a “magic cure” to this documentation issue.

Q&A: Fluid overload in ESRD patient

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Q: I need help identifying the principal diagnosis for the following situation. The patient presented with shortness of breath and hypoxia, and had emergent dialysis which resolved his symptoms. However the patient’s international normalized ratio (INR) was sub therapeutic due to his end stage renal disease. A high dose of warfarin had to be given, and the patient was admitted as inpatient. I am trying to decide if this would be a principle diagnosis of fluid overload (276.69) or abnormal coagulation profile (790.92)

A: The patient had fluid overload, was emergently dialyzed, and “symptoms resolved post dialysis” which suggested to me that the fluid overload was resolved, and they were prepared to discharge the patient. However, the INR was noted to be too low, and it was not possible to bridge with Lovenox injections on an outpatient basis, so needed to be admitted to manage the anti-coagulation (get the INR to goal levels).  So, the reason for the patient becoming an inpatient was the INR, not the fluid overload that was resolved prior to the decision to admit, so I would go with 790.92.

Editor’s Note: This question was answered by ACDIS Advisory Board member Donald A. Butler, RN, BSN, CDI Manager at Vidant Medical Center in Greenville, N.C. Contact him at

Q&A: Accounting for SOI/ROM in neonatal death

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You’ve got questions? We’ve got answers.

Q: I am looking for help on reviewing a neonatal intensive-care unit (NICU) death chart for severity of illness/risk of mortality (SOI/ROM). Prior to birth the child was diagnosed with a severe brain abnormality, holoprosencephaly. The family decided upon comfort care once the baby was born, at which time (37 weeks) the child weighed 2207 grams, small-for-gestational age. The hospital kept the child comfortable until it passed the same day as the birth. The physician documented that baby would experience apnea and bradycardia as part of the dying process. The nursing flow sheet confirms the apnea and bradycardia but the physician did not actually document these conditions, only that the baby would be expected to experience them.

This baby was delivered and essentially treated as a hospice patient. All interventions were geared at comfort. As the case stands the SOI/ROM would be 1/1.

I could use some help identifying some possible diagnoses besides the regular birth codes, the anomaly codes, and the V66.7 code? Can we query for respiratory failure even though it is part of the dying process?

A: A query for respiratory failure would probably not be appropriate as the baby was comfortable, says Kerry Seekircher, RN, BS, CCDS, CDIP, Documentation Specialist Supervisor at Northern Westchester Hospital in Mount Kisco, NY. “If the baby struggled, was intubated, or placed on high flow oxygen, that would be different,” says Seekircher who reviews all NICU charts at her facility and suggests double checking all interventions not geared at comfort to assess for a possible diagnosis.

Additionally, a diagnosis of likely, suspected, evidence of… 348.82 brain death might be an effective query target, suggests Karen Bridgeman MSN, RN, CCDS, CDI educator, at Medical University of South Carolina in Charleston. Bridgeman points to Coding Clinic for ICD-9-CM and to the National Association of Children’s Hospitals and Related Institutions (NACHRI) specific request for a unique code for brain death.

She cautions that the physician did not document any brain death criteria, however, if such a diagnosis proved appropriate it could move the SOI/ROM to 3/4.

Also look to the 764-779 codes, for “other condition originating in the perinatal period,” suggests Jolene File, RHIT CCS, CPC-H, CCDS, CDI specialist at Hays (Kansas) Medical Center, since such codes incorporate fetal weight, gestation, birth trauma, hematological disorders, etc.

“These NICU cases are difficult to code and, if not well documented, very difficult to know what to query for appropriately,” File says.

Editor’s Note: This Q&A exchange was adapted from CDI Talk, the ACDIS list serv and networking site.

Q&A: Documentation for body mass index

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Q: I’m in a little debate: Does documentation of the patient’s body mass index (BMI) need to come from an ancillary clinician like the dietitian or nurse? I thought that we could use such ancillary documentation for clinical indicators supporting our physician query but that the treating physician needed to document the BMI. Can you help clarify this for me?

A: Documentation of the BMI can be taken from either the physician or a nonphysician (such as a dietitian or nurse). It is usually taken from the documentation a nurse or dietician as this has become a standard piece of their admission assessments. (Nursing staff routinely will weigh the patient during admission.)

The important piece to remember is that the physician must first document the clinical condition (such as obesity) to allow us to then code the BMI. For example a BMI of greater than 40 will provide a CC. But we cannot not code the BMI of greater than 40 without first having the documentation of the obesity from the physician. Obesity alone will not provide a CC.

Q&A: Do not alter queries after issuing

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Ask us a question by leaving a comment here on the ACDIS Blog.

Q: Is it is okay to alter, add to, or take back a query form after the physician answers it?

A: There are two basic situations that support the need for a query.  The first and most common situation is when there is evidence of an incomplete, vague, or missing diagnosis based on clinical indicators in the medical record.  The other situation is when a diagnosis is documented that is not supported by clinical evidence.  There is a nuance to this type of situation.

It isn’t for the CDI or coder to define the condition with particular clinical indicators nor is Coding Clinic a definitive source for clinical indicators, rather my litmus test is whether or not other providers would come to the same conclusion based on the same clinical evidence.

For example, although many providers are using American Society for Parenteral and Enteral Nutrition (ASPEN) criteria to support the diagnosis of malnutrition, it is not incorrect for a provider to make that diagnosis based on albumin levels as that was an accepted clinical indicator for years so other providers would likely come to the same conclusion based on the same evidence.  Remember CDI and coders are not diagnosticians and our role is not to judge the quality of care, but to ensure that a diagnosis meets the definition of a reportable diagnosis before assigning a code (e.g., meets the definition of a principal or secondary diagnosis, is documented by a provider who is delivering direct patient care, is related to this episode of care, is not integral to another condition, etc.)

I cannot think of a situation where it would be acceptable to alter a query or remove a query once the provider addresses it. I would go one step further and suggest even if the provider does not answer the query, it would be inappropriate to alter or remove it. Although organizations are not required to keep the query as part of the legal health record, they are at a minimum, supposed to keep it as part of the business record. A query is discoverable and should be made available to auditors as requested.  Verbal queries should be memoralized in the same format as written queries for the purpose of transparency.

My recommendation is to refer to the various AHIMA physician query practice briefs, which discuss standards of when to issue and how to construct a query. The latest industry standards developed in partnership with ACDIS, (Guidelines for Achieving a Compliant Query Practice) builds on the briefs and collective knowledge of government payment, compliance, and auditing practices.  This 2013 document stresses that the reason for the query is as much, if not more, significant than the construction of the query.

Queries are vulnerable to scrutiny for several reasons.  Below are a few examples.

  • Were there sufficient clinical indicators to justify the query?
    • The threshold I use for this type of query is would other providers come to the same conclusion based on the same evidence.  It is important that CDI use evidence based criteria that is consistently throughout the health record when asking for a diagnosis to be added to the health record especially if that diagnosis would impact reimbursement or quality data
  • Is the documentation open to interpretation?
    • Would all coders reviewing the record come to the same conclusion and apply the same codes or would it be subjective?  If there is too much variability among how the documentation could be translated then a query is necessary for clarification.
  • Do coding guidelines require specific documentation like a cause-and-effect relationship?
  • Is it clear which condition is the principal diagnosis or is it an unusual occasion where more than one diagnosis could be the principal diagnosis?
    • This is a more recent phenomenon as CMS further clarifies what kinds of conditions can support an “admission” to inpatient care compared to a condition that can be treated in the outpatient/observation setting
    • There are several references throughout the coding guidelines and from CMS educational tools that state if it is not clear which is the principal diagnosis the provider should be queried

Additionally, the 2013 document recommends if the provider documents on the query form itself, then it should be retained as part of the permanent health record.  If the query is part of the health record then it must comply with all authentication requirements associated with the medical record.  I know of no situation where a record can be altered following provider validation except by the provider when it is clearly identified as an addendum or alternation.  Your CDI program/organization in consultation with the medical staff should determine whether to keep queries as a permanent part of the legal health record or not.  I do recommend, though, if the coder’s query are part of the health record then the CDI queries should also be part of the health record as it would be difficult from a compliance standpoint to justify why one is part of the health record and the other is not.

However, even if the query form is not governed by authentication requirements associated with the legal health record because it is only part of the business record, it would be inappropriate to alter a document validated by another. I think it would also be an ethical issue as the integrity of the CDI and the provider could be affected by altering a document that was already addressed. The impact of a query is usually recorded as a CDI performance metric. Most CDI departments monitor queries for:

  • Response rate
    • Did the provider responded even if they disagreed
  • Agreement rate
    • Did the query result in a change in the health record
  • Effect on the claim
    • Did the query impact reimbursement and/or quality

Therefore, altering a query could alter CDI metrics.  It could also mask CDI performance issues such as not understanding when a query is warranted as well as issues with query construction.  The best course of action would probably be to “close” the query and then reissue a new query with the new and/or updated information; however, this may be frustrating to the provider if they already responded once to a similar query.  A query that requires additional revision after submitting it to the provider may be a learning opportunity for the CDI constructing the query so they are able to be more precise and accurate the next time they construct a similar query.

Hope this helps!