# principal vs secondary dx



## Lekishak (Jul 5, 2010)

A 34 y/o male was admitted to the hospital with a three day history of visual changes in his right eye including intermittent blurring, light flashes, and “seeing spots”.  The physician documented the following in the H&P:  history of HIV currently on HAART; Pneumocystis carinii pneumonia in 2006 labs one month ago showed increased viral load and CD4 count of 100.  Severe lumbar degenerative disc disease with narcotic dependence was also noted.  The Ophthalmology service was consulted and diagnosed retinitis.  Eye cultures collected on admission reported Cytomegalovirus. The patient was treated with IV Gancyclovir and Similasan eye drops.   Duragesic patch was placed for management of chronic back pain, and the patient was instructed to discontinue all previously prescribed pain medications.  A PICC was placed and the patient was discharged to home health to continue IV antivirals.   Final diagnoses per DS:  CMV, DDD.    

Principal diagnosis code:

Secondary diagnosis code(s):  

ICD-9-CM procedure code(s):   

DRG: 


I was informed to code 042 for the principal dx. My opinion was the pt came in for an eye problem (CMV) and not the HIV. I get confused with that part. The secondary dx also confused me and how to properly list them.  I chose the CMV,DDD as secondary. I also coded the retinitis (would that be too much)? Should I leave that one out due to signs and symptoms? I coded the PICC line insertion as my procedure code. Don't know if that was correct. If I missed any related secondary dx, please inform me. Any help on this doozie would be greatly appreciated. Don't worry about the DRG portion if you don't have access or understand it.

Thanks


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## mitchellde (Jul 5, 2010)

Are coding for the physician or hospital?  The principle is the 042 at the CMV is an HIV related illness, check your guidelines you code the HIV as first-listed if the main dx is a manifestation of the HIV.  Do not code the retinitis as it is a symptom and you have the definitive.  Do code the DDD as a secondary dx.  code the PICC line only if coding for the facility not for the physician.


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## Lekishak (Jul 5, 2010)

Principal diagnosis code: 042

Secondary diagnosis code(s):  DDD, CMV

ICD-9-CM procedure code(s):   38.93 OR SOMETHING, I'll correct later 

DRG: 


Is this the correct format? I'm testing without using encoder or other outside material other than my coding books. I have my CPC-H, but don't use any other books other than my ICD-9 book for employment with Medassurant. I've been working with them for 2 years now. I need to know how to code actual inpatient/outpatient charts for other prospects. All I do now is HCC coding. Do you know of any other resouces I could use for more practice on inpatient billing? 


Thanks


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## kevbshields (Jul 5, 2010)

It appears this is an IP chart and 042 would be the appropriate ICD for the PDX, as CMV is considered a complication of HIV/AIDS.  Also, the patient CD4 count is less than 200, clinically meeting the threshold for AIDS.

Now, ICD guidelines have not caught up with the clinical realm of HIV treatment, in that under ICD guidelines, once a patient is coded to 042, he/she is always coded to 042.  Clinically, based on recent literature, folks who may initially have increased viral load counts, and CD4s less than 200 (thus classified as 042) sometimes rebound to decreased viral loads and greater CD4 counts--technically no longer meeting the definition of AIDS.  Yet, we continue to ignore those clinical pointers (under the auspices of the current ICD guidelines) and code them to 042.  

Regardless, 042 is always coded as principal when it occurs in the setting of an HIV-related illness.  If you're using the Ingenix ICD-9 Hospital Expert, the HIV-related illnesses are easy to identify as they have an "HIV" notation beside the code.  Hope this is of assistance.


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