Inpatient Facility Coding & Compliance Alert

Question: A patient was admitted through the Emergency Department with fluid overload. He has ESRD and missed his dialysis last week. The patient also has a history of congestive heart failure (CHF) along with systolic dysfunction and diastolic dysfunction. Now the patient also has exacerbation of CHF. Other medical conditions include hypertension, diabetes mellitus, and gout. Could you please guide us regarding the best choice for principal diagnosis in this scenario?

Delaware Subscriber

Answer: Both ESRD and acute onset chronic systolic and diastolic dysfunction (CHF) are coequals for principal diagnosis. They both can cause fluid overload, especially for this patient who missed his dialysis. Secondary diagnoses would be diabetes mellitus and gout.

Hopefully, the patient was treated with hemodialysis during this admission as a procedure. If so, link diagnosis 404.92 (Hypertensive heart and chronic kidney disease, unspecified, without heart failure and with chronic kidney disease stage V or end stage renal disease) as the principal diagnosis (you’ll choose this diagnosis that doesn’t specify CHF since you don’t mention having physician documentation linking the CHF and hypertension). Diagnosis 585.6 (Chronic kidney disease, stage V requiring chronic dialysis) should be your secondary. Then list the appropriate diagnoses for CHF, diabetes, and gout, depending on the specific condition.

You have more details about the situation than listed in your question. Go through the documentation to verify which medical condition has a higher DRG weight for coding purposes. If you aren’t sure, query the doctor about what caused the fluid overload so you can code accurately.