Inpatient Facility Coding & Compliance Alert

Question: A patient was admitted with fluid overload. He has ESRD (end stage renal disease) and missed his dialysis last week. He also has a history of congestive heart failure (CHF) with systolic and diastolic dysfunction. Now the patient also has exacerbation of CHF. Other medical conditions include hypertension, diabetes, and gout. How do we choose the primary diagnosis in this scenario?

Michigan Subscriber

Answer: Both ESRD and CHF are co-equals for primary diagnosis. They both can cause fluid overload, especially since the patient missed his dialysis. Check the documentation for notes linking the CHF with hypertension (such as "CHF due to HTN" or "CHF secondary to HTN"). If so, narrow your choices to the appropriate code for hypertension with congestive heart failure and ESRD (such as a choice from 404.x, Hypertensive heart and renal disease).

Also include diabetes (250.x) and gout (274.x) as secondary diagnoses.