Health Information Management

Avoid incorrectly applying Coding Clinic guidance

JustCoding News: Inpatient, March 17, 2010

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The American Hospital Association’s Coding Clinic is the bible of coding, providing guidance and direction for a wide variety of clinical scenarios. By responding to specific coding questions the HIM/coding community submits, Coding Clinic provides guidance that coders often use as a basis for code assignment. Our natural instinct is to refer to Coding Clinic when uncertain about code assignment, sequencing, and/or additional diagnoses.

But coders must remember one important fact: Coding Clinic guidance may not necessarily be relevant or appropriate to your clinical scenario at hand.

Consider two scenarios

Coding Clinic guidance is often based on a specific clinical case that a member of the coding community submits to the publication. Therefore, Coding Clinic guidance does not necessarily apply universally, and it’s important to bear in mind the context of the original question.

Consider the following clinical scenario for a hospital patient:

A 79-year-old patient with known bladder cancer that was previously resected six months prior presented to the emergency room with a chief complaint of severe, ongoing abdominal pain of unrelenting nature. It was noted the patient had significant abdominal distension with the nursing home personnel indicating the patient was not making any urine over the course of the last three to four days. Laboratory values were notable for the following: WBC 14, Potassium 6.8 (critical value), Bun 54/Cr 5.6, and calculated Glomerular Filtration Rate 18.

Patient had no known chronic renal failure according to his outside primary care physician. Radiology work-up indicated the patient was experiencing significant hydronephrosis resulting from the bladder cancer locked ureter, causing acute renal failure (ARF) with oliguria, and oliguric ARF with poor prognosis. The physician treated the patient’s life-threatening hyperkalemia with IV insulin and Kayaxalate. The patient and the patient’s family refused emergent dialysis to address the ARF. Instead the patient elected to undergo a percutaneous nephrostomy tube as a conservative measure as part of decision to enter the hospital’s hospice program.

Final diagnoses as charted in the record by the resident and attested to by the attending physician included:

  • ARF
  • Bladder cancer recurrent
  • Ureter obstruction and hydronephrosis second to the recurrent bladder cancer

The procedure performed: Percutaneous nephrostomy tube

For this clinical scenario, the coder assigned a principal diagnosis of bladder cancer (code 188.9) with secondary diagnoses of ARF (code 584.9), hydronephrosis (code 591), and ureteral obstruction (code 593.4). This resulted in assignment of MS-DRG 656: Kidney and ureter procedures for neoplasm with MCC.

As a result of a DRG-validation review, an auditor questioned the principal diagnosis selection based on the patient’s clinical presentation and medical management.

The coder proceeded to reference Coding Clinic, second quarter, 1997, p. 4, to substantiate the appropriateness of ARF due to obstructive recurrent bladder cancer as the principal diagnosis in this clinical scenario.

However, the question posed in this Coding Clinic was regarding the principal diagnosis selection of a patient who was admitted with obstruction of the ureter secondary to intra-abdominal metastasis from a previously resected cancer. The physician placed a nephrostomy tube to relieve the obstruction, and provided no other therapy to the patient as part of clinical management and treatment. Coding Clinic’s response guided coders in this case to assign:

  • Principal diagnosis: Code 198.89 (Malignant neoplasm of other specified sites)
  • Secondary diagnosis: Code 593.4 (Other ureteric obstruction)
  • Procedure code 55.02 (Nephrostomy)

Understand the differences

Let’s take a closer look and compare the scenario presented above versus the scenario referenced in the Coding Clinic.

The 79-year-old hospital patient was admitted in oliguric ARF with life-threatening hyperkalemia at serious risk for ventricular tachycardia with ventricular fibrillation if the provider did not address and quickly correct the significant hyperkalemia. The patient’s kidneys were in the process of shutting down and as part of a conservative medical management, the patient underwent a nephrostomy tube to relieve the hydronephrosis from the obstructed ureter related to bladder cancer contributing to the acute renal failure. The patient refused emergent dialysis for the ARF and hyperkalemia.

So what is the principal diagnosis after study and work-up that occasioned this patient’s admission to the hospital? Using the Coding Clinic, second quarter, 1997 reference, is the principal diagnosis bladder cancer with ureteral obstruction? Or is the principal diagnosis ARF? Does this hospital patient’s clinical scenario include any unique features or “twists” that allow the coder to conclude that the Coding Clinic guidance may not be completely relevant to this particular case?

A closer look at the clinical facts reveals that the Coding Clinic guidance is not applicable to this case.

As clearly documented in the record the patient was admitted with obvious oliguric ARF and life-threatening hyperkalemia. The precipitating factor in all of this is the patient’s recurrent bladder cancer causing ureter obstruction.

When comparing this clinical scenario to the one described in the Coding Clinic, coders should easily infer that the guidance is not applicable in principal diagnosis selection for this particular case. One must assume the patient described in the Coding Clinic presented with a clear cut case of ureteral obstruction secondary to intra-abdominal metastasis with no other documented sequel of obstruction such as ARF. Therefore, although these two cases are similar in nature, they have distinct clinical differences that the coder must take into account.

The most clinically relevant and appropriate principal diagnosis after study and work-up is ARF with assignment of recurrent bladder cancer, ureteral obstruction, and hydronephrosis as secondary diagnoses. The appropriate resulting MS-DRG is 660: Kidney and ureter procedures for non-neoplasm with CC.

Remain cognizant of important tasks

Coders must adhere to official coding guidelines, policies, procedures, and guidance Coding Clinics provide, but it is equally important that they remain cognizant of the clinical presentation and treatment and management of the patient.

To execute their jobs, coders must:

  • Build, expand, and apply clinical knowledge and acumen in the review of the record 
  • Assess the accuracy and completeness of the clinical documentation
  • Ensure a thorough understanding of the clinical processes documented 
  • Seek clinical clarification from the attending physician when appropriate
  • Research any unrecognized clinical disease processes through research either via the Internet or other literature

Only after completing these relevant, salient tasks can coders accurately apply and adhere to pertinent official coding guidelines and appropriately follow Coding Clinic advice.

To do otherwise constitutes “coding in a vacuum,” which is certainly a recipe for inaccurate code assignment and potential financial recoupements by government auditors as well as third-party payers.

Editor’s note: Krauss is an independent coding consultant in Milton, WI. E-mail him at

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