Health Information Management

Consider published clinical references when appealing denials of coding for serious conditions

JustCoding News: Inpatient, April 28, 2010

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by Joel Moorhead, MD, PhD

The attending physician documents suspicion of sepsis on the history and physical examination and lists sepsis as the principal diagnosis on the discharge summary. The coder then sequences sepsis as principal diagnosis with confidence that he or she has chosen the correct code, only to receive a denial letter from the Recovery Audit Contractor (RAC) disputing the diagnosis of sepsis. How can the RAC contradict the attending physician's documented clinical judgment of the principal diagnosis?

Clear physician documentation of serious medical conditions is necessary to achieve accurate coding. But unfortunately even when the documentation physicians provide in the medical record is clear, it is still sometimes insufficient, as illustrated above when the RAC did not find clinical justification for the diagnosis of sepsis. The American Health Information Management Association (AHIMA) Standards of Ethical Coding (September 2008) advises coders to “assign and report only the codes and data that are clearly and consistently supported by health record documentation.”

By questioning a physician’s diagnosis, RACs and other auditors are putting coders in the awkward position of having to judge the accuracy of a physician’s diagnosis when assigning codes, some of which correspond to life-threatening medical conditions. Coders may feel justified in feeling some discomfort with this unreasonable expectation, not having been to medical school or having the responsibility for diagnosing and treating patients.

Fortunately, guidelines available on various Web sites offer definitions of some common serious medical conditions. When key medical record entries correspond closely to published criteria for the patient's diagnosis, coders may be able to code the diagnosis stated by the attending physician without need for clarification. If not, coders may need to query the physician. Let's look at sepsis first.

SIRS or sepsis
The American College of Chest Physicians/Society of Critical Care Medicine Consensus panel guidelines define systemic inflammatory response syndrome (SIRS) as two or more of the following:

  • Temperature of greater than 38°C or less than 36°C
  • Heart rate greater than 90 beats per minute
  • Respiratory rate greater than 20 breaths per minute
  • White blood cell count greater than 12,000/μL or less than 4,000 /μL, or greater than 10% bands

The ICD-9-CM Tabular List and several Coding Clinics, including Coding Clinic Fourth Quarter 2008, can guide coders in selecting the most accurate codes to identify SIRS and sepsis. Two or more of the above consensus criteria are commonly present in patients diagnosed with SIRS or sepsis.

The eMedicine article “Multisystem Organ Failure of Sepsis” also addresses signs of associated organ dysfunction that can support a physician diagnosis of severe sepsis (code 995.92) or SIRS due to noninfectious process with acute organ dysfunction (code 995.94). These signs include but are not limited to:

  • Altered mental status
  • Hypotension
  • Acidosis
  • Hypoxia
  • Elevated liver function tests
  • Decreased urine output

Decreased urine output is also one of the signs of acute kidney injury.

Acute kidney injury
The attending physician documents acute kidney injury (a more recent term corresponding to acute renal failure) and that the patient's creatinine is only 1.6 mg/dL. Does a serum creatinine of only 1.6 mg/dL support a diagnosis of acute kidney injury? It depends on the circumstances of admission.

The Acute Kidney Injury Network proposed definition for acute kidney injury includes at least one of the following criteria:

  • Increment of serum creatinine greater than or equal to 0.3 mg/dL or 50% from baseline within 48 hours
  • Urine output less than 5 mL/kg/hour for greater than six hours despite fluid resuscitation when applicable

These criteria are based on the observation that small changes in renal function predict important clinical outcomes, such as mortality rates and median length of hospital stays.

A patient's baseline renal function and documentation of how rapidly the patient's renal function has declined are important factors in assessing support for a diagnosis of acute kidney injury. For example, if a patient's creatinine had started out at a baseline of 0.9 mg/dL and rose quickly under circumstances supportive of a diagnosis of acute kidney injury, the attending physician's diagnosis may be well-supported.

Severity of malnutrition
Laboratory values in the medical record can also support accurate coding of another serious medical condition—malnutrition.

Consider a case in which a patient is underweight and has a low serum albumin. Among the diagnoses documented on admission and at discharge, the attending physician lists malnutrition. Should the coder report malnutrition, unspecified (code 263.9) or is a different code more consistent with coding guidelines?

Coding Clinic May–June 1984 advises that measures for coding accuracy include "attention to specificity in code selection where indicated by physician documentation in the medical record." ICD-9-CM classifies malnutrition according to severity with the following codes:

  • Code 263.1 (mild malnutrition)
  • Code 263.0 (moderate malnutrition)
  • Code 262 (severe malnutrition)

The Merck article, "Protein-Energy Undernutrition (PEU)," includes a table of guidelines for grading undernutrition by severity.

This article introduces PEU, stating that it was previously called protein-energy malnutrition. Table 3 in the article, under the heading "Values Commonly Used to Grade the Severity of PEU," provides the following values that correspond to mild, moderate, and severe undernutrition (i.e., malnutrition):

  • Percent of normal weight
  • Body mass index (BMI)
  • Serum albumin
  • Serum transferring
  • Total lymphocyte count
  • Delayed hypersensitivity index

For example, weight <75% of normal weight, BMI <16, and serum albumin <2.4 are consistent with severe undernutrition, according to this table.

The October 2008 AHIMA practice brief, "Managing an Effective Query Process," advises coders to query physicians "when there is clinical evidence for a higher degree of specificity or severity." A query for severity may be reasonable when clinical findings indicate that a nutritional status consistent with severe malnutrition is possible. (To view this practice brief in its entirety, click here. Then click on “All current practice briefs in chronological order by publication date” and scroll down to the brief.)

Editor’s Note: Joel Moorhead MD, PhD is an Adjunct Assistant Professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Baltimore, MD. E-mail him at

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