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Q&A: Parsing out the principal diagnosis in possible coronary patient

CDI Strategies, April 2, 2015

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Q: A patient came to the emergency department with shortness of breath (SOB). The admitting diagnosis was possible acute coronary syndrome (ACS) due to SOB and elevated troponin levels. The ACS was ruled out. Elevated troponin levels were assumed to be due to chronic renal failure (CRF), and no reason was given for SOB. Before discharge, the patient was noted with an elevated temperature and found to have a urinary tract infection (UTI). All treatment was directed at the UTI, and the doctor noted the discharge diagnosis as the UTI. What would be the principal diagnosis in this case?

A: Without knowing all the specifics, I would say the UTI could not be taken as the principal diagnosis. For the UTI to be the principal diagnosis, we would need to query for two pieces of information.

The first issue would be whether or not the UTI was present on admission. From this description, it does not was appear to have been present on admission; yet the symptoms appear before discharge.

The second concern would be to determine whether the UTI was somehow linked to the patient’s presenting symptoms. A UTI and SOB is a difficult connection to make.

If we eliminate the UTI as a choice, even if the majority of treatment was directed towards to the UTI, we have little to work with. I would query for the probable or likely cause of the SOB. If the provider answers with a definitive diagnosis then this would be your principal diagnosis. If not, the symptom of SOB would be your principal diagnosis.

The bigger concern with this patient might be that the wrong status was assigned. This patient most likely should have remained outpatient and placed in observation status until a more definitive diagnosis could be found warranting an inpatient admission.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview. The next Boot Camp will be held April 27-30, 2015 in Washington, D.C.

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