Health Information Management

Article of the month: Avoid sequencing oversights

CDI Strategies, February 18, 2010

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by Robert S. Gold, MD
Every so often, I come across some coding issues that recall other coding issues. I found this situation within the last few weeks and it deserves some discussion.
A baby arrives at the hospital with weight loss. The baby can’t keep anything down. The pediatrician and the baby’s mother tried various dietary modifications, size of feeding, and various formula changes—they eliminated breast milk, tried soy products, fed the baby small amounts of food frequently, fed the baby large amounts a few times a day, and added a little farina to thicken the feeding. Nothing worked. The child’s weight continued to decrease as the baby became more malnourished. Eventually, the baby became sleepy, and weak, and dehydrated.
The child was admitted to the hospital for workup. IV fluids were administered and parenteral nutrition started to provide the baby with some caloric intake. Pediatric GI studies showed a significant sliding hiatal hernia and the baby underwent Nissen fundoplication. Success! Feeds were retained, the patient started gaining weight, all was well. The baby was discharged.
Coders evaluated the chart and dehydration (276.51) and malnutrition (263.9) were assigned as the first two diagnoses, with hiatal hernia (750.6) with gastroesophageal reflux (530.81) as subsequent diagnostic information. The case grouped to MS-DRG 982, Extensive OR Procedure Unrelated to Principal Diagnosis with CC.
A typical CDI specialist might think this scenario played out appropriately. Cool, right? We know MS-DRG 982 is a good-paying DRG (with a relative weight of 2.8954). So, it must be right. After all, that’s what brought the patient into the hospital, right?
The malnutrition and the dehydration were symptoms, manifestations of a disease process. After workup, treating physicians discovered the hiatal hernia with significant esophageal reflux, so that became the diagnosis after workup and must be considered the principal diagnosis.
Re-sequencing the diagnoses properly, then, the MS-DRG assignment is now 327, Stomach. Esophageal and Duodenal Procedures with CC (with a relative weight of 2.7062). Sure, it’s a DRG that reimburses less, but clinically speaking it is the correct DRG.
If you consider the co-principal diagnosis argument and the fact that you can sequence either first, the following concepts apply:
Co-principal diagnoses are equally serious and equally treated. In our case, one was treated with an IV and fluids and calories, the other with a trip to the operating room. Is this equal?
 The definition of principal diagnosis. Do not sequence a symptom of the diagnostic entity first (unless sequencing guidance prevails, such as only treating the symptom or sequencing of acute respiratory failure and its cause, etc.)
Note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement, and an ACDIS Board Member. Reach him by phone at 770/216-9691 or by e-mail at
Read the complete February ACDIS Article of the Month online at, or view the complete archive collection of ACDIS Articles of the Month under the ACDIS Helpful Resources section.

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