Health Information Management

Q&A: Coding and sequencing clarification

CDI Strategies, April 21, 2016

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Q: I have a patient with Stage 4 lung cancer that presented with fatigue, cough, and loss of appetite. Initially, they thought he had pulmonary nodular amyloidosis (PNA) but when they did an echo-cardiogram on day one they found a pericardial effusion (malignant). The initial report says no tamponade. The next day the patient had a cardiac arrest. Given the pericardial effusion, they did a bedside echo during resuscitation. This showed right atrial collapse and performed an emergent pericardiocentesis for pericardial tamponade. The patient was resuscitated but deemed terminal and later died. No definitive treatment was directed at the lung cancer.
We are discussing two concerns related to this case:
  1. How to code the effusion: Our coder thinks it may be appropriate to only code C7989 (secondary malignant neoplasm) but I think that I39.3 (pleural effusion) should be coded.
  2. Sequencing: Our coder assigned C7989 as the principal diagnosis. If we code I39.3, would that end up being the principal? The Official Guidelines for Coding and Reporting say that complications of neoplasm should be listed as principal.
Any suggestions or thoughts you might have would be greatly appreciated.
A: J91.0 (Malignant pleural effusion) is a manifestation code and cannot be sequenced as the principal diagnosis, says Sharon Salinas, CCS, Health Information Management, at Barlow Respiratory Hospital in Los Angeles.
“The underlying condition is to be sequenced first, per the National Institutes of Health, malignant pericardial effusion is also a manifestation so I think the lung neoplasm might have to be the principal – if that is the underlying cause,” Salinas says.
Look also at ICD-10-CM code I30.9 for acute neoplastic pericardial effusion present on admission (POA) plus the C code for secondary malignancy POA and finally, pericardial tamponade, not POA, suggests Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
Gold points to a AHA Coding Clinic for ICD-9-CM, Second Quarter, 1989, which directs coders to the Alphabetic Index entry for effusion, pericardium, which has a note to “see also pericarditis,” and leads to options of pericarditis (with effusion), neoplastic (chronic), and acute.
“The physician should be asked if, in this particular instance, the pericarditis is acute or chronic in nature. One of the causes of noninfectious pericarditis with effusion is a tumor, either a primary tumor (benign or malignant) of the pericardial site, or a tumor metastasizing to the pericardium (commonly carcinoma of the lung or breast and lymphomas),” says Gold.
Unfortunately, says Salinas, ICD-10-CM lost some specificity for situations like this. Code I313, for pericardial effusion isn’t specifically for malignant pericardial effusion but comes close. Code J91.0, is a manifestation code and cannot be sequenced as principal diagnosis.
“I would query for acuity and for underlying cause of effusion (primary, metastatic, other, undetermined. I think you need both queries to determine the principal,” she says.
Editor’s note: This QA is an example of the information shared daily amongst ACDIS members on CDI Talk. Join the conversation and make the most of your ACDIS membership.


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