AUDIT DISCUSSION CASES CLINICAL CODING ADVISORY GROUP WA. January Performance Activity and Quality Division

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1 AUDIT DISCUSSION CASES CLINICAL CODING ADVISORY GROUP WA January 2013 Performance Activity and Quality Division

2 Audit cases from the ADRG 801 audits will resume in March and April In the meantime refinements of the Diabetic Foot classification guidelines (December Q&A) make discussion of the following diabetic foot cases timely: The clinical classification guidelines for diabetic foot were recently modified to emphasise that the principal diagnosis remains subject to the after study rule. The following cases were found in WA Teaching and metropolitan Non-teaching Hospitals immediately after the introduction of the new diabetes rules (July 2012). They illustrate that coders need to be mindful of: the WA Coding Committee advice on Diabetic Foot (see Appendix 1). ACS 1210 (see Appendix 2) the after study principle (see Appendix 3). PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 2

3 CASE: 01 Admission Date: 25/7/2012 Separation Date: 28/7/2012 ORIGINAL AUDIT PRINCIPAL DIAGNOSIS L03.02 E11.73 Additional Diagnoses B95.6 L03.02 E11.42 B95.6 E11.73 E11.42 PRINCIPAL PROCEDURE Other Procedures DRG Version 6.0 ORIGINAL AUDIT J64B Cellulitis Cscc K60B Diabetes -Cscc wt: 0.63 wt: 0.97 Discharge Summary: Cellulitis Diabetes Mellitus Peripheral Neuropathy. Case History: 84 year old woman, known T2DM, admitted via ED Presenting complaint: red swollen painful toe, difficult weight bearing on background of DM2 and 3 weeks non-healing toe ulcer. On admission: ulcer/ cellulitis on dorsum of 3 rd toe, known peripheral neuropathy For IV antibiotics, ulcer dressings, + podiatry Podiatrist on ward: debridement (non-excisional) of ulcerated area toe, On discharge: XXXX Nursing Service to continue ulcer dressings. PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 3

4 CLASSIFICATION NOTES 1. The discharge summary makes no mention of the ulcer which is clearly present and clearly treated. In line with WA Coding Committee advice (Appendix 1), the clinician should have been asked to review the summary before coding, as principal diagnosis, cellulitis of toe (L0302). 2. The examples given in the ACS 0401 do not address ulcer and cellulitis both present on admission. Therefore they do not apply here. The sequencing remains subject to ACS 1210: ACS sequence the skin ulcer code as principal diagnosis, and the cellulitis as additional, if the ulcer is treated. The code for skin ulcer, of the foot/toe, where diabetic foot criteria are met, is: E1173 (diabetes with skin ulcer- multiple causes). This is then sequenced before the cellulitis L0302. Note: Failure to consider ACS 1210 (Appendix 2) can disadvantage the hospital. A medical admission for diabetic foot ulcer with neuropathy (E1173, E1142), even without cellulitis, arrives at K60B. 3. Documentation Issue: Reviewing the case in totality, this cellulitis appears to be associated with a foot ulcer, which itself is diabetic and likely neuropathic. The inadequate discharge summary should have been challenged to check if the principal diagnosis assigned is in line with the after study principle. For example, a principal diagnosis which would tie in all 3 elements of the summary, and include (from the inpatient notes) the ulcer, might be: Diabetic neuropathic foot ulcer with cellulitis PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 4

5 CASE: 02 Admission Date: 6/7/ 12 Separation Date: 26/ 7/ 12 ORIGINAL AUDIT PRINCIPAL DIAGNOSIS L024 E1173 Additional Diagnoses E1173 L024 E1151 E1151 E1122 E1122 N185 N185 I10 I10 T828 T828 Z8643 Z8643 PRINCIPAL PROCEDURE Other Procedures DRG Version 6.0 ORIGINAL AUDIT 801A OR Procedures Unrelated to Principal Diagnosis W/O CC K09B wt: 7.23 wt: 3.12 Other endocrine, nutritional, metabolic OR proc + Smcc Discharge summary: Foot abscess R) SFA / popliteal artery stenosis L) upper limb fistula stenosis CASE HISTORY: ED Notes: Via ED: 6/7/12 74 year old man, from XXX hospital, with foot ulcer Past medical history, DM 2, HT, ESRF on haemodialysis, ex smoker there is soft tissue infection of plantar ulcer, without osteomyelitis Inpatient progress notes: type 2 DM, admitted under Vascular Reg with non-healing foot wound. I&D is performed but the ulcer does not heal. The patient is found to have SFA popliteal artery stenosis and ultimately on day 12 goes for angioplasty. He is also on regular dialysis, but the AVF blocks. Theatre 1: incision and drainage of abscess foot: (anaesthetist: infected ulcer sole of foot) Theatre 2: balloon angioplasty popliteal and SFA stenosis Theatre 3: fistulogram and balloon venoplasty to AVF stenosis PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 5

6 CLASSIFICATION NOTES ACS 1210 does not apply here. There is no cellulitis. The original coding is challenged on the following grounds: 1) The discharge summary makes no mention of the ulcer which is clearly present and clearly treated. The ulcer fails to heal, extending the length of stay (LOS). There is associated PVD, treated on day 12, by angioplasty. Furthermore the abscess is actually an infected plantar ulcer. In line with WA instructions (Appendix 1), the clinician should have been asked to review the summary before coding abscess as principal diagnosis. 2). Documentation Issue: Reviewing the total episode, this abscess appears to be associated with a foot ulcer, which itself is both diabetic and likely ischaemic. The most unsatisfactory aspect of the discharge summary is that it fails to mention two of the critical LOS- extending variables: diabetes itself and a non-healing ulcer.. With an 801DRG resulting and therefore requiring justification, this documentation should not be accepted uncritically. The clinician should assess the principal diagnosis in light of the definition of principal diagnosis (ACS 0001) with particular attention to the after study principle (Appendix 3). For example, is this, after study, an episode of care chiefly occasioned by: infected (abscessed) ischaemic foot ulcer, in a type 2 diabetic? PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 6

7 CASE: 03 Admission Date: 14/07/2012 Separation Date: 26/07/2012 ORIGINAL AUDIT PRINCIPAL DIAGNOSIS L0311 L0311 S9082 S9082 B956 B956 E1165 R02 E1173 E1165 Z9222 Z9222 PRINCIPAL PROCEDURE DRG Version 6.0 ORIGINAL AUDIT J12C J12A Lower limb procs +ulcer/cellulits-ccc Lower limb procs +ulcer/cellulits+-ccc wt: 2.32 wt: 7.51 Discharge Summary: principal diagnosis: foot cellulitis other conditions: nil complications: nil CASE HISTORY A 54 year old woman, via ED. Presenting complaint: cellulitis right metatarsal, bleeding blister; foot versus cat bowl one week ago, seen by GP antibiotics commenced PMH: DM2 on insulin, HTN ED notes: from GP with grossly infected toe, wound swab : staph aureus on examination :discharging wound; no ulcer, admit for IV clindamycin, for review of medications. poor diabetic control Progress notes (day 1): diabetic foot ulcer; for bone scan? OM blister with granulating area; small area of necrosis under granulation, debrided (by RMO on ward) Bone scan: no Osteomyelitis Diamicron, Lantus and Metformin adjusted for better DM control. PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 7

8 CLASSIFICATION NOTES The criteria for diabetic foot ulcer are not met. Early in the progress notes the wound is described as diabetic foot ulcer. Diabetic foot ulcers can be traumatic in origin. Yet in this case, none of the other criteria for diabetic foot are present. At least one of the following would be required: PVD peripheral neuropathy specified deformities of foot/toe amputation status of lower limb, any part, any side Nor is there a final diagnosis, after study, of diabetic foot, against which E1173 could be justified. On the documentation as it currently stands, E1173 is not assignable. If ulcer is present, L97, E1169 would be assignable. (L97 would then displace cellulitis as principal -ACS 1210). One doctor (ED) states no ulcer. Another (progress notes) states ulcer. On balance there is no mention of ulcer on summary, though the summary is clearly inadequate in its detail and therefore unreliable. DOCUMENTATION ISSUE Neither E1173 nor L97, E1169 could be assigned without clinical consultation. With a clearly inadequate summary however, clinical consultation is recommended. In the interim, cellulitis (L0311) is assigned as principal. Incidental notes: Necrotic is coded with an additional diagnosis for skin necrosis (R02), and meets ACS 0002 by requiring debridement. However the pathway diabetes with gangrene: E1169 is not followed unless the word gangrene is documented. see also WA Coding Committee Jan 2010, item 9.6. Diabetic foot ulcer in the progress notes, by one doctor, is not sufficient documentation of the condition diabetic foot. This can mean foot ulcer in diabetes see ACS 0401 page 107 or the 2012 update section 5 foot ulcers in DM. ACS 401 in regard to Diabetic Foot requires that: either the specific criteria are met or the final diagnosis is diabetic foot (so stated). The grossly infected toe was not further enlarged upon, and could be inflammation around the blister. Cellulitis of toe would need to be clearly stated before adding, in addition, L0302. Note that when cellulitis does involve both foot and toe, and is confirmed as such, ICD 10 requires both codes to be assigned. Since this case already needs to be queried, confirming the extent of cellulitis would be recommended. PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 8

9 APPENDIX 1 Coding Committee WA: Diabetes / Education / Diabetic Foot- (The following extract is from Education Resources, published by the Coding Education Team, Dept of Health WA and approved by the Coding Committee WA). Ref: Diabetic foot codes sequencing ACS 0001 must be followed when assigning the principal diagnosis in the case of diabetic foot. Cases with a condition from diabetic foot criteria other than L97 listed as the PD should be queried with the clinician before assigning a code other than E1-.73 as the PD. Example: 65 year old female with type 2 diabetes mellitus admitted with left foot cellulitis. The patient also has PVD and peripheral neuropathy which limit her mobility. She was treated with IV antibiotics and discharged. Principal diagnosis on discharge: Cellulitis The case was queried with the treating clinician and they confirmed that diabetic foot would best reflect the principal diagnosis in this case. Principal Diagnosis E11.73 Type 2 diabetes mellitus with foot ulcer due to multiple causes Additional Diagnosis L03.11 Cellulitis of lower limb E11.51 Type 2 diabetes mellitus with peripheral angiopathy, without gangrene E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy The criteria for diabetic foot have been met. As cellulitis was listed as the PD, the case was queried with the treating clinician and she agreed that diabetic foot should be assigned as the PD. If the criteria for diabetic foot were met but the diabetic foot diagnosis itself did not met ACS 0001 (i.e.: was not nominated by the clinician) then the cellulitis would have been assigned as the PD and E11.73 as an additional diagnosis. PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 9

10 APPENDIX 2 Australian Coding Standard CELLULITIS Where cellulitis is associated with an open wound or with a skin ulcer, sequence the complicated wound code or the skin ulcer code as principal diagnosis and cellulitis as the additional diagnosis if the wound or ulcer is treated. For wounds not requiring treatment or treated earlier, with the current episode being for treatment of the cellulitis, sequence cellulitis as principal diagnosis with the complicated wound as an additional diagnosis. If the clinical coder is in doubt about the sequencing, clinician confirmation should be sought. NB: underlining and bold emphasis added by author PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 10

11 APPENDIX 3 Diabetic foot, ACS 0001 and the after study principle Q&A December extract Assign E1-.73 *Diabetes mellitus with foot ulcer due to multiple causes when: 'diabetic foot' is documented in the clinical record, or the criteria specified in ACS 0401 Diabetes mellitus and intermediate hyperglycaemia, 6. Diabetic foot are met. Additional codes for the specific complications of DM or IH should be assigned in accordance with Rule 4a and Rule 4b. Sequencing of codes for diabetic foot should be determined by: ACS 0001 Principal diagnosis, with particular attention to: the 'after study' principle Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis Two or more diagnoses that equally meet the definition for principal diagnosis ACS 0002 Additional diagnoses. (Coding Q&A, December 2012) PERFORMANCE ACTIVITY QUALITY DIVISION DEPT HEALTH WA Page 11