When two or more diagnoses equally meet the criteria for principal diagnosis and coding guidelines do not provide sequencing direction?

Publication Date: September 2017

ICD 10 AM Edition: Tenth edition

Query Number: 3228

We often see documentation of a principal diagnosis of metastatic cancer ie metastatic colon cancer. As per ACS 0239 Metastases, we note that adjective 'metastatic' is used ambiguously, sometimes to mean secondary deposits from a primary lesion elsewhere and sometimes to mean a primary which is metastasising. 1. If we are able to determine the primary and metastatic site(s)of the cancer, can you please provide clarification on how to assign the principal diagnosis for the following scenarios: a) Principal diagnosis is metastatic colon cancer. Documentation in the progress notes indicate metastatic sites are lung and liver, and the primary site is the colon. The patient is admitted for systemic chemotherapy and there is no documentation indicating which site is being targeted for treatment b) Principal diagnosis is metastatic breast cancer. Documentation in the progress notes indicate metastatic sites are bone and brain, and the primary site is the breast. The primary site was resected 5years previously. The patient is admitted for radiotherapy to bone (spine) and brain.

2. We note ACS 0001 Principal diagnosis states that when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic work up and/or therapy provided, and the Alphabetic Index, Tabular List or the standard does not provide sequencing direction, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition. Where we are unable to obtain clarification from the clinician as to which site best meets the principal diagnosis definition, can you please provide some advice as to how to select the principal diagnosis in these scenarios?

Response

VICC advises to apply ACS 0236 Neoplasm coding and sequencing which states, ‘The sequencing of primary and secondary neoplasm codes are dependent on the treatment performed at each episode of care. Assign the principal diagnosis as per the criteria in ACS 0001 Principal diagnosis'. Therefore, when the principal diagnosis is documented as 'metastatic….. cancer’, and metastatic sites have been documented, VICC considers it is appropriate to assign either the primary or secondary site as principal diagnosis depending on the focus of care for that particular episode. When there is no documentation of the site undergoing treatment or management, assign the primary site as principal diagnosis. In answer to your scenarios: a) As the treatment is not documented as being directed at one particular site, assign the colon cancer as the principal diagnosis.

b) From the documentation provided both the bone and brain metastases are receiving treatment, therefore assign the bone metastases as the principal diagnosis as per ACS 0001 Principal diagnosis as this is the first mentioned metastatic site. Please also refer to #3229 Principal diagnosis selection based on first mentioned diagnosis.

Publication Date: September 2021

Implementation Date: 1/10/2021

ICD 10 AM Edition: Eleventh Edition

Query Number: 3799

ACS 0010 CLINICAL DOCUMENTATION AND GENERAL ABSTRACTION GUIDELINES "Before classifying any documented clinical concept, the clinical coder must verify information on the front sheet and/or the discharge summary (or equivalent) by reviewing pertinent documents/data within the body of the current episode of care.” “If, after following the above guidelines, the documentation within the health care record is inadequate for complete and accurate classification, the clinical coder should seek information from the clinician.” Question 1. If a query is to be done in the above scenario, why does it not contain the ACS 0001 more specific definitions of a Principal Diagnosis relevant to the query as I have included in as numbered below? Without these more specific definitions being included on the principal diagnosis query, the assignment of principal diagnosis based on ACS 0001 is questionable due to the lack of knowledge by the MO of ACS 0001 Principal Diagnosis multiple scenarios. This may leave it open to revenue optimization by not adding context to Principal diagnosis queries regarding the Principal diagnosis definitions ACS 0001. Currently reference for Principal diagnosis on discharge summaries and queries usually only relates to the following: “The phrase after study in the definition means evaluation of findings to establish the condition that was chiefly responsible for occasioning the episode of care. The condition established after study may or may not confirm the admitting diagnosis.” To enhance the quality of Principal diagnosis queries, would it be of benefit to link the query to each of the principal dx scenarios as per ACS 0001 to which the diagnoses relates? Not only would data quality be improved better reflecting accurate casemix as per ACS, a better understanding of ACS 0001 would be gained from both the Medical Officers and HIMs and Clinical Coders. 2. In the case of a Principal Diagnosis Query, should the Principal Diagnosis options be listed from the earliest date to the latest date documented in the current episode to avoid the incidence of placing the diagnosis with the highest cost weight as the first option? For example, if the queries were written in the context of the scenarios outlined in ACS 0001. 1. PROBLEMS AND UNDERLYING CONDITIONS PRINCIPAL DIAGNOSIS QUERY • Coding the underlying condition as the principal diagnosis - When a patient presents with a problem, and during the episode of care the underlying condition is identified. Which of the following is the principal diagnosis after study etc a) TIA, b) Occlusion cerebral artery c) Other:____________________ 2. PROBLEMS AND UNDERLYING CONDITIONS PRINCIPAL DIAGNOSIS QUERY • Coding the problem as the principal diagnosis - underlying condition is known at the time of admission. Which of the following is the principal diagnosis after study etc a) TIA, b) occlusion cerebral artery c) Other:____________________ 3. CODES FOR SYMPTOMS, SIGNS AND ILL-DEFINED CONDITIONS Codes for symptoms, signs and ill-defined conditions from Chapter 18 Symptoms signs and abnormal clinical and laboratory findings are not to be used as principal diagnosis when a related definitive diagnosis has been established. Which of the following is the principal diagnosis after study etc a) Syncope b) Dizziness c) 2nd Degree AV Block d) Other: _______________________ 4. TWO OR MORE INTERRELATED CONDITIONS, EACH POTENTIALLY MEETING THE DEFINITION FOR PRINCIPAL DIAGNOSIS When there are two or more interrelated conditions (such as diseases in the same ICD-10-AM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition. Which of the following is the principal diagnosis after study etc a) COAD b) PNEUMONIA c) Other: _______________________ 5. TWO OR MORE DIAGNOSES THAT EQUALLY MEET THE DEFINITION FOR PRINCIPAL DIAGNOSIS When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic work-up and/or therapy provided, and the Alphabetic Index, Tabular List or the standard does not provide sequencing direction, the clinician should be asked to indicate which diagnosis best meets the principal diagnosis definition. Which of the following is the principal diagnosis after study etc a) Dementia b) UTI

c) Pneumonia_______________________

Response

As per the Introduction of the Australian Coding Standards “A combined effort between the clinician and clinical coder (and the CDIS) is essential to achieve complete and accurate documentation and code assignment using ICD-10-AM and ACHI classification conventions and the ACS”. As per ACS 0010 Clinical documentation and abstraction guidelines, section titled Appropriately formulated queries to clinicians, the query should include information about the patient, with direct reference to the documentation that has prompted the query. There is nothing to preclude the coder from adding information from an ACS to a documentation query where it will enable the clinician to understand why the documentation requires clarification. Bear in mind that clinicians may not be familiar with the ICD-10-AM structure and terminology, therefore it is advisable to avoid references to volumes, chapters, or other classification specifics. VICC considers that if a documentation query is necessary to determine which diagnosis meets the definition of principal diagnosis, then it is important to include the definition so that the clinician has all the information required to answer the query. It may be appropriate to include other parts of ACS 0001 Principal diagnosis where it could explain the reason for the query without confusing the clinician. For example, the clinician may not understand what is meant by ‘problem and underlying condition’. A query must never instruct or indicate to a clinician how to respond, and this includes multiple-choice format queries. To avoid a leading question, it would be appropriate to directly refer to the documentation that has prompted the query in a similar way to how it was documented by the clinician. Example 5 of ACS 0010 Clinical documentation and abstraction guidelines is an example of using the definition of principal diagnosis in a query, and of quoting the documentation as documented by the clinician.

VICC notes the purpose of a documentation query is to clarify the documentation so that the coder can then apply classification rules to the query answer and therefore coders should be careful to avoid using a documentation query to teach the clinician about coding rather than to clarify documentation.