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Monthly CDI Scenario Discussion – July 2020

June 29, 2020

Topic: E-cigarette or Vaping – Associated Pulmonary Lung Injury (EVALI)

Scenario: 23 year old female presents with shortness of breath and cough for one week. No known history. She is attending school at the local community college. Patient works part-time at a local bar on the weekends.

History & Physical:

  • HPI: 23 year old presents with shortness of breath for a week. Patient states she is unable to walk a half block without becoming SOB. She states she started vaping 6 months ago with THC to relieve anxiety from school. Lives at home with both parents and a 16 year old sister
  • PMH: No known history. Patient’s 16 year old sister recently had the flu.  Patient’s influenza came back negative
  • Home medications: Birth control pills
  • PE: Alert and Oriented x 3, moves all extremities, cannot speak in full sentences, use of accessory muscles noted. Lung sounds diminished throughout, abdomen soft with good bowel sounds
  • VS: T-max 38.0, HR 102, RR 24, BP 98/50, oxygen saturation 87 % on room air. At discharge: 110/52, HR 75, RR 18
  • Labs: WBC 13.5, HBG 13.0, Procalcitonin 1.2, Drug screen-positive for THC, Influenza – negative, ABG- PH-7.29, PO2-74, PCO2 -38 (on 3L N/C)
  • Chest X-ray:   Ground–glass opacities bilaterally
  • Treatment: Solumedrol 40mg IV every 8 hours, Levaquin 750mg IV daily, bipap for acute hypoxic respiratory failure. The patient was weaned off bipap to nasal cannula and back to room air by discharge
  • Discharge Diagnoses:  Pneumonia, Acute hypoxic respiratory failure, THC Abuse
  • Discharge Medications:  Levaquin 500mg po daily for 10 days

Question: Are there query opportunities based on the scenario stated above?

Discussion:

  • Vitamin E acetate and tetrahydrocannabinol appear to be associated with EVALI
  • Ensure provider documentation supports an infectious process has been ruled out before starting corticosteroids
  • EVALI is a new health care crisis and codes are limited
  • Due to no specific test or marker existing for its diagnosis, EVALI remains a diagnosis of exclusion
  • Ensure provider documentation clearly rules out other etiologies for pulmonary lung injury

Recommendations:

  • Recommend a query for clarification of etiology of Pneumonia (related to vaping)
  • Recommend a query for clarification of THC abuse vs. overdose/poisoning (the toxic effect of the cannabis)
  • Recommend a query for sepsis

Working Documentation without Clarification:

  • Principal diagnosis: J18.9 Pneumonia, unspecified
  • Secondary diagnoses: J96.01 Acute Respiratory Failure with Hypoxia, F1210 Cannabis Abuse, uncomplicated
  • DRG 193 Simple Pneumonia & Pleurisy W MCC
  • RW: 1.3335 GMLOS: 4.2 SOI/ROM: 3/3

Working Documentation with Clarification: (MD disagreed with Sepsis)

  • Principal diagnosis: U070 Vaping-related disorder
  • Secondary diagnoses: J96.01-Acute respiratory failure with hypoxia, T40.7X1A- Poisoning by Cannabis, accidental, J680 Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors.
  • DRG 205 Other Respiratory System Diagnoses W MCC
  • RW: 1.6342 GMLOS: 4.1 SOI/ROM: 3/3

CDI Educational Tips:

U07.0 – Vaping- related disorder as principal

Some additional manifestation codes:

  • Acute respiratory distress syndrome (J80)
  • Pulmonary eosinophilia, not elsewhere classified (J82)
  • Acute interstitial pneumonitis (J84.114)
  • Drug-induced interstitial lung disorder (J70.4)

These diagnoses will not be an MCC when U07.0-Vaping-related disorder is principal:

  • Hypersensitivity pneumonitis due to other organic dusts (J67.0)
  • Hypersensitivity pneumonitis due to unspecified organic dust (J697.9)
  • Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors (J68.0)
  • Pulmonary edema due to chemicals, gases, fumes and vapors (J68.1)
  • Pneumonitis due to inhalation of oils and essences (J69.1)

References:

  1. ICD-10-CM Official Coding Guidelines – Supplement, Coding encounters related to E-cigarette, or Vaping, Product Use; April 2020 ICD-10-CM Addenda
  2. CC Exclusion List, ICD -10 MS-DRGs Version 37.1 effective April 1, 2020

This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.