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Monthly CDI Scenario Discussion – January 2020

Topic: Pathological Fracture

Scenario: 82 year old female presented with right hip pain after ground level fall

History & Physical:

  • HPI: 82 year old female presented with right hip pain after ground level fall. Patient stated that she tripped over the cat and landed on her right hip. She felt an immediate severe pain and was unable to get up.
  • PMH: Hypertension and Hyperlipidemia, Rheumatoid Arthritis, Diabetes Mellitus Type 2.
  • Home Medications:
    • Coreg 12.5mg PO BID, Atorvastatin 20mg PO QHS, Metformin ER 1000mg PO daily, Prednisone PO 5mg daily, Percocet 5/325 PO TID
  • PE: Musculoskeletal: 5/5 strength BUE and LLE.  Right leg good sensation, capillary refill, DP and PT pulses strong. Mild edema right leg. All compartments soft. Right hip shows a positive log roll test and demonstrates pain with range of motion. The patient’s right leg is flexed and shortened.
  • Labs: WBC: 11.3. HGB: 12.6. HCT: 36.8. Glucose: 146, Calcium: 8.5, Vitamin D: 23.  
  • Hip X-Ray: displaced subtrochanteric right femoral fracture. Osteopenia noted throughout the right lower extremity and pelvic region.
  • Orthopedic Consult: Assessment: Right subtrochanteric femoral fracture. Plan: right femur IM nailing in the AM, type and screen, Ancef 2gm IV x1dose 30 minutes prior to surgery
  • Operative Report: Postoperative Diagnosis: displaced subtrochanteric right femur fracture. Procedure: right femoral IM nailing. Complications: none. EBL: 300 ml.
  • Postoperative H&Hs:
    • Post-Op Day #1: HGB: 10.3, HCT: 33.9
    • Post-Op Day #2: HGB: 8.7, HCT: 31.6
  • Discharge Summary: Discharge Diagnoses: Right femoral hip fracture, Hypertension, Hyperlipidemia, Diabetes Mellitus type 2.
  • Discharge Medications:
    • Resume home medications, add Calcium 1000mg PO daily, Vitamin D3 2000mcg PO daily, Hydrocodone 7.5/325mg PO Q4hrs PRN for 4 days, Xarelto 10mg PO daily x30 days then dc

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

Discussion: Patient was noted to have rheumatoid arthritis being treated with Prednisone posing an increased risk of osteoporosis. Patient noted to have a minor fall that should not have resulted in a fracture in normal bone. Postoperative HGB dropped 3.9 grams from admission. Patient takes Percocet TID for chronic pain from rheumatoid arthritis.

UASI Recommendations:

  • Query for Pathological fracture specificity, acute blood loss anemia, and opioid dependence.
    • Recommend a query for fracture specificity: (M80.051A)
    • Recommend a query for acute blood loss anemia (D62)
    • Recommend a query for opioid dependence (F1120). This will not change DRG/SOI/ROM but will provide a second CC to solidify the DRG.

Documentation Without Clarification:

  • Principal Diagnosis: S72001A Fracture of unspecified part of neck of right femur, initial encounter for closed fracture
  • Secondary Diagnoses:  I10, E119, E785, M069
  • Procedure: 0QS6O6Z Reposition right upper femur with intramedullary internal fixation device, open approach
  • DRG 482 Hip and Femur Procedures except Major Joint w/o CC/MCC   RW= 1.6453 GMLOS= 3.3, SOI/ROM 1/1

Documentation With Clarification:

  • Principal Diagnosis: M80051A Acute age-related osteoporosis with current pathological fracture, right femur, initial encounter
  • Secondary diagnosis: I10, E119, E785, M069, D62, F1120
  • Procedure: 0QS6O6Z   Reposition right upper femur with intramedullary internal fixation device, open approach
  • DRG 481 Hip and Femur Procedures except Major Joint w CC RW=2.0878, GMLOS=4.4, SOI/ROM 1/1

CDI Educational Tips:

  • Look at the circumstances that brought the patient to the hospital and make sure that the injuries correspond with the severity of the event. If they do not, query the physician for the etiology of the fracture.
  • Monitor the patient’s postoperative labs. If there are any abnormal values that do not have a corresponding diagnosis, are significant and are being monitored or treated, the physician should be queried.
  • Review home and inpatient medications and link them to a corresponding diagnosis.

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.