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Pancreatitis CDI Scenario – April 2022

H&P: 41-year-old male presents with nausea, vomiting, diarrhea, and abdominal pain for 2 days decided to go to the ER as he could no longer control his pain at home

PMH: Obesity, type 2 diabetes, hypertriglyceridemia, HTN, recurrent pancreatitis, peripheral neuropathy, cholecystectomy, appendectomy, Whipple procedure

Pertinent Family History: Familial hypertriglyceridemia, type 2 diabetes, pancreatitis

Pertinent Social History: Former smoker quit 4 months ago, denies alcohol use, smokes marijuana, and is a former heroin addict

Home Meds: Novolog FlexPen 4 units SQ three times daily before meals, Lantus 10 units SQ daily, atorvastatin 40 mg daily, metformin 500 mg twice daily, pantoprazole 20 mg twice daily, lisinopril 10 mg daily, fenofibrate 160 mg daily, pancrelipase 1 capsule three times daily with meals, Vascepa  2g twice daily

Physical Exam: VS:154/94, 108, 18, 36.4C, BMI 34.1; Abdomen: moderately tender to palpation epigastric region, some tenderness to palpation in right upper quadrant, mildly hypoactive bowel sounds

Labs: Admission- WBC 9.61, Glu 328, Na 123, BUN 14, Creatinine 0.75, Anion gap 24, pH venous 7.490, AST 83, ALT 99, Serum Lipase 31 (Normal range: 0-160 U/L), triglycerides 2,236 (Normal range: 0-150 mg/dL), Hemoglobin A1c 8.5%, beta hydroxybutyrate 0.28 (Normal range: 0.10-0.27 mmol/L)

Diagnostic Testing: CT abdomen – no significant peripancreatic inflammatory changes. Mesenteric and retroperitoneal edema with trace amount of free fluid, diffuse hepatic steatosis, splenomegaly

Consult: None

Treatment: IVF – D10LR @ 250 ml/hr, Insulin drip 9.5 units/hr, clear liquid diet, Zofran PRN, BMP every 4 hrs, repeat triglyceride every 12 hrs, continued home meds – Vascepa, atorvastatin, fenofibrate, pancrelipase, pantoprazole, lisinopril

Discharge Diagnosis: Hypertriglyceridemia, epigastric pain, pancreatitis, N/V, hyponatremia, type 1 diabetes, HTN

Discharge Instruction: Regular/Diabetic diet, reviewed importance of dietary factors in disease process and the importance of following dietary recommendations, will D/C with small amount of oxycodone as patient has opioid use agreement, f/u with Family Medicine in 1 week

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

Discussion: The patient presents with moderate abdominal pain, nausea with vomiting, history of hypertriglyceridemia, and diabetes.  CT abdomen was mesenteric and retroperitoneal edema with trace amount of free fluid, diffuse hepatic steatosis and splenomegaly. His triglycerides, blood sugar, and liver enzymes are elevated while his lipase is within normal limits.

What is Pancreatitis: Pancreatitis is inflammation of the pancreas not typically associated with an infection. It can be acute or chronic; it may be mild or severe, and even potentially life-threatening. Causes of pancreatitis include: Alcoholism, elevated triglycerides (especially with diabetes), hypercalcemia, medications, and gallstone obstruction of the pancreatic or common bile duct (gallstone pancreatitis). Complications of acute pancreatitis include hypocalcemia, ileus, acute kidney injury, sepsis, or ARDS. Pancreatic enzymes amylase and lipase are usually both elevated; lipase is the more sensitive test.

UASI Recommends:

  • Query to determine if the pancreatitis is acute or chronic – these terms are sub-terms under Pancreatitis and should be specified in the documentation.
  • Query for the etiology of the Pancreatitis
  • Query conflicting documentation as patient with documented pm hx of type 2 diabetes and documentation of type 1 diabetes
  • Query for the relationship between the diabetes and the hypertriglyceridemia, as there is no assumed link here.

Documentation without Clarification:

  • Principal Diagnosis: K85.90 Acute pancreatitis without necrosis or infection, unspecified
  • Secondary diagnosis: K86.1 Other chronic pancreatitis, E87.1 hypo-osmolality and hyponatremia, I10 Essential hypertension, E66.9 Obesity, unspecified, E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy, Z68.34 Body mass index (BMI) 3.0-34.9, adult
  • Working DRG: 439 Disorders of pancreas except malignancy with CC
  • RW: 0.8444         GLMOS: 3.1        SOI/ROM:1/1

Documentation with Clarification:

  • Principal diagnosis: K85.80 Other acute pancreatitis without necrosis or infection
  • Secondary diagnoses: E87.1 hypo-osmolality and hyponatremia, I10 Essential hypertension, E66.9 Obesity, unspecified, E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy, Z68.34 Body mass index (BMI) 3.0-34.9, adult, K86.1 Other chronic pancreatitis
  • Working DRG: 439 Disorders of pancreas except malignancy with CC
  • RW: 0.8444         GLMOS: 3.1        SOI/ROM:1/1

CDI Educational Tips:

  • ICD-10 has multiple codes for acute pancreatitis, all of which are MCCs allowing greater specificity. A query should be placed to provide the most specific code
  • Chronic pancreatitis is not usually the principal reason for admission unless there is an acute exacerbation. A query may be needed for clarification
  • Insulin therapy is being used to lower triglyceride levels.

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.