H&P: 68-year-old male presents with a history of a sudden onset of acute upper central abdominal pain radiating to his back. The pain began two days prior with intermittent vomiting, without relief of his pain
PMH: Appendectomy, Tonsillectomy, Hypertension, Pre-diabetic
Pertinent Family History: Cholelithiasis and cholecystectomy in multiple family members
Pertinent Social History: Patient admits to drinking 3-4 shots of bourbon most evenings. No history of smoking
Home Meds: Aspirin 325mg per day, Propranolol 30mg per day, Hydrochlorothiazide 25mg per day
Physical Exam: VS:110/60, 114, 27, 100.9F, BMI 38.2; Pain: 8 out of 10, Abdomen: tender in the mid-epigastrium with guarding and rebound tenderness
Labs: Admission- WBC 13.6, Glu 123, BUN 30, Creatinine 1.5 (repeat 1.1, 0.8), C-reactive protein (CRP) 18, Serum Amylase 280 (Normal range: 23-85 U/L), Serum Lipase 680 (Normal range: 0-160 U/L)
Diagnostic Testing: Ultrasound abdomen: generalized pancreatic inflammation. No gallstones noted
Consult: Psychiatry- Reports drinking more since he spends time home alone during pandemic. Relies on alcohol to alleviate his anxiety. Diagnosis-Moderate alcohol use disorder-Monitor for withdrawal
Treatment: IVF, NPO, H2 receptor antagonists, Morphine prn, CIWA protocol
Discharge Diagnosis: Pancreatitis, Dehydration, Obesity, HTN, Pre-Diabetes, Alcohol abuse
Discharge Instruction: Dietary restrictions: avoid spicy or gas-producing foods; Medications as ordered, call if your temperature is 100.4 or higher, N/V, or severe pain. Avoid alcoholic beverages. Follow up with primary care physician in 1 week
Question: Are there query opportunities based on the scenario stated above?
The patient presents with severe abdominal pain and history of alcohol abuse. Ultrasound was negative for gallstones. His creatinine, amylase, and lipase are elevated. He also exhibits SIRS criteria on presentation.
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.
- 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 for AKI
- Query for non-infectious SIRS with or without organ failure
- Query for clarification of alcohol abuse
Documentation without Clarification:
Principal diagnosis: K85.90 Acute pancreatitis with necrosis or infection, unspecified
Secondary diagnoses: I10 Essential hypertension, E86.0 Dehydration, E66.9 Obesity, unspecified, R73.03 Prediabetes, Z68.38 Body mass index (BMI) 38.0-38.9, adult, F10.10 Alcohol abuse, uncomplicated
Working DRG: 440 Disorders of pancreas except malignancy without CC/MCC
RW: 0.606 GLMOS: 2.4 SOI/ROM:1/1
Documentation with Clarification:
Principal Diagnosis: K85.20 Alcohol induced acute pancreatitis without necrosis or infection
Secondary diagnosis: I10 Essential hypertension, R65.11 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction, N17.9 Acute kidney injury, unspecified, E86.0 Dehydration, E66.9 Obesity, unspecified, R73.03 Prediabetes, Z68.38 Body mass index (BMI) 38.0-38.9, adult, F10.20 Alcohol dependence, uncomplicated
Working DRG: 438 Disorders of pancreas except malignancy with MCC
RW: 1.596 GLMOS: 4.6 SOI/ROM:3/3
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
- When provider documentation includes terms such as use, abuse, or dependence all related to the same substance, only one code is assigned. Per ICD 10 OCG: When the provider documentation refers to use, abuse and dependence of the same substance (e.g. alcohol, opioid, cannabis, etc.), only one code should be assigned to identify the pattern of use based on the following hierarchy:
- If both use and abuse are documented, assign only the code for abuse
- If both abuse and dependence are documented, assign only the code for dependence
- If use, abuse and dependence are all documented, assign only the code for dependence
- If both use and dependence are documented, assign only the code for dependence.
- According to ICD-10 Official Guidelines for Coding and Reporting Oct. 2020-Sept. 2021: SIRS due to Non-Infectious Process: The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code R65.10, Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction, or code R65.11 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. If an associated acute organ dysfunction is documented, the appropriate code(s) for the specific type of organ dysfunction(s) should be assigned in addition to code R65.11. If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.
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.