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Pulmonary Embolism CDI Scenario – July 2022

H&P: 55-year-old female presents to ER with sudden shortness of breath, swelling, and redness in left lower extremity. No recent injuries or acute respiratory infections

PMH: Morbid Obesity, tobacco abuse, HTN, GERD, DM2, anxiety

Home Medications: Metformin 1000 mg twice a day, Lisinopril 10 mg twice a day, Prilosec 40 mg daily, Citalopram 20 mg daily, Tylenol 650 mg prn

Vitals: 142/96, 110, 22, 94% room air, 98.2F, BMI 46.4

Physical Exam: Shortness of breath, breath sounds course and muffled, bulging neck veins, chest pain 4/10, wheezing, coughing, cyanotic lips and fingers, 2+ edema left foot and ankle, warm to touch and painful rated at 5/10

Labs: RBC 59, WBC 14.3, PLT 988, glucose 379, D-dimer 975 ng\ml (<500 normal), A1c 12.3, all other labs within normal range

Radiology:  CT chest with contrast- Saddle Pulmonary Embolism, US of LLE- Acute DVT left popliteal vein, Echo- EF 55% with severe right heart strain

Treatment: 02 2 LPM per nasal cannula, EKG, Labs, radiology studies, Lovenox 1mg per kg twice a day, NS 125 ml\hr., heart healthy 1800 calorie day diet, smoking cessation consult, dietary consult for diabetic diet, hematology consult, sliding scale insulin 4 times a day at meals and bedtime

Hematology Consult: Based on current labs, pt likely has Polycythemia Vera. Add Hydroxyurea daily. Will need further work up as outpatient

Discharge Summary: Pulmonary Embolism unspecified, Acute left leg DVT, Morbid Obesity, DM2 uncontrolled, follow up with hematology for Polycythemia Vera

Discharge Medication: warfarin 5mg daily with monthly lab review per primary provider, follow up with hematology, finger stick blood sugars 4 times a day, Humalog sliding scale insulin, Hydroxyurea per Hematology

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

Discussion: Pt admitted with shortness of breath with bulging neck pains, redness and swelling of left foot and ankle, chest pain 4/10, wheezing, coughing, cyanotic lips and fingers, elevated blood glucose, and elevated A1c. RBC, WBC, and PLT all elevated.

  • Saddle Pulmonary Embolism, Acute DVT of left lower extremity popliteal vein, Echo revealed right heart strain
  • Lovenox while in hospital and warfarin at discharge
  • RBC 59, WBC 14.3, PLT 988,
  • Consult to Hematology, addition of Hydroxyruea PO daily

UASI Recommends:

  • Query for specificity of PE- with or without Acute Cor Pulmonale
  • Query for specificity of Diabetes, documented as uncontrolled
  • Query for link of the PE and DVT to Polycythemia Vera

Documentation without Clarification:

  • Principle Diagnosis: Saddle Pulmonary Embolism w/o Acute Cor Pulmonale (I26.92)
  • Secondary Diagnosis: Acute DVT left popliteal vein (I82.432), DM2 (E11.9), Polycythemia Vera (D45), Morbid Obesity (E6601), BMI 46.4 (Z6842)
  • Working DRG: 176 Pulmonary embolism without MCC
  • RW: 0.8878     GLMOS: 2.6     SOI/ROM: 2/1 

Documentation with Clarification:

  • Principal Diagnosis: Polycythemia Vera (D45)
  • Secondary Diagnosis: Saddle Embolus of Pulmonary Artery with Acute Cor Pulmonale (I26.02), Acute DVT of left popliteal vein (I82.432), DM2 with hyperglycemia (E11.65), Morbid Obesity (E6601), BMI 46.4 (Z6842)
  • Working DRG: 840 Lymphoma and non-acute Leukemia with MCC
  • RW: 3.2205     GLMOS: 6.7     SOI/ROM:  3/4

CDI Educational Tips: Coding Considerations

  • Polycythemia Vera is a disease in which there are too many red blood cells in the bone marrow and blood, causing the blood to thicken. The number of white blood cells and platelets may also increase. Complications are blood clots, stroke, and tissue or organ damage
  • Pulmonary emboli are classified to the I26 code grouping, inclusion terms are pulmonary infarction, pulmonary thromboembolism, and pulmonary thrombosis.  There are several terms listed as Excludes2 notes, meaning one can report I26 with the following:
    • Chronic pulmonary embolism
    • Personal history of pulmonary embolism
    • Pulmonary embolism complicating abortion, ectopic, or molar pregnancy
    • Pulmonary embolism due to trauma
    • Pulmonary embolism due to complication of surgical and medical care
    • Septic atrial embolism
  • The codes within the I26 category differentiate between septic, saddle, or other specified PE with or without associated acute cor pulmonale, and a single sub segmental or multiple sub segmental PE without acute cor pulmonale
  • Saddle PEs rest in the bifurcation in the main pulmonary arteries
  • Pulmonary infarct describes death of a portion of lung tissue due to lack of perfusion
  • Cor pulmonale describes an abnormal enlargement of the right side of the heart caused by disease in the lung or the pulmonary blood vessels
  • Septic PE results from the embolization of infectious particles entering the lungs causing the PE
  • Sub segmental PE is not involved in the more proximal (larger) pulmonary arteries
  • Chronic PE the presence of residual clots after treatment for an acute PE
  • Always query for acuity of PE when not documented
  • Ensure cause of PE and DVT is documented if known
  • Remember to clarify Diabetes when uncontrolled is documented. There is no sub term for uncontrolled – see Coding Clinic 1st Q 2017 P.42

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.