H&P: 38 y/o male presents with nausea, vomiting, dizziness, dark urine, and thigh pain after participating in a marathon.
PMH: ADHD
Home medications: Adderall XR 20mg once daily
Vitals: HR 125, RR 23, BP 90/42
PE: lethargic, dry mucous membranes, poor skin turgor, thigh muscle pain
Labs: Admission labs -calcium 7.0 mg/dl , Potassium 4.4, BUN 43, Creatinine 3.1, CK >40,000, Myoglobin in urine, UA: 1+ blood, 1+ protein, proteinuria in urine, urine sodium concentration >40
Discharge Summary: Dehydration, renal insufficiency, ADHD. Improved with IV fluid administration.
Discharge Medication: Adderall XR 20 mg once daily
Question: Are there query opportunities based on the scenario stated above?
Discussion: The patient exhibited the following risk factors and clinical indicators:
- Overexertion, marathon race, vomiting, dark urine
- Dehydration
- Low calcium, IV calcium gluconate replacement
- Elevated CK, IV fluids
- Elevated BUN/Creatinine, IV fluids
- Myoglobin in urine
- Proteinuria
- Urine sodium concentration > 40
Diagnostic criteria for Rhabdomyolysis:
- CK level elevation, myoglobin in urine, thigh pain, extreme physical exertion (participated in marathon), dark urine
Treatment for Rhabdomyolysis:
- Aggressive 0.9 % NaCl IV fluids, electrolyte replacements
UASI Recommends:
Query for… rhabdomyolysis, AKI/ATN, hypocalcemia
Documentation without clarification:
Principal Diagnosis: Dehydration (E86.0)
Secondary Diagnosis: Renal insufficiency- Disorder of kidney and ureter, unspecified (N28.9) and ADHD (F909)
Working DRG: 641 Miscellaneous disorders of nutrition, metabolism, fluids and electrolytes without mcc
RW: 0.7702 GLMOS: 2.6 SOI/ROM: 2/1
Documentation with clarification:
Principal Diagnosis: Acute kidney failure with tubular necrosis (N170)
Secondary Diagnosis: Rhabdomyolysis (M62.82); Hypocalcemia (E8351), dehydration (E860), ADHD (F909)
Working DRG : 683 Renal failure with cc
RW: 0.8949 GLMOS: 3.10 SOI/ROM: 2/1
CDI Educational Tips:
- ICD-10 differentiates rhabdomyolysis by etiology non-traumatic or due to trauma.
- AHA Coding Clinic, Second Quarter 2019, p. 12, rhabdomyolysis is only coded as traumatic when the provider documents “traumatic rhabdomyolysis.” Query if indicators support trauma as a contributing factor.
- Traumatic rhabdomyolysis (T79.6XXA) reserved for severe soft tissue/muscle injury, not just lying immobile after fall without significant trauma.
- Sequencing depends on the circumstance of admission. Condition that led to rhabdomyolysis, the rhabdomyolysis itself or complications from rhabdomyolysis can all be sequenced as principal. Decide which best meets definition of principle diagnosis.
Watch for common accompanying conditions or complications such as electrolyte imbalance, AKI and acute tubular necrosis.
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.