Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
By Elena Miller, MPH, RHIA, CCS
After all these years, gallstone pancreatitis still appears to be a favorite topic for RAC audits. As you know, coding this condition requires two codes. One code for the pancreatitis and one code for the calculus of the gallbladder or biliary passages. While code assignment for this condition is straightforward, determining which of the two codes to assign as the principal diagnosis can be challenging.
What exactly is gallstone pancreatitis? Gallstone pancreatitis is inflammation of the pancreas that results from blockage of the pancreas duct by a gallstone. It can be a life-threatening disease that requires urgent evaluation by a physician. Treatment depends on the severity of the condition. Typical treatment includes: no oral intake, IV fluids and pain medications in the hospital. In more severe cases, surgical intervention is required to remove the gallstone. Depending on the patient’s condition, surgery will either take place immediately or after several days of treatment to allow the inflammation to subside first.
There are varied schools of thoughts about the sequencing of the codes related to this condition. Even though coding the condition results in two codes, the physician is documenting “gallstone pancreatitis” throughout the record. It is the reason for admission, the pre- and post-operative diagnosis, and the discharge diagnosis. This makes it extremely difficult for some coders to mentally separate the two and think of treatment being directed at one over the other. This often results in coders applying the “two conditions equally meeting the definition of the principal diagnosis” guideline. There are some coders and auditors that seem to be of the opinion that acute pancreatitis is always the more serious condition and always the focus of treatment. There are also some coders that believe that if surgical intervention is performed at any time during the stay then the calculus should be assigned as the principal diagnosis.
What does Coding Clinic say?
The following questions and answers are from Coding Clinic Second Quarter 1996 pg. 13-15.
If a patient has gallstone pancreatitis and documented acute cholecystitis and/or cholelithiasis, would this be the principal diagnosis over the pancreatitis?
Sequencing depends upon the circumstances of the admission.
A patient undergoes cholecystectomy for gallstone pancreatitis. The pathology report identifies chronic cholecystitis and cholelithiasis. No common bile duct stones are found. Is 574.51, Calculus of the bile duct without mention of cholecysititis, with obstruction, always used for gallstone pancreatitis?
Do not assume a bile duct obstruction for gallstone pancreatitis. Since no common bile duct stones were found, assign code 574.1x, Calculus of gallstone with other cholecystitis.
In short, Coding Clinic says the correct code assignment depends on the individual medical record documentation and sequencing depends on the circumstances of admission. As we are all aware, coding is not a science. It is often a gray area. Interpretation of the medical record and circumstances of admission can vary among coders reviewing the same information. For example, a hospital coder may determine that the calculus was the focus of treatment and finalize coding; then later, an external auditor may decide that the pancreatitis was the focus of treatment. Both have reviewed the same medical record but interpreted the information differently.
How do we get it right?
First thing, we need to throw out any beliefs that a particular diagnosis is always the principal diagnosis when “gallstone pancreatitis” is documented. This simply is not true. We need to thoroughly review the record for documentation of the focus of treatment. The physician may explicitly state that the pancreatitis is the focus of treatment and needs to be resolved before proceeding with removal of the gallstone or they may state that no surgical intervention is needed as it is possible for the gallstone to pass on its own. A patient may also be received by a facility, specifically for the removal of the gallstone. There are many scenarios and each one will be different.
The medical staff and clinical documentation improvement (CDI) team need to be aware of issues related to coding gallstone pancreatitis. Their help is needed to ensure that accurate and complete documentation is present in the record. Unless previous conversations have been had, they may not be aware of the issues related to coding this condition. It is not an obvious one for individuals outside of coding. It is not a case of a diagnosis that could be more specific or has conflicting documentation. The condition is often consistently documented in the record. Physicians and CDI may not be aware that coders face difficulties deciding on the principal diagnosis when this condition is documented in the record.
As the “circumstances of admission” can often be interpreted differently, it all comes down to the documentation—our best defense against audits. Clear documentation is needed to ensure an accurate clinical picture for the patient and accurate reimbursement for the hospital.
Elena Miller is the director of coding audit and education at a healthcare system.