Coder Q&A with Pat Macc: Principal Dx Selection

Pat Maccariella‑Hafey
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador

This coder has a question about choosing the principal diagnosis in this case.

Question:

Per the medical record notes this patient presented due to CHF exacerbation. It was noted she had not taken her Lasix for two weeks. The discharge summary notes CHF exacerbation due to MR due to dehiscence and leaking of prosthetic mitral valve. ​The patient already has a scheduled appointment for her surgery for the mitral valve prosthetic repair. Cardiology consulted and they attempted to change her surgery to be done while she was in the hospital. However, patient went home AMA to take care of some business and await original surgery.

Would it be appropriate to code the complication code T82.03XA, Leakage of heart valve prosthesis, initial encounter as the principal diagnosis over the HFpEF (heart failure exacerbation) code?

HPI: Patient is 51 year old female with s/p replacement with #31 Biocor tissue valve in Feb 2019 w/ left atrial appendage clip, with dehiscence and leaking of bioprosthetic valve with moderate to severe mitral regurgitation, scheduled for MVR on 6/7/2019, hx of HFpEF, presents with worsening SOB since last 2 days. Last 3-4 days she has progressively had noticed shortness of breath on exertion, but from yesterday she is short of breath at rest. Also complains of cough with minimal expectoration, no hemoptysis. No chest pain, no swelling in feet or increase in abdominal girth no palpitations, no fever chills, No n/v/d/c No dizziness or syncope  She has gained 10 lb. of weight in last 2 weeks She was not compliant with her medications, has not taken Lasix for 2 weeks. She just did not go the pharmacy to refill. No excuse for not refilling She has anxiety about the surgery next week, that may be adding up to the stress

PROBLEM: Acute Heart Failure Exacerbation – HFpEF
– MV dehiscence/leakage –> severe MR
– BNP 318
– Troponin 0.03, peaked at 0.04
– Last Echo showed LVEF 60-65%
– Reports non-compliance with Lasix and Valsartan from previous admission.

PLAN:
– ASA 81 mg PO daily
– Coreg 6.25 mg PO bid
– Switch Valsartan to Losartan 100 mg PO daily on discharge

PROBLEM: Moderate to Severe MR due to Mitral Valve Dehiscence with leakage 
– Previously evaluated on last admission with scheduled date for MVR

PLAN:
– Scheduled for mitral valve replacement on 6/7

5/31/19 SUMMARY:  is a 60 y.o. Female with PMH of rheumatic heart disease s/p MV replacement with #31 Biocor tissue valve 1/2019, with subsequent dehiscence of valve with leaking and moderate MR, and MVR scheduled for 6/5/19, hx of HFpEF who presented with worsening shortness of breath, previously only on exertion but now at rest. Found to have acute decompensated HFpEF heart failure.

Subjective: Shortness of breath is improved since she has been on Lasix. Patient is happy to be getting her valve replacement on 6/7.

# Heart failure exacerbation – HFpEF
Patient s/p MVR with dehiscence and leaking with severe MR,  Home diuretic regimen is Lasix 40 mg,
History of noncompliance, she did not Lasix for 2 weeks,
Weight gain 10 lbs.
JVD +, no pedal edema
BNP 318, negative troponin
Received Lasix 40 mg in ED, will be given another dose of 40 mg IV

Plan
IV Lasix 40 mg bid, change to po tomorrow
Continue Coreg 6.25 mg bid
Monitor BNP
Strict ins and outs
Daily weight

# Recent MVR with leaking, moderate to Severe MR,
Scheduled for MVR on 6/7
Plan
Discuss with Cardiac surgery if they surgery can be done this admission,

ECHOCARDIOGRAPHY
Conclusion
Patient is s/p mitral valve replacement with a 31 Biocor tissue valve 1/2019.

Dehiscence of bioprosthetic valve with leaking and with moderate to severe wall-hugging eccentric periprosthetic mitral regurgitation noted.

Small mobile echogenic structure noted at the dehisced site of bioprosthetic valve which may represent suture material vs vegetation.

Systolic flow reversal was observed in the RLPV spectral doppler flow pattern.

Cardio PN 6/1

Called to bedside to speak to patient wants to go home and return for her valve replacement on 6/7 Spoke to patient about previously missed appointment and that it would be in her best interest to stay and get the surgery in house as CTS is willing to operate while in house and possibly even sooner than 6/7. Discussed the risks of leaving without having the procedure done including further decompensation and including but not limited to more serious complications including death.

Patient adamantly expresses that she has some personal business to take care of and does not want to delay those appointments and that she will take her Lasix daily and return to get her valve surgery on 6/7. Patient to leave AMA. 6/1/19

Answer:

Assign the acute exacerbation of CHF (HFpEF) code I50.33, Acute on chronic diastolic (congestive) heart failure as the principal diagnosis in this case. The surgery date was already set and not performed on this admission. The patient ran out of Lasix and did not go to the pharmacy to get it (noncompliance). That is the reason she went into CHF (HFpEF) exacerbation and presented with SOB and elevated BNP on admission. She later went home AMA to come back for original surgery. In addition, assign T82.03XA, Leakage of heart valve prosthesis, initial encounter; T50.1X6A, Underdosing of loop [high-ceiling] (Lasix) diuretics, initial encounter; Z91.128, Patient’s intentional underdosing of medication regimen for other reason; and any other secondary diagnoses on the case.

We know that every case is unique. The above post is simply our opinion based on the information we have received. We encourage readers to research subsequent official guidance in the areas associated with this topic as they can change rapidly.