Correct PDX Selection in Inpatient Coding: COVID-19 vs. CHF

 Question:


The OE orders for this inpatient account include pulmonary edema and pleural effusion. The patient is also COVID-19 positive. According to the progress notes, the patient was admitted for altered mental status (AMS), with the etiology documented as dementia and delirium.

The patient actually had heart failure with reduced ejection fraction (HFREF) exacerbation.


Since pleural effusion has a higher DRG, it was assigned as the principal diagnosis (PDX). However, the patient was also actively treated for COVID-19 and CHF exacerbation.


Considering ICD-10-CM coding guidelines, what should be the appropriate PDX selection, and are there any potential query opportunities?




Answer:


1. CHF, Pulmonary Edema & Pleural Effusion


The auto-suggested CHF code was not validated, which led to coding CHF unspecified, while the patient actually had HFREF exacerbation.


Pulmonary edema and pleural effusion are symptoms of CHF and should not be coded separately unless specifically treated.



2. COVID-19 as PDX


The patient was actively treated for COVID-19 along with CHF.


Per ICD-10-CM guidelines, COVID-19 (U07.1) should be assigned as the PDX since it was equally treated with CHF and has a higher DRG impact.



3. AMS & Underlying Etiology


AMS was secondary to dementia and delirium, meaning it cannot be the PDX.



4. Sepsis Query Possibility


Review for any SIRS indicators; if sepsis is suspected, a query may be needed.



Final PDX Selection: COVID-19 (U07.1)


COVID-19 should be assigned as the PDX for optimal DRG assignment.


CHF exacerbation (HFREF) must be properly coded.


Pulmonary edema & pleural effusion should not be coded separately unless treated independently.



Accurate PDX selection ensures correct reimbursment, compliance, and documentation integrity.


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