April 30, 2025

Top Questions from the Navigating Coding & Documentation Challenges for High-Volume Diagnoses Webinar

Looking for more information about Navigating Coding & Documentation Challenges for High-Volume Diagnoses? BESLER’s Senior Manager of Revenue Integrity Kristen Eglintine answers your questions from the recent webinar.

To watch Kristen’s Navigating Coding & Documentation Challenges for High-Volume Diagnoses Webinar, click HERE.

1. 1. 1. When a patient presents with an acute MI and newly decreased LV EF under 40% and diagnoses include NSTEMI, and new ischemic cardiomyopathy/new-onset HFrEF with no signs or symptoms of heart failure on exam, not requiring diuresis or CHF specific treatment, do you query for “acute” HFrEF, don’t send query and code systolic CHF, unspecified, or send a clinical validation query to see if this is really heart failure vs just new ischemic cardiomyopathy with reduced EF due to NSTEMI without heart failure?
      
      I would want to read the EMR on this claim. In general, LV EF <40% is a clinical indicator of CHF. I would look for a NT-proBNP based on age (if no renal impairment): > 450 (Age < 50), > 900 (Age 50-75), > 1,800 (Age > 75), and I would look for IV meds for heart failure given to query for Acute CHF. The CHF is documented as new-onset so systolic CHF unspec sound appropriate, as it’s not chronic. Lastly, I do like your suggestion for a clinical validation query, and that’s probably what I would do; however, without reading through the PN notes and the discharge summary, I can’t say for certain.
    2. If the provider is documenting acute delirium, but the clinical indicators support acute encephalopathy, would a query be in order? Or would this be out of line since the provider is clearly documenting delirium?
      
      I would recommend a query for clarification. Providers often use delirium and encephalopathy interchangeably to describe impaired mental function. However, they are not synonymous. The codes for delirium are classified to ICD-10-CM Chapter 5 (Mental, Behavioral, and Neurodevelopmental Disorders), while encephalopathy is classified to Chapter 6 (Diseases of the Nervous System).
    3. If the Nephrologist is documenting AKI d/t ATN, but the Attending is only documenting AKI, can the ATN code be assigned? Or is a query needed?
      
      As a coder, ATN can be reported if a Nephrologist documents this condition exists in the medical record. However, 2 things…first I would check facility protocol to confirm. I work with a few Hospitals that require the Attending to confirm diagnoses in the Discharge Summary. Second, I would also confirm the patient has clinical criteria for AKI and ATN. ATN is defined as AKI with dysfunction of renal tubules. The patient must meet AKI criteria that lasts for greater than three days after fluid resuscitation or if the fractional excretion of sodium is greater than two percent.
    4. A patient with OFD type 1 came in to monitor risk of CKD. Please advise what is the better code for monitor risk of CKD–N code or Z code?
      I would first confirm you are asking about an IP admission. If so, if the patient is not diagnosed with CKD and does not have clinical criteria, such as a GFR less than 60 mL for more than 3 months, I wouldn’t recommend reporting a N code, such as N18.9. Documentation must support the patient having CKD. A code for OFD type 1 would be sufficient. You could report a Z code as a secondary diagnosis for preventive care or a screening if you feel it’s necessary. Z codes don’t represent a specific illness or injury, but do serve as additional information that help healthcare providers and insurers understand the patient’s overall health context.
      For an OP encounter, a Z code is most appropriate for monitoring/screening of CKD.
    5. Do providers have to state Acute or Chronic when dx?
      
      No, encephalopathy has many different types, which are referred to as acute or chronic. If a Provider documents Metabolic Encephalopathy, that suffices to code G93.41. The Provider doesn’t need to document Acute Metabolic Encephalopathy.
    6. As far as acute encephalopathy: It was stated that it needs to be at or close to baseline at discharge, then later, “Return to baseline” isn’t required. I need help with that.
      
      Returning to baseline depends on the type of encephalopathy. For most acute encephalopathies, documentation that the patient returned or is close to baseline at discharge supports their AMS was due to encephalopathy rather than dementia or a chronic type of encephalopathy. For example, if a patient has AMS with hyponatremia and is admitted with acute metabolic encephalopathy, the Provider will treat the underlying case of the encephalopathy (the hyponatremia) and will return to baseline. If a patient has anoxic brain damage due to a traumatic SAD from a fall, this chronic encephalopathy will present differently. Per ACDIS, it’s a common misconception that encephalopathy has only one definition. Encephalopathy can be either metabolic/transient or chronic/progressive/degenerative.
    7. There are no guidelines/coding clinic supporting metabolic encephalopathy due to hyperglycemia, only hypoglycemia — therefore metabolic encephalopathy is often denied – how can we support this? (Even when documentation clearly shows met enc due to hyperglycemia.)
      
      The NIH National Library of Medicine states that metabolic encephalopathy has been associated with acute insults such as DKA, but importantly, the risk of cerebral injury is also related to chronic hyperglycemia. To support metabolic encephalopathy due to hyperglycemia, I would stick to definitions and Physician documentation. Metabolic encephalopathy is a condition that affects brain function due to problems with the body’s metabolism. Hyperglycemia can cause dehydration and acidosis (high levels of acid in the blood), which can damage brain cells.