A Minute for the Medical Staff
A supplement to
medical records briefing
January 2001
Always name the pathophysiology
of the disease
By Robert Gold, MD
Vice President
Healthcare Management Advisors
Alpharetta, GA
The purpose of the International Classification of
Diseases (ICD) is to communicate statistics about
disease processes, their etiologies, demographic
elements, treatment choices, and outcomes among all
areas of the world. In order to have a chance of
delivering good statistics, the proper codes must be
applied to the diseases your patients have, and to the
operative interventions used to treat those diseases.
In some cases, it’s a breeze. Acute appendicitis
without diffuse peritonitis or obstruction is treated with
an appendectomy, and has a certain expected outcome.
People all over the world can easily compare their
morbidity and mortality statistics for that disease and
treatment.
But sometimes, it’s not so easy.
In the usual course of practice, physicians evaluate and
treat certain disease processes with innate knowledge
of the usual etiologies and the pathophysiology of the
disease. In these cases, in order to apply the proper
codes, the physician has to go through a bit more
description than usual.
Understanding and appreciating the difference that
extra documentation can make is the difference
between thinking of it as a burden and taking it as a
matter of course necessary for accurate comparative
data.
Angina
Most physicians call coronary artery occlusive chest
pain “angina.” Some don’t. Some name new onset
angina, worsening angina, angina at rest, and preinfarction angina “unstable.” Some don’t.
It is important to name the clinical situation. If it’s
heart-induced chest pain resulting from the inability to
supply the myocardiu7m with oxygenated blood, call it
“angina.” If it meets the definitions above, call it
“unstable.”
Angina can be induced to occur because of other
clinical situations that result in the heart not getting
enough oxygenated blood and causing cardiac chest
pain that is truly angina.
If your patient has uncontrollable angina because of
the anemia of chronic renal failure and the only way to
treat it is by transfusion, then name the
pathophysiology: “Angina, unstable due to severe
anemia of chronic renal failure.”
If you patient has uncontrollable angina and the EKG
reveals a tachyarrhythmia (e.g., atrial fibrillation with
rapid ventricular response) or bradyarrhythmia such
that the coronaries cannot get enough blood flow and
you have to break the rhythm abnormality to stop the
chest pain, then name the pathophysiology: “Angina,
unstable, due to arrhythmia.”
If your patient has uncontrollable angina or unstable
angina because of the increased metabolic demands of
a high fever or of thyrotoxicosis, then name the
pathophysiology: “Angina, unstable, because of the
increased metabolic demands of (whatever the cause.)”
Why should you go through the trouble of naming the
pathophysiology? It makes sense. You are telling the
world why you selected the treatment modalities you
selected in those cases.
In addition, it tells them why you didn’t select certain
modalities. And finally, when you involve a higher
level of evaluation and management skills, and
document that you justifiably involved several body
systems, you can bill at a higher level of E/M.
Pulmonary edema
Again, we have a condition that is usually associated
with one pathologic process, but even that pathologic
process has several etiologies. Congestive heart failure
(CHF) can be due to arteriosclerotic, hypertensive
heart disease, ischemic heart disease, a primary
cardiomyopathy, or cor pulmonale. We know that left
heart failure is the usual cause of acute pulmonary
edema, regardless of the etiology, but there are other
disease processes that are noncardiogenic that can
result in acute pulmonary edema.
In cases of noncardiac pulmonary edema, it becomes
essential to demonstrate with the proper words your
thoughts about the cause—the pathophysiologic
process that has led to soggy lungs. Because if you do
not elucidate the cause of the pulmonary edema,
coders will automatically apply the code for CHF to
the case, and that’s just not what’s going on.
When a patient develops acute pulmonary edema from
a pulmonary embolus, name the pathophysiology:
“Noncardiac pulmonary edema from pulmonary
embolism.”
When a patient develops acute pulmonary edema from
a crush injury, name the pathophysiology:
“Noncardiac pulmonary edema from pulmonary
contusion.” When a patient develops acute pulmonary
edema from volume overload from chronic renal
failure, has a normal ejection fraction under normal
conditions, has not had ischemic heart disease, and is
basically not a CHF patient, name the
pathophysiology: “Noncardiac pulmonary edema from
volume overload from chronic renal failure.”
When a patient aspirates a significant amount of
gastric acid and burns the lungs, whether or not there
has been time to develop a superinfection, name the
pathophysiology: “Noncardiac pulmonary edema from
aspiration of gastric acid.”
When a patient develops Adult Respiratory Distress
Syndrome (ARDS), he or she needs a ventilator from
overwhelming sepsis, and the chest x-ray shows
pulmonary edema, name the pathophysiology:
“Noncardiac pulmonary edema of ARDS resulting
from overwhelming sepsis.”
The reasons for going through this additional “burden”
of adding a few words is that it makes a tremendous
difference to the ICD coding, and thus to the statistics
in the United States, of patients with pulmonary edema
related to CHO or from noncardiac causes.
It makes a difference in the amount of resources that
you can utilize without question because you have
reflected a more severely ill patient. It makes a
difference to the bill you can submit for your thought
processes and your work because you have
documented and validated a higher level of thought
and management.
More examples of the differences that documentation
can make to the proper assignment of ICD codes will
follow in subsequent issues. In the meantime, be
careful out there.
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