Q&A: Sequencing an overdose, a fall, Rhabdomyolysis, and AKI

Q: Can you provide some guidance on the sequencing/principal diagnosis selection for the following scenario?

The patient was found unresponsive with unknown down time (likely several hours), given Narcan at home with success. The patient was transported to the ED, found to have Rhabdomyolysis and an acute kidney injury (AKI). No further Narcan given besides the dose at home.

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The ED physician documented the following: “I did discuss the patient with the admitting hospitalist and she will be admitted for further IV hydration and monitoring of her kidney function and mental status.” The ED notes “intravenous drug abuse.”

The admission diagnoses were IV drug abuse, Rhabdomyolysis, AKI, and tachycardia.

Progress notes documented “acute toxic encephalopathy present on admission (POA) resolving in the setting of heroin overdose/AKI/Rhabdomyolysis as evidenced by increased lethargy and somnolence and decreased responsiveness treated and improved with Narcan and IVF.”

The final diagnosis on the discharge summary was “heroin overdose, rhabdomyolysis.”

A CDI specialist reviewed the chart and stated that, clinically, the renal failure was caused by Rhabdomyolysis which was caused by immobility (laying in the same position for hours). The renal failure had nothing to do with heroin. The patient didn’t need any further Narcan after the one dose at home. After study, the reason for admission was treatment of a renal condition.

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Do you agree with this assessment?

A:In this case, the Official Guidelines for Coding and Reporting suggest that the poisoning from the heroin overdose should be sequenced as the principal diagnosis. The remaining sequela that came about after the overdose would be listed as secondary diagnoses. Make sure the AKI gets included in the final code set and doesn’t get skipped because it was omitted from the discharge summary.

This one is a bit controversial because the stated reason for admission being the AKI/Rhabdomyolysis would invoke the guideline that the diagnoses which was chiefly responsible for occasioning the admission be sequenced first. This is in direct conflict with another guideline from ICD-10 which says that when patient is admitted with a sequela from a poisoning event, the poisoning is always sequenced first.

You may write to the American Hospital Association (AHA) with this question to get further feedback from Coding Clinic. My rationale is that ICD-10 conventions themselves supersede even the Uniform Hospital Discharge Data Set (UHDDS) guidelines in the hierarchy of coding. The UHDDS definitions are the standards for interpreting the guidelines, but I do not believe they can directly contradict an instructional note in the ICD-10 system itself which includes those “code first” type of instructions.

If the doctor documented that the patient clearly would not have been admitted for the overdose and clearly was only being admitted for the Rhabdomyolysis/AKI, then you would have additional support for placing Rhabdomyolysis or AKI as the principal diagnosis. However, the way the physician listed the diagnoses in his or her discharge summary, I don’t think you are on solid grounds for making that suggestion.

Issues like these tend to have a strong subjective element.

The Rhabdomyolysis was a direct result of the muscle damage from laying on a hard surface for hours. It happens to patients on operating tables in some instances and even from muscle damage from overexertion at sporting events. It is also a well-known result of intoxication and drug use presentations. The Rhabdomyolysis then causes renal failure. So, what caused the original muscle damage that caused the renal failure? The answer is immobility from a drug overdose.

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Here are a few clinical references for you:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056317/
• https://www.healthline.com/health/rhabdomyolysis#causes
• https://www.ncbi.nlm.nih.gov/pubmed/15645612
• https://www.ncbi.nlm.nih.gov/pubmed/15645612

The Official Guidelines for Coding and Reporting (2019, p. 81) says the following:

When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50. The poisoning codes have an associated intent as their 5th or 6th character (accidental, intentional self-harm, assault and undetermined. If the intent of the poisoning is unknown or unspecified, code the intent as accidental intent. The undetermined intent is only for use if the documentation in the record specifies that the intent cannot be determined. Use additional code(s) for all manifestations of poisonings.

Many people think that the patient must still have “toxicity” in order for the drug overdose to be sequenced as the principal diagnosis, but that is not the standard. A further review of the guidelines (pp. 81-82) reveals the following language over and over again: “drug toxicity or other reaction resulting from,” and “when a reaction results from.”

Observe that ICD-10 isn’t defining poisoning as just being in active toxicity, but it is also defined as if the reaction to the poisoning is still present then the poisoning is principal diagnosis.

The order of events in this case are also important for sequencing. The poisoning resulted in the patient being on the floor, which resulted in the Rhabdomyolysis, which lead to the AKI. In other words, downstream from the original poisoning (rather as a direct result of toxicity or if the toxicity was still present or not), is still a result of the poisoning and therefore likely still falls under the guidelines above as far as sequencing as a “reaction.”

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CRC, CDI education specialist for HCPro in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here.

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