Where I work, some of the Billing reviewers often ask us to make questionable diagnoses. For example, they may notice a patient has heart rate over 90 and a WBC over 12 and ask us to document the diagnosis of sepsis. Or, any time a patient has an elevated RVSP on their Echo they ask us to document Pulmonary Hypertension. This is often not a correct diagnosis, and here are some of my standard responses to these.

SIRS and Sepsis

This is SIRS.

Sepsis is not defined by SIRS and an infectious source. See:
   Singer M, Deutschman CS, Seymour CW, et al.
   The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).
   JAMA. 2016;315(8):801–810. doi:10.1001/jama.2016.0287

"The current use of 2 or more SIRS criteria (Box 1) to identify sepsis was unanimously considered by the task force to be unhelpful. Changes in white blood cell count, temperature, and heart rate reflect inflammation, the host response to “danger” in the form of infection or other insults. The SIRS criteria do not necessarily indicate a dysregulated, life-threatening response. SIRS criteria are present in many hospitalized patients, including those who never develop infection and never incur adverse outcomes (poor discriminant validity).25
Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Organ dysfunction can be identified as an acute change in total SOFA score >=2 points consequent to the infection. The baseline SOFA score can be assumed to be zero in patients not known to have preexisting organ dysfunction. A SOFA score =2 reflects an overall mortality risk of approximately 10% in a general hospital population with suspected infection. Even patients presenting with modest dysfunction can deteriorate further, emphasizing the seriousness of this condition and the need for prompt and appropriate intervention, if not already being instituted."

Echo Findings

This is "Abnormal Echocardiogram Finding"

First, an Echocardiogram is not sufficient to diagnose Pulmonary Hypertension. This is documented in current cardiology guidelines.

"PH is defined as an increase in mean pulmonary artery (mPA) =25 mm Hg at rest, as assessed by right heart catheterization"
    Galiè N, Humbert M, Vachiery JL, et al.
    2015 ESC/ERS Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension. Eur Heart J 2015;Aug 29

"The diagnosis of PAH requires confirmation with a complete right heart catheterization (RHC)"
    ACCF/AHA 2009 Expert Consensus Document on Pulmonary Hypertension
    A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association:
    Developed in Collaboration With the American College of Chest Physicians, American Thoracic Society, Inc., and the Pulmonary Hypertension Association

Now, you may ask why not diagnose with an Echo? Studies show an Echo is not sufficiently sensitive or specific. Again, from current cardiology guidelines:

"Noninvasive tests are frequently performed to determine whether or not PH might bepresent. However, such tests are notsufficiently accurate to replace direct hemodynamic measurements in patients with SCD. Therefore, the diagnosis of PHrequires RHC [Right Heart Catheterization]. Doppler echocardiography is one such noninvasive test (Figure 1). It evaluates the heart for abnormalities suggestive of PH, such as right atrial enlargement, right ventricular dilation or hypertrophy, tricuspid regurgitation, and/or a right-to-left septum shift. It also measures the TRV and uses this to estimate the pulmonary artery systolic pressure. Although an attractive option because it is noninvasive and readily available in most institutions, Doppler echocardiography is imperfect asa diagnostic test. This has been illustrated by a study of a population of patients with SCD with a prevalence of PH of 6%; the positive predictive value for PH was only 25% among patients with a TRV of at least 2.5 m/second, although this improved to 64% when a TRV greater than 2.9 m/second was used as the threshold instead. The positive predictive value of Doppler echocardiography was also improved by combining it with other tests. The combination of a TRV of at least 2.5 m/second and either an NT-pro-BNP levelgreater than 164 pg/ml or a 6-minute walk distance less than 333 m improved the positive predictive value to 62% (2). Because only positive results were reported, it is not possible to estimate how many results were negative. In another study, a TRV of at least 2.5 m/second identifiedPH with a sensitivity and specificity of78 and 19%, respectively. The sensitivity decreased but the specificity increased to 67 and 81%, respectively, when a TRV of at least 2.88 m/second was used instead (14)."
    S. Klings, et al
    American Thoracic Society Clinical Practice Guideline: Diagnosis, Risk Stratification, and Management of Pulmonary Hypertension of Sickle Cell Disease
    Am J Respir Crit Care Med. 2014 Mar 15;189(6):727-40.

Documentation Query Responses

This is a response to a coding query from our documentation team:
- The patient has hypomagnesemia
- The patient is clinically obese with a BMI over 30
- The patient has low albumin