Health data standards and systems

Please advise on the correct code assignment of rhabdomyolysis following a fall in the two scenarios below. Case 1 did not result in any acute injury, whereas in Case 2, the patient suffered a # NOF. Case 3 is an example of rhabdomyolysis due to strenuous exercise. Please provide code assignment advice on this scenario also.

CASE 1 Discharge Summary - Principal Diagnosis:
Urosepsis
Rhabdomyolysis
Fall

69 year old male presenting with fall + 3 days on floor unable to get up on b/g metastatic colorectal cancer

HOPC
- had fall at home, unable to get back up
- ?seizures vs presyncopal, pt has poor recollection of event, fell out of bed
- dysuria 3-4 days prior

Progress
#Urosepsis
- BC - E coli sensitive to penicillin, pt has allergy to penicillin (rash), given ceftriaxone, cefazolin 2g TDS (5 days IV total), changed to PO antibiotics on 7/11/14
- Urine- E coli sensitive to penicillin
- initially had mild delirium, now settled

#rhabdomyolysis + Acute renal impairment
- was on floor for 3 days
- CK 2000-3000 on arrival, now normalised
- responded well to IVT

#rehab
- recommended by allied health for rehab before d/c home to improve mobility

Follow up
- defer chemo until well + r/v in oncology clinic approx 2 weeks

CASE 2 Discharge Summary - Principal Diagnosis:
Left subcapital NOF
Rhabdomyolysis:
- Cr 1712
- Dehydrated
- Tx with IVT

AoCRF
- IDC inserted
- Treated with IV hydration
- Nephrotoxics withheld

Fall from bed
- XRays reviewed- nil fracture
- Neuro obs stable

Summary of Inpatient Management:
87 yo female with L hip # post fall off bed:
- L hemiarthroplasty (18/11/2014)
- DVT prophylaxis
- IV antibiotics
- Analgesia
- For subacute transfer to improve mobility/function
- For wound review in 2 weeks

Progress notes
87 yo female with # NOF
- Rhabdomyolysis
- Mild AoCRF (Cr 102 - 110)

Patient lives at home alone and this pm was found by visiting relative on floor. Patient unable to recall how she got there or how long she was there.

CASE 3
Principal Diagnosis: Rhabdomyolysis

Summary of Inpatient Management:
43 year old male referred from GP with high CK

HOPC:
- Underwent 1/2 hour exercise at gym
- Felt pain in legs, muscular aches and pain
- Noticed dark urine
- Presented to GP - CK shown to be 80 000
- GP sent patient to emergency department
- CK on admission to hospital found to be 123 000

O/E:
- Appears well
- No myopathy symptoms,
- normal neurologic examination

Bloods otherwise normal

- Treated with IV hydration
- CK carefully monitored. Initial decrease in same and then rebound increase. ? cause.
- Reviewed by rheumatology team during admission- likely rhabdomyolysis. No current indication for muscle biopsy
- Patient well throughout admission

Plan:
- Discharge home
- Outpatients clinic with repeat bloods in 4-6 weeks, including vasculitic, metabolic, and myositis work up

Progress Notes:
ATSP re: CK 15000 today (9000 yesterday). 43 yo presents with rhabdo post exercise on Sunday and Monday,pain tonight.

Imp:
Not overloaded, no evidence of compartment syndrome, CK high 1.5 days later, likely still elevated from muscle damage 2/7 ago, however still at risk of AKI. (P) cont IVT and check CK.

The default code in the Index leads to the nontraumatic M code. Can VICC please advise on when it is appropriate to assign the code for traumatic rhabdomyolysis? Is it enough to select this option when it is following a fall or due to other external cause, or does traumatic need to be documented?

In Case 1 and 2, documentation supports rhabdomyolysis due to immobility. Should the M code be assigned?

In Case 3, rhabdomyolysis is post exercise and muscle damage. Is this enough to assign T79.6 Traumatic ischaemia of muscle?

Also, please refer to Pain versus injury post trauma, December 2006 Coding Matters Vol 13, No 3. This advice instructs the coder to assign an injury code as it could be argued that pain signifies an underlying injury. Could we apply similar logic to the above scenarios? If rhabdomyolysis results following an external cause, can we assume traumatic?

Search details:
Rhabdomyolysis is a serious syndrome due to a direct or indirect muscle injury. It results from the death of muscle fibers and release of their content into the bloodstream. This can lead to complications such as renal failure. The most common causes are:
- The use of alcohol or illegal drugs
- Extreme muscle strain
- A crush injury such as from an auto accident, fall, or building collapse
- Long-lasting muscle compression such as that caused by prolonged immobilization after a fall or lying unconscious on a hard surface during illness or while under the influence of alcohol or medication.

The ICD-10-AM Alphabetic Index entry is:
Rhabdomyolysis (idiopathic) NEC M62.8-
-traumatic T79.6

VICC advises that in order to follow the essential modifier 'traumatic' under Index entry Rhabdomyolysis (idiopathic) NEC /traumatic, there needs to be documentation of a causal relationship between the trauma and the rhabdomyolysis.

If you are in doubt or unable to seek clinical clarification, assign the default code at lead term Rhabdomyolysis.

In respect to the scenarios cited, VICC does not consider that there is a documented causal relationship in any of the scenarios to allow the assignment of T79.6 Traumatic ischaemia of muscle and would therefore assign M62.8-Other specified disorders of muscle.