CDI Tips: Rhabdomyolysis

Topic: Rhabdomyolysis

Definition: Muscle necrosis with release of creatine kinase (CK), potassium, phosphate and myoglobin into the blood stream. The causes can be traumatic or non-traumatic

  • Traumatic- any severe soft tissue/muscle trauma
  • External causes-intense physical activity such as extreme weightlifting
  • Non-traumatic-infections, drugs, toxins, or metabolic disorders. Ischemia, such as prolonged pressure on muscle tissue after a fall, can cause rhabdomyolysis. The fall itself is not the cause; rather, it’s the resulting muscle ischemia due to the prolonged pressure.

Diagnostic Criteria:

  • CK levels at presentation are typically 5 times the upper limit of normal, and can range from 1,500-100K u/L.
    • Normal levels can range 22-198 u/L depending on lab test used
  • Myoglobin may be present in urine, but it is quickly eliminated
  • Clinical presentations may include muscle pain (50% of cases), weakness and dark-colored urine
  • The condition may result in Acute Kidney Injury (AKI)/Acute Tubular Necrosis (ATN) and electrolyte abnormalities
  • Treatment includes aggressive IV fluid hydration and correction of electrolyte imbalance

 

 

CDI Tip January

Coding Considerations:

  • High CK levels can often be indicative of an acute MI, and this could be a differential diagnosis upon admission.
  • It is important to always consider the definition of principal diagnosis when coding: that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
  • Coding Clinics to consider:
    • AHA Coding Clinic 2002 Third Quarter, p. 28: Acute renal failure due to rhabdomyolysis
    • AHA Coding Clinic 2019 Second Quarter, p. 12: Rhabdomyolysis (traumatic vs non-traumatic)

CDI Practice Considerations:

  • Rhabdomyolysis is assigned to ICD-10-CM code M62.82 and is recognized as a Complication/Comorbidity (CC) whereas Traumatic Rhabdomyolysis is assigned code T79.6XXA and is a non-CC.
  • The term traumatic rhabdomyolysis should be reserved for cases involving significant trauma, and not for situations such as prolonged immobility after a fall without evidence of severe injury.
  • Traumatic rhabdomyolysis should only be coded when explicitly documented by the provider.
  • A urine dipstick may yield a false positive for blood in the absence of or with minimal red blood cells (RBCs), often due to the presence of myoglobin, which is commonly seen in rhabdomyolysis.
  • When AKI or ATN is the primary focus of treatment, it may be appropriate to assign it as the principal diagnosis.

Query Opportunity:

  • Query as necessary, based on clinical indicators, to clarify whether the rhabdomyolysis is traumatic in nature.
  • AKI secondary to rhabdomyolysis is almost always due to ATN, though ATN may not be explicitly documented. In such cases, a provider query may be warranted to clarify the underlying etiology.
  • When a patient is admitted with significant traumatic fractures (e.g., hip or femur) review for traumatic rhabdomyolysis querying as necessary, as when traumatic rhabdomyolysis is added the MS-DRG assignment shifts to 963–965: Other Multiple Significant Trauma. This can significantly affect reimbursement and resource utilization

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