HYPERTENSION QUERY

dvitalone1dvitalone1
in CDI Talk Archive
I need some assistance. I have a patient that is diagnosed this admission with Right hemisphere multiple infarcts with left hemiparesis. BP on arrival 193/106, 188/118, 195/107. H/o hypertensive heart disease. Pt given IV Labetalol, Lopressor PO and norvasc PO in ER and continues to have meds adjustments during admission. Per Cardio consult "1. Right hemisphere multiple infarcts with left hemiparesis. 2. Labile hypertension, probably causing this stroke. Uncontrolled hypertension or secondary stroke. 3. Hypertensive cardiovascular disease."
I have no CC/MCC on this case and want to formulate a query related to more specific hypertension, any suggestions on how to word the query and what chocies to give? Thank you for your help!
Dawn V.

Comments

  • sharon.colesharon.cole
    edited May 2016
    Before querying for a more specific hypertension, you need to make sure they meet criteria for malignant or accelerated HTN. If there are no other signs/symptoms except the elevation in patient's blood pressure, I'm not sure you will get any additional diagnoses. Here is what we look for in the documentation.

    Malignant HTN (medical emergency) indicators:
    • Blood pressure > 200/140
    • Papilledema
    • Retinal hemorrhage
    • Other organ compromise
    • IV vasodilators: Beta blockers, ACE, Calcium channel blockers
    Accelerated HTN indicators:
    • Sustained elevated blood pressure
    • No evidence of papilledema

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org


  • Unknown
    edited May 2016
    Example of query question:

    Based on your clinical judgment are you able to further specify this patients hypertension?
    {List all appropriate clinical indicators.}

    - uncontrolled
    - accelerated (significant increase over baseline B/P c associated target organ damage)
    - malignant (as above + papilledema on fundoscopic exam)
    - HTN urgency (no evidence of target organ damage; Severely elevated B/P S>220 OR D>120)
    - HTN emergency (requires immediate Rx)
    - other more appropriate diagnosis
    - unable to determine


    I have included the definitions I go by (taken from an article by Dr. Gold) to determine if a query is needed.


    Myself, I would not choose to query in this case.



    Charlene Thiry RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Quality Resources
    Menorah Medical Center
    5721 W. 119th Street | Overland Park, Kansas 66209




  • dvitalone1dvitalone1
    edited May 2016
    Thank you


    Dawn M. Vitalone, RN
    Clinical Documentation Improvement Specialist
    Community Hospital
    Munster, IN 46321
    dvitalone@comhs.org
    219-513-2611

  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited May 2016
    Hemiparesis is still cc, isn't it? I would be at MS-DRG 65.

    Sharon Cooper, RN-BC, CCS, CDIP, CCDS
    AHIMA-Approved ICD-10-CM/PCS Trainer

  • linda.steinhofflinda.steinhoff
    edited May 2016
    Testing, testing...I have not seen any CDI activity since Friday - just checking......Linda :)

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    May *some* lucky folks are on vacation...

    Or, they've got all their problems sorted out. If that's the case, I'm VERY jeaous!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • dvitalone1dvitalone1
    edited May 2016
    Or, we are working hard reviewing cases, educating physicians and posting queries that we don't have time to write :)


    Dawn


  • sharon.colesharon.cole
    edited May 2016
    Joint commission survey - need I say more :(

    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org

  • ssalinasssalinas
    edited May 2016
    Wishing you all the best..........

    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    213-250-4200 Extension 3336


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