Acute CHF and Respiratory Failure

mdomineseymdominesey
in CDI Talk Archive
Patient is admitted with “hypoxia” and “acidoisis”. Physician clearly writes “Acute on Chronic Respiratory Failure”.



Also included is the cause of the Respiratory Failure: “…multifactorial, but primarily related to his congestive heart failure”.



As this is a cause and effect scenario, which is principle? They did not vent, but aggressively diuresed the patient.



Respiratory Failure as principle: DRG 189 wt: 1.2694; Acute CHF: DRG 291, wt: 1.5010. Yes we are talking a grand or two, but, each time this is missed/coded wrong, it contributes to a death by a thousand cuts.



What is the consensus? What should be principle? Should the cause be principle with manifestation as secondary? Or the effect of the acute CHF be principle?



Thanks,



Mark



Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

Information Technology
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mdominesey@sibley.org
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Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    If they were equally treated, and its sounds like they were, then you could choose either. I would go with the CHF for higher reimbursement.

    I’m interested in other opinions….

    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

  • Unknown
    edited May 2016
    I agree. I would go with CHF unless they were vented(capture 207/208 and more resources). Both conditions were present on admission and treated. Also, according to this documentation, they would not have the resp failure if they did not have acute CHF.

    Jane Hoyt BSN, RN, CCDS
    Manager, Clinical Documentation Integrity
    Health Information Management
    PAV A, Fifth Floor, #505
    Mail Code 1801
    Denver Health and Hospital Authority
    303.602.3830
    Jane.hoyt@dhha.org

  • robert.hodges2robert.hodges2
    edited May 2016
    I hate to disagree this but it sounds like the principle reason for admission was the respiratory failure. To me the CHF sounds chronic at this time. Unless the provider documents acute CHF exacerbation and type with the acute on chronic respiratory failure, I’d have to go with respiratory failure.



    I can’t wait to see the other responses.



    Robert



    Robert S. Hodges, BSN, MSN, RN, CCDS

    Clinical Documentation Improvement Specialist

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  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    If the CHF is causing the resp failure, then clinically it is not acute. However, that would obviously have to be clearly documented and if it wasn’t it would warrant a query (regardless of whether it was being used as the Pdx).

    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

  • sharon.colesharon.cole
    edited May 2016
    Coming from a case management (severity of illness and intensity of service) background, I would have to say the CHF. Rationale: if not vented, pretty much all other resp treatments could be done as OP. IV diuresis is typically done IP, unless pt goes to a CHF clinic where they are routinely diuresed with IV meds. When the OP IV diuresis is not effective (or they are not a CHF clinic patient), then they require admission for additional IV drugs that are not generally administered in the outpatient setting.

    A patient has to meet IP criteria otherwise RAC will discount it. So I don’t necessarily use the “were both present on admission” rule any longer. Equally treated should mean both treatments meet inpatient criteria for admission.

    Or at least that’s my two cents☺

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

  • mdomineseymdominesey
    edited May 2016
    The H&P stated “CHF Exacerbation” and the Palliative Care Consult stated same. I queried for type AND severity and the answer to that was “Systolic HF”.

    It is not a stretch to interpret this as “Acute on Chronic Systolic Heart Failure”. And with the mentioned aggressive IV dieresis and no vent, I am of the opinion that the CHF should be principle. Also, short of venting, I do not see how the Respiratory failure would be a bigger problem than actually treating the cause of the Respiratory Failure, thus causing the Respiratory Failure to go away. Again, the treatment was directed at the CHF, very little beyond nasal cannula as the pt would not wear CPAP.

    Thanks so much for the great info!

    Mark



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
    Clinical Documentation Excellence
    Sr. Clinical Documentation Improvement Specialist
    Sibley Memorial Hospital

    Information Technology
    5255 Loughboro Rd NW
    Washington DC, 20016-2695

    W: 202.660.6782
    F: 202.537.4477
    mdominesey@sibley.org
    [cid:image002.gif@01CD552A.84149060]
    http://www.sibley.org

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Oops. I meant its not chronic!!

    Sorry
  • vdavis2vdavis2
    edited May 2016
    I would use CHF with mcc Resp Failure…query for specificity of CHF just for quality. Treatments given take care of both issues. If CHF was noted to be the underlying cause of Acute Resp Failure with acidosis, you should be ok.

    My best recommendation would be to double check the documentation to make sure you can clinically validate that actual “resp failure” was present. Make sure clinical indicators and treatments were well documented to justify resp failure, especially if this was a short stay case (LOS less than 3 days). PEPPER and RAC flag those 1-2 day cases, especially CHF with mcc. If documentation is conflicting or vague (ex: dyspnea noted by one MD, SOB by another, Resp failure by another….) you should query to validate the diagnosis. RAC and insurance companies really like to take this mcc away. Good luck-V

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

  • Unknown
    edited May 2016
    3Q 2008 Coding Clinic answers your question:


    Question:

    When a patient with a known history of CHF is admitted with an exacerbation of diastolic congestive heart failure, how would this be coded?

    Answer:

    Assign code 428.33, Diastolic heart failure, acute on chronic, and code 428.0, Congestive heart failure, unspecified. Dorland's Medical Dictionary defines "exacerbation" as an increase in the severity of disease or any of its symptoms. The terms "exacerbated," and "decompensated" indicate that there has been a flare-up (acute phase) of a chronic condition.


    So you would have acute on chronic systolic CHF

    Charlene

  • vdavis2vdavis2
    edited May 2016
    I agree with you MARK!!! J

    Vicki S. Davis, RN CDS
    Clinical Documentation Improvement Manager
    Health Information Management Department
    Alamance Regional Medical Center
    Office (336) 586-3765
    Ascom Mobile (336) 586-4191
    Fax (336) 538-7428
    vdavis2@armc.com

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

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