New onset =acute?

vanessa.falkoffvanessa.falkoff
in CDI Talk Archive
Happy Friday everyone!
Does anyone have a written reference regarding the meaning of "new onset?"
If a physician dictates "new onset systolic heart failure", and it's a secondary Dx , should it be coded as systolic heart failure? acute systolic heart failure ? or queried for acute vs chronic?
Thanks!

Vanessa Falkoff, RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
office (702) 383-7322
cell (702) 204-0054
vanessa.falkoff@umcsn.com

Comments

  • mdomineseymdominesey
    edited May 2016
    Likely the first time a CHF is diagnosed, it is because of an acute event. Nevertheless, a query is warranted to establish the acuity. Include any clinical indicators of acute CHF (edema, effusion, dyspnea, xray, BNP, etc).

    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
    http://www.sibley.org
  • ddouthitddouthit
    edited May 2016
    Unfortunately, you will need to query for acuity. New onset is not synonymous with "acute" in ICD9 coding.

    Dorie Douthit, RHIT,CCS
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