HCVD

ddouthitddouthit
in CDI Talk Archive
Suggestions on verbiage for query for correlation between CHF and hypertension. Patient admitted with acute on chronic CHF secondary progressive chronic kidney disease. Patient with hx. of controlled HTN.

Thanks,
Dorie Douthit

Comments

  • dvitalone1dvitalone1
    edited May 2016
    A cause and effect relationship between HTN and Chronic renal disease can be assumed per CMS guidelines but a cause and effect relationship between HTN and CAD may not be assumed and coded unless documented as such by the attending physician.

    Patient has a history of HTN, CAD and Chronic renal disease with presenting diagnosis of CHF.

    Please reply to this query and document in your next progress note the relationship, if any, between HTN and CAD.
  • robert.hodges2robert.hodges2
    edited May 2016
    I hate seeing "history of" in a diagnosis, especially when it's being treated! Coders have to use a V code for that.

    Back to the original question. I would ask if the hypertension is an active diagnosis or if it has been fully resolved first. Then I would simply ask the provider if there is a link between the two conditions, and if there is could they document that link.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
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    E: Robert.Hodges2@va.gov
     
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