Advice on coding of cardiorenal syndrome
Please help us with the coding for cardiorenal syndrome and hypertensive heart disease. If a patient has documented "hypertensive heart disease" as well as CKD and came in with acute on chronic diastolic CHF, what should be coded and what DRG should be used? Does the physician need to document that the CHF was caused by the hypertension?
Also, if the physician documents that the patient has "cardiorenal syndrome" has HTN, CKD and comes in with acute on chronic diastolic CHF, how should this be coded/DRG assigned? What , if any cause and effect documentation is needed?
Lastly, if a patient has hypertension, acute on chronic CHF and CKD or AKI, what is the best way to capture the SOI for the patient in terms of clarification to the documentation?
Any thoughts on this would be appreciated!!
Thanks,
Robin
Robin Van Vught, RN, BSN
Care Coordination Manager
Meriter Hospital
(608) 417-5476
rvanvught@meriter.com
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Also, if the physician documents that the patient has "cardiorenal syndrome" has HTN, CKD and comes in with acute on chronic diastolic CHF, how should this be coded/DRG assigned? What , if any cause and effect documentation is needed?
Lastly, if a patient has hypertension, acute on chronic CHF and CKD or AKI, what is the best way to capture the SOI for the patient in terms of clarification to the documentation?
Any thoughts on this would be appreciated!!
Thanks,
Robin
Robin Van Vught, RN, BSN
Care Coordination Manager
Meriter Hospital
(608) 417-5476
rvanvught@meriter.com
Confidentiality Notice follows:
The information in this message (and the documents attached to it, if any) is confidential and may be legally privileged. It is intended solely for the addressee. Access to this message by anyone else is unauthorized. If you are not the intended recipient, any disclosure, copying, distribution or any action taken, or omitted to be taken in reliance on it is prohibited and may be unlawful. If you have received this message in error, please delete all electronic copies of this message (and the documents attached to it, if any), destroy any hard copies you may have created and notify me immediately by replying to this email. Thank you.
Comments
If a pt. has CKD.... and hypertension, a cause & effect is assumed. With cardiovascular disease, you must have a linkage. The physician must document hypertensive cardiovasular disease and also CKD or cardiorenal disease. Below is how I would assign the codes for the HCVD + CKD + ac/ch diastolic HF.
With the term documented as cardiorenal disease/syndrome, I believe there is a linkage. No additional query is needed. I would code the principal as HCVD+HCKD (404.XX )+ CKD, unspecified (585.9) -+ 428.33 and 428.0 for the ac/ch diastolic CHF. I used unspecified for the stage as you didn't specify. The DRG would be 291 if you have an MCC and no procedure. It all depends on the other diagnoses and procedures that are performed as to the DRG assignment.
You can reference Coding Clinic July-August- 1984- Hypertensive disease - guidelines for the rules. Hope that is helpful.
Jolene File,RHIT,CCS,CPC-H,CCDS
Documentation Improvement Specialist-Coder
Hays Medical Center
jolene.file@haysmed.com
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