RE: CHF

pfowlerpfowler
edited May 2016 in CDI Talk Archive
If the physician documents acute CHF in the discharge note and on the
list of d/c diagnoses he documented CHF, systolic and diastolic. Does
this need to be clarified for acute systolic and diastolic CHF?

Patsy Fowler RN, MSN, CCDS
Certified Clinical Documentation Specialist
Marion Regional Hospital
PO Box 1150
Marion, SC 29571
Office 843-431-2044
Cell 843-431-2863
Fax 843-431-2432







Comments

  • bea.smithbea.smith
    edited May 2016
    In my opinion, it would be safe for a coder to make that link and code
    acute on chronic systolic and diastolic CHF. I don't feel you'd need to
    get any further clarification.

    Bea Smith, RHIT
    Clinical Documentation Specialist
    Cullman Regional Medical Center
    ph: 256-737-2926
    fax: 256-737-2714






    .
  • pfowlerpfowler
    edited May 2016
    Thanks. That was my thought also, just wanted to be sure.

    Patsy Fowler RN, MSN, CCDS
    Certified Clinical Documentation Specialist
    Marion Regional Hospital
    PO Box 1150
    Marion, SC 29571
    Office 843-431-2044
    Cell 843-431-2863
    Fax 843-431-2432



  • NormaBNormaB
    edited May 2016
    You may connect them all for Ac on Chr. Combined heart failure


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    I agree. We would not query under those circumstances.


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