chronic DVT/PE

tkreilingtkreiling
in CDI Talk Archive
Can anyone share how they determine on whether or not to code a DVT or PE as chronic vs history code? Do you query the physician for a chronic DVT or PE if you notice they are still on treatment? Any help with this situation would be appreciated.
Thanks,
Tara

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    I would query. In fact if I see something being treated and it's not mentioned in the note it is obviously something being evaluated and managed and so we should take credit for it. I usually ask "what is being treated with medication X", to leave it open ended and compliant.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

  • dbutlerdbutler
    edited May 2016
    My understanding is that a chronic DVT/PE is considered under tx with coumadin for 6 months following initial diagnosis. Depending on documentation & clinical specifics, may need to query physician to clarify.
    Would tend to support coding if on tx & < 6 months with diagnosis documentation.

    Don

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