preserved EF

morrisonbalrock@aol.com

We are getting some feed back that the current standard for documentation possibly from the ACC for is for documentation of
preserved EF and diastolic dysfunction, not the specificity of systolic chf, diastolic chf.
any one else with this issue?

ssalinas

CC First Qtr 2014 confirmed that a query is necessary in both I-9 and I-10 for this sort of documentation. "Coders cannot assume either systolic or diastolic based on these newer terms."

Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org

catladyrn

I usually have included language to this effect in my queries: "Although the term preserved EF is well-understood clinically, CMS reporting requirements still mandate the use of systolic and/or diastolic when reporting cases of heart failure."

My favorite response when they don't get it came from Charlie Morell in CDI Talk a long time ago:

"We explain that we are currently using ICD-9-CM codes. The rest of the world has been using ICD-10-CM since 1999. New coding terminology is a long process because it has input from physician panels, the four cooperating parties etc. So, while the AHA and ACC may now be using newer terminology and even including NYHA Class information...these cannot be coded. Certainly the physician can document these newer terms,but if they wish the great care they render to be reflected in the medical record and positively impact their quality ratings they ALSO need to use the terminology that can be coded. Otherwise that patient with Pneumonia and a decreased ejection fraction will look like he stayed too long in the hospital and the physician may not be a "preferred provider" in the future."

Renee

Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
Director, Clinical Documentation, Core Measures and Outcomes
Tanner Health System