Acute on chronic CHF

ddraizeddraize
edited May 2016 in CDI Talk Archive
I have a physician that documented acute on chronic CHF combined. My coders are telling me that they can not code this as combined systolic/diastolic unless he documents combine acute on chronic CHF. Does any one have any input or know of any reference that the words must be turned around. Thanks for your help.

Diane Draize RN, CPUR,CCDS
Clinical Documentation Specialist

Ministry Door County Medical Center
diane.draize@ministryhealth.org
920-743-5566 ex 3143

We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do

Comments

  • mark.domineseymark.dominesey
    edited May 2016
    Did your physician intend to convey systolic AND diastolic with the "combined" term? CHF must be clarified to systolic/diastolic/both AND acute/chronic/both.

    Hope this helps!

    Mark


    _______________________________________
    Mark Dominesey, RN/BSN, MBA
    Clinical Documentation Improvement Specialist
    Martha Jefferson Hospital



  • catladyrncatladyrn
    I have never heard that the sequence of the words is relevant. In fact, they can write systolic CHF in one note and write acute CHF in another note and we take that as acute systolic HF. But I agree that the physician probably needs to specify what they mean by combined, even though we know what they mean.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • Unknown
    edited May 2016
    Sorry to change the subject here. I need your help out there. Acute perforated appendicitis with an open appendectomy performed. Surgeon states in OR report that it was perforated at base but he also stated, "there is no generalized peritonitis." If we code perforated appendicitis it codes out to appendicitis with generalized peritonitis. Path report states, Acute appendicitis. How would you code this one?

  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    If the chart stated acute CHF -- you would query for systolic or diastolic
    If the chart stated chronic CHF -- you would query for systolic or diastolic
    If the chart stated acute on chronic CHF -- you would query for systolic or diastolic

    The addition of the word "combined" may have been interpreted by the coder to mean that the CHF was both "acute and chronic" combined. I agree that a query for "systolic/diastolic" would clarify the statement. Where it may be obvious those in the clinical setting it may be interpreted differently otherwise.

    debbie

  • NormaBNormaB
    edited May 2016
    It was implied that he meant diastolic and systolic but he will need to document them. What else could combined mean other than the two types?

    I couldn't locate a coding clinic which addresses the "assumption" of combined as both natures. Only the severity seems to be addressed.

    Anyone else know of info. ?

  • NormaBNormaB
    edited May 2016
    Just looking at the "includes notes" within the AC Appendicitis w/rupture - it seems to cover a variety of scenarios that I believe will cover your case.

    One being "Appendicitis w/perforation".

    Because if you look at the one w/o peritonitis it specifically mentions, "w/o mention of perforation, peritonitis or rupture".

    So it would seem w/rupture but w/o peritonitis is still covered in 540.0.

  • cstukenbergcstukenberg
    edited May 2016
    For clarification sake, I would probably query it. It may seem obvious to be diastolic/systolic; but remember nursing 101, if it was not documented, it was not done.


    Colleen Stukenberg MSN, RN, CMSRN, CCDS
    815-599-6820
  • bea.smithbea.smith
    edited May 2016
    I agree with everyone else, you have to get him to clarify the type of CHF. I am a coder, now working in the CDI program at my facility and if I read those words in the chart I would interpret that as an acute exacerbation combined with chronic CHF. It wouldn't have even crossed my mind that he meant combined systolic and diastolic. Interesting how one reads and interprets the same words differently, which is why I would be sure to clarify. We don't know how an auditor would interpret the wording, so better safe than sorry.

    Hope this helps.

    Bea Smith, RHIT
    Clinical Documentation Specialist
    Cullman Regional Medical Center
    256-737-2926

  • catladyrncatladyrn
    I'm reading everyone's responses, including mine, and what's interesting is that the OP is apparently saying that had the physician written, "combined acute on chronic CHF," her coders would have taken that as 428.43, but because he wrote "acute on chronic CHF, combined," they won't. Would like to hear from her coders what their rationale is, because it won't fly either way without more specificity.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • NormaBNormaB
    edited May 2016
    I didn't interpret it that way. I took it to mean the coder would not accept the "combined" to mean systolic and diastolic.

    Theres a coding clinic for merging the severity of the condition but not one for the nature or type of the condition.

    Did I misunderstand her case? :(

  • epraczepracz
    My only question is do you need the wording Acute on Chronic combined systolic & diastolic heart failure documented? If you don
  • mark.domineseymark.dominesey
    edited May 2016
    Some advice from coding clinic:



    Clarification



    Diastolic and Systolic Failure with Congestive Heart Failure



    Question:



    According to Coding Clinic, Fourth Quarter 2002, pages 52-53, when a
    diagnosis is listed as systolic, diastolic, or combined systolic and
    diastolic congestive heart failure, code 428.0, Congestive heart
    failure, is reported in addition to the new codes that were created for
    systolic heart failure (428.20-428.23), diastolic heart failure
    (428.30-428.33), and combined systolic and diastolic heart failure
    (428.40-428.43). While we understand that the additional code for the
    congestive heart failure is necessary for specificity, we would like
    clarification on this matter since there are no instructional notes to
    "code also 428.0" or "use additional code 428.0" printed in ICD-9-CM
    under subcategories 428.2, 428.3, or 428.4 (or programmed into the
    encoders).



    Answer:



    The advice published in Coding Clinic, Fourth Quarter 2002, pages 52-53,
    is still valid.



    Congestive heart failure is not an inherent component of systolic or
    diastolic heart failure. When the diagnostic statement lists congestive
    heart failure along with either systolic or diastolic heart failure, two
    codes are required. For example, a diagnosis of "acute combined systolic
    and diastolic congestive heart," would be assigned two codes 428.41,
    Combined systolic and diastolic heart failure, acute, and 428.0,
    Congestive heart failure, unspecified. Both codes are needed to report
    the specific type of heart failure, congestive, diastolic, and systolic.






    Kindest Regards,



    Mark





    ___________________________________________

    Mark Dominesey, RN/BSN, MBA

    Clinical Documentation Improvement Specialist

    Health Information Management Services

    Martha Jefferson Hospital

    459 Locust Ave

    Charlottesville, VA 22902


  • NormaBNormaB
    edited May 2016
    I looked at that coding clinic but it did not address the phrase the coders were stumped over.

    How would you code "Acute Combiined Heart Failure"?

    Would you have the physician specify that by combined he means sysolic and diastolic? Or would you assume that by combined he means S&D and just code it?

    I think the OP's coders want more specificity than combined - if I am reading her question correctly.

    I think I may ammend my first answer and just say combined is S&D and would code it that way.

    Norma

  • angelamckee@uh.organgelamckee@uh.org
    edited May 2016
    I would not code combined CHF to systolic and diastolic without further clarification from the physician. I see nothing in what has been written thus far to allow this. We have this opportunity to query. When in doubt, query.
    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga.  30901
    706-774-7836  

  • robert.hodges2robert.hodges2
    edited May 2016
    My understanding based on everything I've been taught and told is for
    coding you need to have the systolic and diastolic clarified along with
    the acute on chronic. Otherwise it codes as CHF unspecified since the
    systolic/diastolic is the 4th digit of the ICD-9 code and acute/chronic
    is the 5th digit.



    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



  • MelindascharfMelindascharf
    edited May 2016
    I would never assume that combined means systolic and diastolic. Maybe he means combined "left" and "right" or combined who knows what. We would always query that.
    Melinda Scharf RN BSN CCDS

  • kmaritankmaritan
    edited May 2016
    In the recent past in an answer to a clarification, a physician wrote "acute on chronic combined CHF". I went to our coders and only one stated she would feel comfortable in coding "diastolic and systolic" for "combined." I decided then that I would always write a clarification when only combined was documented. I also changed my wording in the clarification to ask, i.e., "diastolic or systolic or both diastolic and systolic" to get the word combined out of the response. It has been quite successful. It seems the shortcut of "combined" is removed encouraging the physician to respond with "diastolic and systolic."

    Karen Maritano, RN
    Documentation Specialist
    Care Management
    Legacy Health
    phone 503-413-7154
    pager 503-983-0683


  • Unknown
    edited May 2016
    Yes, this is what we have been told too

    Juanita B. Seel, RN
    Greenville Memorial Hospital



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