CHF

Unknown

We had a consultant at our facility that gave some interesting advice I'd like some opinions on. Regarding CHF she questioned our query. Her opinion was that we were introducing new information if there is no mention of systolic/diastolic anywhere else in the chart. We never place query unless MD states CHF in chart; then we query for the type. What are your thoughts, is it new information if MD says CHF & we ask systolic/diastolic? Thanks

Laura Bohls, RN BSN
Clinical Documentation Specialist
Prairie Lakes Healthcare System

stacy.vaughn

This is an excerpt from AHIMA Managing an effective query Process.
Therefore, you are seeking Precision/specificity on your CHF. The
information in the chart would suggest a possible acute? or an echo
completed would suggest diastolic? etc.

Healthcare entities could consider a policy in which queries may be
appropriate when documentation in the patient?s record fails to meet one
of the following five criteria:
Legibility. This might include an illegible handwritten entry in the
provider?s progress notes, and the reader cannot determine the provider?s
assessment on the date of discharge.
Completeness. This might include a report indicating abnormal test results
without notation of the clinical significance of these results (e.g., an
x-ray shows a compression fracture of lumbar vertebrae in a patient with
osteoporosis and no evidence of injury).
Clarity. This might include patient diagnosis noted without statement of a
cause or suspected cause (e.g., the patient is admitted with abdominal
pain, fever, and chest pain and no underlying cause or suspected cause is
documented).
Consistency. This might include a disagreement between two or more
treating providers with respect to a diagnosis (e.g., the patient presents
with shortness of breath. The pulmonologist documents pneumonia as the
cause, and the attending documents congestive heart failure as the cause).

Precision. This might include an instance where clinical reports and
clinical condition suggest a more specific diagnosis than is documented
(e.g., congestive heart failure is documented when an echocardiogram and
the patient?s documented clinical condition on admission suggest acute or
chronic diastolic congestive heart failure).


Stacy Vaughn, RHIT, CCS
Data Support Specialist/DRG Assurance
Aurora Baycare Medical Center
2845 Greenbrier Rd
Green Bay, WI 54311
Phone: (920) 288-8655
Fax: (920) 288-3052

arobinso

Im sorry but CHF has to be one or the other....sometimes both. I disagree.

Mandi Robinson, BS, RN, CPC
Clinical Documentation Specialist
Trover Health System
270-326-4982
arobinso@trover.org
"Excellent Care, Every Time"

catladyrn

You have a very interesting consultant. If the information you are seeking is already in the chart, then you don't need to ask for it, do you? You are asking the physician to use the correct terminology based on the clinical information already documented. Your know-it-a^H^H^H^consultant is taking the concept of leading query to an absurd extreme, IMNSHO.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

dallend@einstein.edu

I disagree with that. We have been told to query for systolic/diastolic if CHF is documented, especially if they have had an ECHO during the admission or have results of a previous ECHO documented.

bmurphy@hcpro.com

I agree with Renee. I know and have spoken with several people who put together the AHIMA CDI Practice Brief, and it includes several examples of asking for new information that's not documented in the chart. You can find the practice brief here:

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

It gives an example of a patient admitted with COPD exacerbation and among the options presented in the query are acute respiratory failure.

Brian Murphy, CPC
Director
Association of Clinical Documentation Improvement Specialists (ACDIS)
200 Hoods Lane
Marblehead, MA 01945
781-639-1872, ext. 3216
bmurphy@cdiassociation.com

bea.smith

I agree. If CHF has been mentioned already I feel it is okay to query
for type. I have had someone recently tell me that you shouldn't query
for type if chronic CHF when home meds were not continued inhouse. Their
point was it wasn't addressed and care was not given for this chronic
condition. I don't think it would happen very often where home meds were
not continued (wouldn't that just throw them into an acute CHF
exacerbation?) but if the case ever arises I will investigate more. As
for now, I query for type when the dx is already in the chart.



Bea Smith, RHIT

Clinical Documentation Specialist

Cullman Regional Medical Center

ph: 256-737-2926

robert.hodges2

It's not new information in my mind. To me it's requesting further clarification.

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
 

dbutler

Agreed...especially if the presented options cover the reasonably full clinical spectrum of options (covered by ICD9 codes) to further specify CHF, as well as "other" and the equivalent of "don't know". In my opinion, that gives you a strongly compliant query.

On not continuing home meds -- depending on the clinical situation, as long as the rationale is given, thought, attention, professional judgement, etc. on WHY the home meds are discontinued, then treatment decisions are being made toward that diagnosis and I would suggest it could be captured.

Don

==============

catladyrn

If CHF is only listed as a history, and they're not either continuing their home meds or putting them on new meds for CHF, I would be hard pressed to query for chronic s/d HF, as I don't know how it would meet the definition of secondary diagnosis.

judithbates

I think the fact that they are as you say "putting them on new meds", would say to me they are treating CHF...I would not hesitate to query for specificity in this case. The only time I don't query is when it is written as "Hx of CHF" and the patient is not receiving any medical management. But this documentation will be something I query if I see any further treatment that would indicate new treatment, ie, f/u CXR, one time lasix order, documentation of SOB.

Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906

robert.hodges2

I'm a smaller facility, but I rarely have to query on CHF anymore. My providers know that if they document heart failure without a type and acuity and I don't see an order for an echo, I'll send them a query 100% of the time. They also know that if they order an echo, I'll give them 24 hours to review the results and if there is no comment in their note, they get a query too.

I think they are getting better just to avoid my queries. LOL

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
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
 

sharon.cole

We have a ton of CHF queries as well. We have a large cards group and they know we will query if they don't specify, they just prefer to be difficult (or maybe attention seeking?). Job security for me! We have a quarterly CDI Leadership meeting and every time I am asked why so many CHF queries. The Medical Director and admin then go on about the physicians needing to be confronted by admin/medical director to document better and then nothing is ever said to the physicians. Sometimes I wonder why they continue to have a CDI team. One of these days, I really do plan to go back and try and figure out who wanted information on failing programs. I can give them an earful

judithbates

That would be Don Butler...

Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906

afloyd

We have eight Cardiologist at our facility and I can safely bet we have one that is on the money EVERY time he documents CHF, two that feebly try to document correctly and the rest have to be queried every, single time. Job security, yes! They know I am going to query every time I see it and they answer when queried but are hard pressed to VOLUNTEER anything on their own. I have 13 years of Cardiology nursing background and have worked with these guys, if anything, they know that I am persistent. I think they are just "bucking the system" and don't want to conform quitely to guidelines. At least they answer their queries.....

evanspx@sutterhealth.org

Notable that Cardiology is particularly reported as resistant so
uniformly - the same issue has been noted in my workplace, as well.

Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739

judithbates

I just said yesterday that when I had to educate the nephrology groups about the importance of AKI with ATN...THEY GOT IT... Not the same with the ongoing issue with CHF. I am glad to hear that you share my pain and I'm not alone!!!

Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906

dbutler

We have a similar problem, seems to me that cards tends to get too far into details and underlying causes, as well as having some varied opinions. Because they look so closely at the multiple factors that drive HF for different patients, it is like they feel diastolic / systolic is too simple and general to adequately describe their pt's condition that is under treatment; or that they want to be too specific as to the type or cause of HF.

Does anyone else have that feeling?

Don

mary.a.dunn

One of our cardiologists tells us that he is" too busy saving lives to bother with specific documentation". As a whole our cardiologists refuse to document anything but CHF. They see no need to specify. Even when we query them, we have to hunt them down to get an answer. The nurse practitioners who work for them don't specify either.
Interestingly we can count on the pulmonologist or the nephrologists to document the specific type of CHF. Go figure!

lauriehiggins

As an ER nurse this amazes &I frustrates me. What about continuity of care?
When a pt comes into ER the doc & nurse will look up their old h&p & dc
summary. So....if the severity of the illness is not documented unnecessary
tests are re-done & worst yet pt care could be compromised. I have said this
to docs who have said they were too busy. What if it was your family
member? Its not just for wording its for safety!!

Connected by DROID on Verizon Wireless

robert.hodges2

I agree. Continuity of care is the key here, and very important especially here where we have long term relationships with the Veterans. Especially when so many are seen at different VA facilities, yes it’s that time of year when the “snowbirds” start heading south again for the winter.



Robert



Robert S. Hodges, BSN, MSN, RN, CCDS

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

mary.a.dunn

You’re preaching to the choir here. I agree. The questions is how to get the cardiologist more invested in quality documentation and continuity of care.
Isn’t that the tread of all the discussion this morning?
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Friday, September 09, 2011 10:57 AM
To: Mary A. Dunn
Subject: RE: [cdi_talk] CHF

I agree. Continuity of care is the key here, and very important especially here where we have long term relationships with the Veterans. Especially when so many are seen at different VA facilities, yes it’s that time of year when the “snowbirds” start heading south again for the winter.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
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
[cid:image001.jpg@01CC6EDF.EC9B39E0]
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley


4

lauriehiggins

Yes Bob im in Michigan too. My little town will be losing snowbirds soon. Just because they go south for winter their illnesses don't stop. And we all know they don't being their health records with them

robert.hodges2

Absolutely. Would capture of SOI/ROI work for them? I’m sure the ones who are doing more precise documentation are looking better on HealthGrades and other site. Maybe a little peer review/posting of their scores? They do tend to be a competitive group.



Robert S. Hodges, BSN, MSN, RN, CCDS

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

dbutler

We are part of the University Healthsystems Collaborative, and I have
been able to dig into the details of their statistical mortality model.
Would suppose that it is likely to be similar to many others (since it
is driven by statistical multiple regression analysis). Interestingly,
428.0 triggers the diagnosis group for HF just as easily as the more
specific codes -- so, getting the more specific documentation does not
seem to affect the mortality risk based on the UHC model.

Part of me feels really disappointed about that -- but of course there
are other models & other reasons (such as RAC defensive depth by getting
an additional cc).

Don

catladyrn

Aside from the continuity of care issues already mentioned, you might suggest to your cardiologists that if they don't document appropriately, they might not have any lives to save. The hospital will receive lower scores and lower reimbursement, meaning less money for staff and equipment, and patients tend to stay away from hospitals that seem to perform poorly.

Because it just takes sooooo long to write acute systolic heart failure instead of CHF. Not even the length of a six-second strip....

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

judithbates

Hi Renee,
I was hoping you were going to add something to the topic...And your words are right on time. Yes it is long to write it out. Tried to get medical records to accept ADHF...no go. Has anyone else been able to get an acceptible abreviation at their facility? Wondering whether that may also be a barrier to the needed documentation.

robert.hodges2

Abbreviation use is a big pain. Our medical staff executive committee wanted a new abbreviation list and we found an online reference that they approved. The instructions on how to access the list (with the link) are in the electronic record. We also have a policy that addresses abbreviation use with the following key points.
1. If an abbreviation has more than one meaning on the approved list (like DM) it must be defined the first time it is used in a note, and
2. If an abbreviation has an intended meaning not on the approved list (like pg for pregnancy) then it must be spelled out each time it is used, and
3. If an abbreviation is not on the approved list it cannot be used.

It's a lot of effort to enforce abbreviation use and it takes a lot of time, but we have seen some providers stop using abbreviations all together because we query when it is unclear and coders cannot figure out the intended meaning. I also do a lot of education and reminders on abbreviation use.

And for the record, ADHF is not on our facility approved list. LOL

Robert

dallend@einstein.edu

If CHF is the principal there is absolutely no impact. You are correct. We do not do post discharge queries to clarify CHF when it is the principal.

dbutler

Actually, I was not thinking of when CHF is the pdx -- rather only when
it is a secondary (and further when there would not be any DRG impact).


Robert had suggested that perhaps encouraging physicians to add the
specificity to strengthen profiling for ROM/SOI as well as
Healthgrades.com and other profiling. From the model I have been
reviewing in detail (UHC), there is no added ROM value between 428.0 and
more specific codes.

Don

judithbates

well said Robert!!!

katysuegood@gmail.com

Looks like your MD is using the newer classification system to describe the patient's heart failure (see AHA guidelines from 2013). Unfortunately, ICD-10 did not choose to include HF with preserved/reduced EF in the code set. We continue to ask our providers to please state the types as systolic/diastolic when possible.

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

kerryseekircher

It would be appropriate to have a follow up conversation with the MD.
If the MD does not agree with you this time, sometimes it's better to walk away. At a later time, go back to the MD (or present at a staff meeting) with a case study and show a side by side analysis of the two cases -one with specificity and the other without to demonstrate the difference in los, soi, and even reimbursement (so long as you are not discussing an open case!).
As Katy said, sometimes the terminology they use does not coincide with the coding language and it can help to explain the differences.
Good luck-keep us posted.
Kerry

Kerry Seekircher, RN, BS, CCDS, CDIP
Clinical Documentation Program Manager
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013

Unknown

Everyone please read the minutes of the Coordination and Maintenance Committee of September 22- 23, 2015 where AHIMA has already agreed to most of the cardiac code modifications I submitted in the past few years - you'll have your HFrEF defined in I50.2x and so forth. You'll have codes for right heart failure, acute and chronic. You'll have codes for end-stage heart failure (for those places that do VADs or transplant). The docs don't have to learn these new things. We do.

Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)

mulled2

Hi,
I would say education for the physician on specificity of TYPE of CHF and show him how unspecified CHF codes out vs specified. In addition HFpEF and HFrEF are being taught as acceptable abbreviations in school however CMS doesn’t recognize them. We did a quick 1 min update on this with our providers
Good luck