POST operative Cabgs and Valve surgeries

annnd2009@gmail.com

Happy Friday!

What type of things do you look for to query for CHF after CT surgeries? when is Lasix inherent(for how long)? Any differences between valves and Cabgs? Does history of ( or no history of CHF) effect your decisions?

Thanks.
Ann

Unknown

Ann - be careful about jumping to conclusions. With use of long anesthetic agents, with bypass, with people being different, use of Lasix is normal (many of them have been on Lasix for years pre-op), use of pressors does NOT mean cardiogenic shock but attempts at stabilizing autonomic nerve dysfunction - in fact, it may alternate with milrinone, use of the vent does NOT mean respiratory failure but desire of the anesthesiologist and the surgeon to minimize the stress on the cardiorespiratory system. Many patients going into valve surgery have had chronic left ventricular failure due to valvular cardiomyopathy - and guess what - after surgery, they have chronic heart failure due to valvular cardiomyopathy. And it's usually going to be chronic diastolic failure with preserved ejection fraction for valve surgeries. CABG patients may have dilation and chronic systolic failure. Fluid balance can be a bear after cardiopulmonary bypass, especially in diabetic patients. Look for "acute pulmonary edema" (not some unchanging pulmonary edema or congestion on chest x-ray - they all have that). Look for bumps in BNP followed by intensive work in trying to reduce preload (that's where the high doses of diuretic might come into play, but you'll see significant changes in x-ray and BNP going along with that). Just use of Lasix is nothing.

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

heidi.koenig

I have a question about cardiogenic shock. Some coders reject it as a MCC because they feel it is an expected outcome of a CABG. Others are OK with shock. My argument is that ABLA, for example, is an expected outcome of a major joint replacement, but is routinely accepted as a CC.

lsipos@monument.health

From my standpoint, coders should NOT get to-nor should they "reject" a diagnosis! Wouldn’t that mean they are practicing medicine without a license?!

I think there-in lies our job... to question if it is integral or not... much like a post-op ileus post related to GI surgery.
We query (if appropriate) for if this an expected outcome integral to the procedure or not. Especially if using resources and extending LOS....etc

Juli

evanspx@sutterhealth.org

I agree coders should not 'reject' a diagnosis recorded in the record..no one should.

One the other hand, ACDIS/AHIMA Best Practice now states there may be times a CDI or Coder may need to issue a query for a condition that is 'not clinically supported'. Acknowledging all of the implications with this stance, that is what is now stated. Also bear in mind guideance from CMS that a coder 'should issue a query for a condition stated repeatedly, but not clinically supported".

The reality is that a CDI is not going to be able to 'vet' any/all diagnoses. Hence, sometimes this may fall to a coder.



2013 ACDIS/AHIMA guidance titled “Guidelines for Achieving a Compliant Query Practice” states “generation of a query should be considered when health record documentation ... provides a diagnosis without underlying clinical validation.” In addition, the brief states:

“The focus of external audits has expanded in recent years to include clinical validation review. … When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in The health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

MLN Volume 1, issue 4, July 2011, Published by CMS – Advises a Coder to Query the MD for Acute Respiratory Failure that is clearly stated on multiple occasions.

An 81-year-old female was admitted with complaints of dry cough for a couple of weeks. The patient was admitted through the emergency department and was assessed for wheezing and coughing. H&P impression is acute respiratory failure secondary to exacerbation of Chronic Obstructive Pulmonary Disease (COPD). Progress notes through the stay also document the diagnosis of acute respiratory failure secondary to exacerbation of COPD. Final diagnosis on the discharge summary is acute respiratory failure secondary to COPD exacerbation. Additional documentation sheet supplied in the record list the patient's diagnoses as: Principal Diagnosis: COPD exacerbation; Other Diagnoses: high blood pressure, Coronary Artery Disease (CAD), Congestive Heart Failure (CHF), Diabetes Mellitus (DM), Parkinson's, and rheumatoid arthritis.
Auditor finding: After physician and auditor review, it was determined that the clinical evidence in the medical record did not support respiratory failure, despite physician documentation of the condition.
Action: The auditor deleted acute respiratory failure and changed the principal diagnosis to COPD Exacerbation. The auditor deleted respiratory failure code 518.81 and changed the principal diagnosis to hypoxemia code 799.02. This resulted in a MS-DRG change from 189 to 192–Chronic Obstructive Pulmonary Disease without CC/MCC. This change resulted in an overpayment.

Guidance on How Providers Can Avoid These Problems:
✓ The condition chiefly responsible for a patient’s admission to the hospital should be sequenced as the principal diagnosis, and the other diagnoses identified should represent all CC/MCC present during the admission that affect the stay. Code only those conditions documented by the physician.
✓ Refer to the coding clinic guidelines and query the physician when clinical validation is required.



Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

lsipos@monument.health

Yes, we call that an "ANTI-Query" LOL ....where we query for clinical indicators, treatment or monitoring to substantiate or support a documented diagnosis!
Lately it has been "Sepsis"; documented Sepsis with NO clinical indicators for SIRS.... WBC, RR, Temp, Pulse, LA - ALL NORMAL!

Have a good weekend everyone!

Juli