complication

katysuegood@gmail.comkatysuegood@gmail.com
in Clinical & Coding
Hi all,

I have an elderly patient who came in with cardiogenic shock and renal failure/resp failure. He was quickly moved to comfort care. We have this documentation repeatedly in the record referring to this as r/t his recent mitral valve clipping.


"presents with RV cardiogenic shock with wide open TR by stat admit TTE requiring high dose dobutamine and dopamine support felt to be sequela of MV clipping"


"past medical history most pertinent for ischemic cardiomyopathy as well as mitral regurgitation for which he underwent a relatively recent mitral valve clipping. He has been admitted to for cardiogenic shock, primarily due to right-sided heart failure with wide open tricuspid regurgitation noted on admit transthoracic echocardiogram, felt to be secondary to recent mitral valve clipping per Cardiology."

Should this be coded as a complication or is this disease progression??? Ideas?

Thanks!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • gwojogwojo
    edited May 2016
    I would query to clarify Katie. This could easily be misinterpreted incorrectly.  Query just how you have stated it, due to procedure, or, progression of disease.                                                                      Sent from my BlackBerry 10 smartphone. From: CDI TalkSent: Monday, April 18, 2016 10:24 AMTo: gwojo@wowway.comReply To: cdi_talk@hcprotalk.comSubject: [cdi_talk] complication






    Hi all,

     

    I have an elderly patient who came in with cardiogenic shock and renal failure/resp failure. He was quickly moved to comfort care. We have this documentation repeatedly in the record referring to this as r/t his recent mitral valve clipping.

     

    “presents with RV cardiogenic shock with wide open TR by stat admit TTE requiring high dose dobutamine and dopamine support felt to
    be sequela of MV clipping”

     

    “past medical history most pertinent for ischemic cardiomyopathy as well as mitral regurgitation
    for which he underwent a relatively recent mitral valve clipping.  He has been admitted to for cardiogenic shock, primarily due to right-sided heart failure with wide open tricuspid regurgitation noted on admit transthoracic echocardiogram, felt to be secondary
    to recent mitral valve clipping per Cardiology.”

     

    Should this be coded as a complication or is this disease progression??? Ideas?

     

    Thanks!

     

    Katy Good, RN, BSN, CCDS, CCS

    Clinical Documentation Program Coordinator

    Flagstaff Medical Center

    Kathryn.Good@nahealth.com

    Cell: 928.814.9404

     





  • utuk350@hotmail.comutuk350@hotmail.com
    edited May 2016
    Thanks Dr. Gold,

    I was of similar thought. The clipping of MV leaves the potential for regurgitation, fluid overload and cardiogenic Shock.

    Margaret Utik, RN

    On Apr 18, 2016, at 5:10 PM, CDI Talk wrote:

    Katy - interesting conundrum. Apparently, the literature that comes with the device says that there are certain clinical situations that you have to be aware of before doing the MitraClip and take the risk that the patient could suffer harm or death from them. Here's the list:

    PRECAUTIONS

    Patient Selection:
    Prohibitive risk is determined by the clinical judgment of a heart team, including a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease, due to the presence of one or more of the following documented surgical risk factors:
    30-day STS predicted operative mortality risk score of
    ≥8% for patients deemed likely to undergo mitral valve replacement or
    ≥6% for patients deemed likely to undergo mitral valve repair
    Porcelain aorta or extensively calcified ascending aorta.
    Frailty (assessed by in-person cardiac surgeon consultation)
    Hostile chest
    Severe liver disease / cirrhosis (MELD Score >12)
    Severe pulmonary hypertension (systolic pulmonary artery pressure >2/3 systemic pressure)
    Unusual extenuating circumstance, such as right ventricular dysfunction with severe tricuspid regurgitation, chemotherapy for malignancy, major bleeding diathesis, immobility, AIDS, severe dementia, high risk of aspiration, internal mammary artery (IMA) at high risk of injury, etc.
    Evaluable data regarding safety or effectiveness is not available for prohibitive risk DMR patients with an LVEF < 20% or an LVESD > 60mm. MitraClip should be used only when criteria for clip suitability for DMR have been met.

    If your patient had severe tricuspid regurg BEFORE the procedure, then the patient and the docs should have gone into the procedure on the mitral valve knowing the risks. To that end, I think it would be advisable to confirm that. In either case, this is a complication of the procedure - one possibility a known risk, the other they missed the risk. Even if the tricuspid regurg happened because of the mitral clip, it's a complication of the procedure.

    Dr. G.

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Agreed. Thanks to both of you!

    The 'clipping' was done at another facility so I don’t have access to the surgeon or the documentation form the procedure itself to identify whether this was identified prior.

    Any help on code selection to capture the complication? Would it be I9789?

    Thanks!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404



  • mlucianomluciano
    edited May 2016
    Thank you for the update!


    Mayra Luciano, BS, BSN, RN
    Clinical Documentation Improvement Specialist
    Brookhaven Memorial Hospital Medical Center
    101 Hospital Road
    Patchogue, NY 11772
    631 438 5268
    mluciano@bmhmc.org







  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Thank you all, as always, for further educating us all about another key process.

    As I read this, a question occurred.

    What is a 'hostile chest'?



    Thanks, Paul


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



    evanspx@sutterhealth.org




  • utuk350@hotmail.comutuk350@hotmail.com
    edited May 2016
    A "hostile chest" occurs when any condition prohibit the redo of stenotomy or right anterior thoracotomy e.g. (skin burns, bone destruction/loss, muscle loss, esophageal stricture, severe lung disease, osteoporosis, pott's disease, kyphosciosis, etc.).

    Sometimes, these patients may be candidates for TAVI/TAVR if valve replacements are needed.

    On Apr 18, 2016, at 5:30 PM, CDI Talk wrote:

    Thank you all, as always, for further educating us all about another key process.

    As I read this, a question occurred.

    What is a 'hostile chest'?



    Thanks, Paul


    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421



    evanspx@sutterhealth.org




  • utuk350@hotmail.comutuk350@hotmail.com
    edited May 2016
    A "hostile chest" occurs when any condition prohibit the redo of stenotomy or right anterior thoracotomy e.g. (skin burns, bone destruction/loss, muscle loss, esophageal stricture, severe lung disease, osteoporosis, pott's disease, kyphosciosis, etc.).

    Sometimes, these patients may be candidates for TAVI/TAVR if valve replacements are needed.

    Margaret Utuk, RN


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Thank you for that clarification, Margaret.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
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