CHF queries

dhedlund1

Our group has a couple of questions to throw out, specifically about queries for the type of CHF (systolic, diastolic, combined)
1. If an echo is referenced by a provider, how old can the echo be before it would be considered not acceptable to use in supporting a query for CHF? I was taught that within a year would be considered acceptable but wondered if that is still correct.
2. If the type of CHF is not documented would a query be appropriate regardless of what other documentation is on the chart (specifically if there is no recent echo)?
We had a discussion with our Physician Advisor who thinks we should query for type if CHF is written and not specified because the physician may have access to records of diagnostic tests done outside the hospital that are not documented in the patient hospital record. Theoretically the physician would answer the question and document the test results to support the type of CHF.
I seem to remember learning that CDI shouldn't query for type of CHF unless there is supporting evidence (e.g. an echo) that could be used to make the diagnosis of type.
We want to get it right and would love any input; I couldn't find any specific guidelines regarding these issues.

cericson1

Hi. You might want to check out the Use of Prior Information ACDIS White Paper  http://www.acdis.org/system/files/resources/physician-queries-prior-information.pdf which discusses the use of prior information like an ECHO.  Some coders are uncomfortable using a prior ECHO if it is not part of the current episode of care regardless of the age of the ECHO.  In my opinion, the key is if the diagnosis of CHF is part of the current episode of care in which case, the ECHO allows greater specificity.  As discussed in the white paper, providers have always reviewed prior health records to clarify a patient's condition (which is already being addressed in this episode of care).  From a clinical standpoint, if the heart failure is stable the ECHO can be "valid" for more than a year depending on when the next ECHO is scheduled. Best practice would be encouraging the provider to reference the result of any prior diagnostics, like the ejection fraction, when clarifying the diagnosis so the coder and any future auditors would have the same information so they would come to the same conclusion when reviewing the record.  

The second question is a lot trickier.  I can see both perspectives.  Since CHF defaults to an unspecified code, it is appropriate (and common practice) to clarify the type, which can be determined even without an ECHO, but most providers don't know those criteria so it isn't a straight forward as the ejection fraction. However, I would be sure to always query for CHF specificity not only when it can add a CC or MCC to a case.  The organization can also make a policy that states it is your practice to query unspecified diagnoses like CHF, pneumonia, etc.  Unlike other diagnoses, CHF has been addressed by coding clinic in the past as a chronic condition stating that it is always reportable.  I think the advice regarding the need for the ECHO may be in support of CHF as a "reportable" diagnosis, which is not required based on that coding clinic.  Specifically, coding clinic from 3rd Qtr 2007 states

"If there is documentation in the medical record to indicate that the patient has COPD, it should be coded. Even if this condition is listed only in the history section with no contradictory information, the condition should be coded. Chronic conditions such as, but not limited to, hypertension, Parkinson's disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded even in the absence of documented intervention or further evaluation.

Some chronic conditions affect the patient for the rest of his or her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization, and therefore should be coded. This advice applies to inpatient coding."

Hope this helps.  Cheryl Ericson 

dhedlund1

Thanks, Cheryl! We appreciate your expertise! I do remember reading that white paper, so will review it again and share it.

renmeyer@sbcglobal.net

If there is only a history of CHF documented would it be appropriate to query for type? Specifically when there is no recent ECHO or treatment other than home meds. I believe 'type' will always give a cc.  Will this not be a red flag to query for type in every chronic CHF. I'm asking as it seems to become a trend at my hospital to query for type of chronic CHF.  Thanks!

kbalogun

First  of all, the codes for chronic and acute CHF are different specifically for situations like this. Chronic CHF patients are normally on home meds. It is chronic because there is no exacerbation and they are able to function. Asking for type of CHF is NOT fraud! I repeat asking for type of CHF is good CDI practice.

1) Coding rule : Code all pertinent chronic illnesses
2) Another coding rule: Code to the highest level of specificity
3) Yes, You have to query for all types of CHF because it is being treated with MEDS. If all you have is the ECHO, yes still query. Querying for CHF type and acuity based on "history of CHF" documentation is actually good medical practice. 

renmeyer@sbcglobal.net

Thanks for clarifying.