acute PE

I am looking for assistance,we are trying to clarify acute PE's. We have been told by our consultant to query for acute PE on any patient that has been admitted with a history or recent PE (within 3-6 months) and current treatment of anticoagulation. This is the reference: "Acute" defines the period of time beginning with the initial diagnosis,up to and including the entire period of time where anticoagulation is instituted (3-12 months). *During this period of time there is slow resolution of the PE itself as well as a substantial risk of recurrent embolization if anticoagulation therapy is discontinued for any reason.
Has anyone else come across this? If so, how do you approach the providers?
Thank you!

Comments

  • I haven't been told what your consultant told you, but I have queried for acute PE if it looks like they've initiated treatment beyond what the pt was getting on the outside. I think you could ask the physician to choose if the PE is active/chronic/or history only, and guide them where you think it ought to be based on how aggressively it's being treated.

    I just queried the other day on a patient who had an IVC filter placed at another hospital for a PE and was transferred here the same day due to epistaxis r/t the concomitant heparin therapy. They won't write PE as an active diagnosis, and it's hard for me because they're not treating the PE (because of the epistaxis), but I threw out the query anyway. I don't think the filter magically made the PE disappear.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • edited May 2016
    I haven't heard that either. Where is the reference from? I think that would be something that RACs would target...just my opinion. Does the consultant recommend to verify if the diagnosis impacted the inpatient stay, caused increased monitoring, therapy, LOS, etc?


    Kathy
    Kathy Shumpert, RN, BSN

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Pager 765-604-0424
    Fax 765-453-8152

    Writing is easy: All you do is sit staring at a blank sheet of paper until drops of blood form on your forehead. ~Gene Fowler
  • edited May 2016
    This is take from Coding Clinic 4th qtr 2009. I think this maybe where
    the consultant is searching for more specificity on PE. Therefore, the
    question lies in "acute" treatment or "chronic" or "maintenence"

    Effective October 1, 2009, a new code (416.2) has been created to describe
    chronic pulmonary embolism to distinguish between patients who are being
    treated for an acute pulmonary embolism and patients with chronic
    pulmonary embolism who are being maintained on anticoagulant therapy for
    an extended period of time. Previously the classification did not
    differentiate between acute and chronic pulmonary embolism.

    An embolus is a blood clot that most commonly originates in the veins of
    the legs (deep vein thrombosis). The blood clot can dislodge and travel as
    an embolus to other organs in the body. A pulmonary embolism is a clot
    that lodges in the lungs, blocking the pulmonary arteries and reducing
    blood flow to a region of the lungs.

    Pulmonary embolic disease may be acute or chronic (longstanding, having
    occurred over many weeks, months or years). In the majority of cases acute
    pulmonary emboli do not cause chronic disease because the body?s
    mechanisms will usually break down the blood clot. An acute embolus is
    usually treated with anticoagulants (e.g., intravenous heparin and
    warfarin or oral Coumadin) to dissolve the clot and prevent new ones.

    For acute pulmonary embolism, anticoagulant therapy may be carried out for
    3 to 6 months. Therapy is discontinued when the embolus dissolves.
    However, it can persist. In patients with recurrent pulmonary embolic
    disease while on blood thinners or patients who cannot tolerate blood
    thinners, a filter can be placed to interrupt the vena cava. The device
    filters the blood returning to the heart and lungs. In some cases of
    chronic pulmonary embolism, the clot develops fibrous tissue, and surgery
    is needed to remove this fibrous tissue.

    Thrombolytic therapy (e.g., streptokinase, urokinase, and tissue
    plasminogen activator) is another treatment option for acute pulmonary
    embolism. However, thrombolytics are generally contraindicated in patients
    that are pregnant, have had a recent cerebrovascular accident, have a
    bleeding disorder, or have had recent surgery.

    Code 415.19, Pulmonary embolism and infarct, Other, is used for an acute
    pulmonary embolism. There is no specific timeframe that distinguishes
    acute from chronic pulmonary embolism. These codes should be assigned on
    the basis of the provider?s documentation. Query the provider for
    clarification if the documentation is unclear.

    415 Acute pulmonary heart disease

    415.1 Pulmonary embolism and infarction

    Add Excludes: chronic pulmonary embolism (416.2)
    Add personal history of pulmonary embolism
    (V12.51)

    416 Chronic pulmonary heart disease

    New code 416.2 Chronic pulmonary embolism

    Use additional code, if applicable, for associated
    long-term (current) use of anticoagulants (V58.61)

    Excludes: personal history of pulmonary embolism
    (V12.51)


    Stacy Vaughn, RHIT, CCS, CCDS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052
  • edited May 2016
    Thanks Stacey, this highlights what I was going to respond with -- to whit:
    Treatment for an acute PE may be continued for as much as 3-6 months. It can take some time for the acute PE to resolve. A patient with a recent PE and who is on anti-coagulant therapy we may query for the acute PE. The monitoring of INR, etc. is often an acute management issue if for no other reason than the change in physiological status of the patient during the admission. In addition, there is an increased risk of co-morbidity with the recent acute PE. Pts who are on tx for longer than the 3-6 months we would consider query for chronic pe (not acute) vs prophylactic tx.

    Don
  • edited May 2016
    If the physician documented "Pulmonary Embolism" with no mention of acute or chronic - regardless of treatment- I think you could go ahead and code 415.19.

    Looking in the ICD-9 book under "pulmonary embolism" it defaults to 415.19. The word acute appears in parenthesis which means that it is included but is not restricted to that code.

    Otherwise it would be listed as:

    Pulmonary Embolism
    Acute-415.19
    Chronic- 416.2

    I don't know that I would bother the physician with specifying unless he has already documented.
  • edited May 2016
    This is great, Don. I foresee this changing once CMS realizes this MCC is
    clinically shown by med management. Maybe creating a "subacute" status.
    You think?

    Stacy Vaughn, RHIT, CCS, CCDS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052
  • edited May 2016
    Might be difficult for CMS to change if we are appropriate and selective on how we (CDI & coding) handle. It is not every pt with a recent PE that we query, just those where there is provider 'attention' toward the matter.
    Clinically, I understand that the PE is considered present and active for a period of time after the initial diagnosis and there is usually a 'tone' in the documentation that points in that direction.

    Don
  • edited May 2016
    Excellent point Don, we have to be responsible for our actions. I
    appreciate all the responses to my question, it is a difficult transition
    after a consultant visit, even though a lot of use full information is
    brought, it can be easily misunderstood and become a struggle to get every
    one back on course.

    Thank You,
    Susan Tiffany RN, CCDS
    Supervisor Clinical Documentation Program

    "Twenty years from now you will be more disappointed by the things you
    didn't do than by the ones you did do. So throw off the bowlines. Sail
    away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
    Discover." Mark Twain
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