acute PE

tiffany_susan

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!

catladyrn

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

kshumpert

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

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stacy.vaughn

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

dbutler

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

NormaB

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.

stacy.vaughn

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

dbutler

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

tiffany_susan

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

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