PFO
When is coding a PFO (Q21.1) appropriate? We are trying to define this for consistent coding as this is a CC. I've discovered that about 25% of the population has an unknown, asymptomatic PFO. An echo may be done for a stroke patient looking for a PFO as the cause of the stroke and be clinically significant. On the other hand, a PFO may be incidentally discovered on an echo which is done as protocol during an elective admission for a-fib cardioversion and may not be addressed. If a PFO is noted in the past medical history only and no surgery has been done, should this not be coded because none of the 5 criteria have been met to report it (evaluation, treatment, diagnostic procedure, extended length of stay or increased nursing care and/or monitoring) or because this is a congenital condition, does this status trump those criteria making code assignment appropriate? Page 66 of the guidelines notes "assign an appropriate code(s) from categories Q00-Q99, Congenital malformations, deformations, and chromosomal abnormalities when a malformation/deformation or chromosomal abnormality is documented".