query
Don't laugh at my question but the coding supervisor here wanted me to put this question out to all of you. Is it appropriate to query a physician on a case to clarify CHF after the account has been billed? Pt came in with a-fib with RVR and Chf secondary to a fib. Cardio consult states "diastolic dysfunction" in the IMPRESSION section of consultation. EP physician states "variable degree of LV systolic dysfunction" in History section of Consultation and "Congestive Heart Failure, acute on chronic" in the IMPRESSION section of consultation. Throughout progress notes no other mention of sys or dias is noted but acute chf and acute on chronic CHF is documented. EF documented by both MDs 45-59% This is a chart unfortunately that I initially reviewed, saw the EP MD consult, did not feel query needed query and was unable to get back into chart prior to discharge. Thanks!
Comments
I do not see that clarification is needed.
It just needs to be coded correctly and rebilled if it meets the timeframe guidelines.
Charlene
Thanks,
Amy
A cause and effect relationship between diagnoses may not be assumed and coded unless documented as such by the attending.
The patient presented with _____________________________
Please document the relationship, if any, between ___________ and ___________ in your progress notes and d/c summary.
I have used this and it has been pretty effective so far.
Dawn
My Docs had input into this one and they like it.
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054
Maybe this will help
Karen Maritano, RN
Clinical Documentation Specialist
Legacy Health
Portland, Oregon
503-413-7154
kmaritan@lhs.org
In the setting of HTN / CHF/ CKD requiring treatment with IV lasix, are you managing:
* HHD W/ CKD III/ with acute on chronic DHF
(Hypertensive heart disease with CKD III with acute on chronic DHF
* Other- with explanation of the clinical findings
* Clinically unable to determine
* Risk Factors:Admits with acute on chronic DHF, HTN, CKD III and A-fib with no Hx of MI.
* Clinical Indicators:3/16/2013 Echo impressions include, "left ventricular hypertrophy...at least moderate pulmonary hypertension....The left and right atria are severely enlarged"
* Treatments: Home meds include; Metoprolol, Torsemide, and Amiodarone. Patient was given IV lasix in ER and as in-patient ,Lasix 20 mg IV daily
Please clarify and document your clinical opinion in the Progress Notes and DS the definitive and/or presumptive diagnosis, related to the above clinical findings. Please include clinical findings supporting your diagnosis.
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In the setting of CHF/HTN/CKD requiring treatment with IV lasix, are you managing:
* HHD w/ Acute on Chronic SHF and CKD III-IV
(hypertensive heart Dz w/ Acute on Chronic Systolic HF and CKD III-IV)
* Other- with explanation of the clinical findings
* Clinically unable to determine
* Risk Factors:Admits w/ known a-fib, systolic and valvular heart disease, HTN, and systolic Head failure. Admits w/ acute on chronic SHF.
* Clinical Indicators: Per review of labs GFR from 2012-2013 fluctuates between 24-35 over last 2 years in carecast. 5/20/2013 ECHO --The left and right atria are severely enlarged, severe pulmonary hypertension, concentric left ventricular hypertrophy, Left ventricular ejection fraction is 45%, & severe tricuspid regurgitation.
* Treatments: Home meds: Benicar 20 mg 1/2 tablet daily- changed to Benicar to 20 mg daily on admit, Lasix 20 mg daily, & Metoprolol tartrate 50 mg 3 b.i.d. Admits on intravenous Lasix.
Please clarify and document your clinical opinion in the Progress Notes and DS the definitive and/or presumptive diagnosis, related to the above clinical findings. Please include clinical findings supporting your diagnosis.
Janice Schoonhoven RN, MSN, CCDS
Clinical Documentation Integrity
Manager- PeaceHealth Oregon West Network
A cause and effect relationship between HTN and Chronic Renal Failure can be assumed per CMS guidelines.
A cause and effect relationship between HTN and CAD/CHF may not be assumed and coded unless documented as such by the attending physician.
Patient has a history of HTN, CAD and CKD with presenting diagnosis of CHF.
Please reply to this query or document in your next progress note the relationship, if any, between HTN and CAD.
Dawn M. Vitalone, RN, CCDS
Clinical Documentation Improvement Specialist
Community Hospital
219-513-2611
dvitalone@comhs.org
Patient has a history of HTN, CAD and CKD and presented with acute CHF.
Please reply to this query the relationship, if any, between HTN and CAD. (see below)
*Hypertensive heart disease
*Hypertensive kidney disease
*Hypertensive heart & kidney disease
*Heart disease only
*Other (please specify)
*Unknown (please state rationale)
ls
Would this statement be congruent or consistent with potential hypertensive CHF with diastolic dysfunction?
I look for LVH, normal LVEJ% and diastolic dysfunction. I find this more often in women, than in men. I noted that Digoxin is not preferred in such patients as it increases the pumping action of the heart, which is not desired to treat diastolic CHF.
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Available data indicate that brain natriuretic peptide levels are not as high in diastolic heart failure as they are in systolic heart failure. The diagnosis of diastolic heart failure can be made on the basis of left ventricular hypertrophy, clinical evidence of heart failure, and a normal ejection fraction, as well as Doppler findings that are consistent with diastolic dysfunction and elevated filling pressures. The initial treatment of diastolic heart failure should be directed at reducing the congestive state (with the use of diuretics). Long-term goals are to control congestion and to eliminate or reduce the factors, including hypertension, tachycardia, and ischemia, that confer a predisposition to diastolic dysfunction.
DHF cannot usually be distinguished from SHF by patient history, physical exam, x-ray, and EKG alone. Diagnosis requires an estimate of LV size and EF. These measurements can be made using echo, MUGA, or catheterization. Really, DHF diagnosis is a matter of ruling out other possible causes in patients seeming to have heart failure but who have normal heart size and EF.
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(Note that a thickened LV wall (hypertrophy) in a patient with an LVEF >40% is one criteria for the diagnosis of diastolic CHF)
[cid:image003.png@01D1752E.F2EAE200]
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
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