Reporting Acute Diastolic /Systolic/Combined CHF on Elective outpatient TAVR's>>> Really?
Well, I knew it would happen. I have had some spirited debates with Nurse Practitioners lately who must have attended the same conference sponsored by Edwards Life Sciences or Medtronic (the makers of the Valve). They are now saying it is perfectly fine to document Acute Diastolic CHF on the day of admission and the the Stent is the RX for the CHF.
So decided to see if anyone has ever looked at how much time constitutes Defining Acute (decompensated) Heart Failure? Would documenting Acute CHF hold up (to an audit) as POA on the day of an elective surgery ?
The Term Acute
In medicine, describing a disease as acute denotes that it is of short duration and, as a corollary of that, of recent onset.
The quantitation of how much time constitutes "short" and "recent" varies by disease and by context, but the core denotation of "acute" is always qualitatively in contrast with "chronic", which denotes long-lasting disease. In addition, "acute" also often connotes two other meanings: sudden onset and severity, such as in acute myocardial infarction, where suddenness and severity are both established aspects of the meaning. It thus often connotes that the condition is fulminant, but not always. The one thing that acute MI and acute rhinitis have in common is that they are not chronic. They can happen again, but they are not the same case ongoing for months or years.
I found this bit of information interesting: What is acute decompensated heart failure? By G Michael Felker, Professor of Medicine Member in the Duke Clinical Research Institute
Acute decompensated heart failure (ADHF) is a clinical syndrome of worsening signs
or symptoms of heart failure requiring hospitalization or other unscheduled medical care.
Are there clinically important subcategories of ADHF? >this area is rapidly evolving, a few general clinical phenotypes of ADHF have emerged.
>Hypertensive acute heart failure-Symptoms often develop quickly (minutes to hours), and many such patients have little or no history of chronic heart failure. Hypertensive urgency with acute pulmonary edema represents an extreme form of this phenotype.
>Decompensated heart failure: This describes patients with a background of significant chronic heart failure, who develop symptoms of volume overload and congestion over a period of days to weeks. These patients typically have significant left ventricular dysfunction and chronic heart failure at baseline. Although specific triggers are poorly understood, episodes are often triggered by noncompliance with diet or medical therapy.
>Cardiogenic shock/advanced heart failure: they are relatively uncommon in the broader population (probably fewer than 10% of ADHF hospitalizations.
I welcome comments on this as I think CMS needs to step in NOW and offer guidance.
Comments
thank you for starting a "think tank"
Cheers
(Googled)
http://ht.edwards.com/scin/edwards/sitecollectionimages/products/transcatheter/walsh_engagement.pdf
I enjoy reading early statements from the Pioneers:
Samuel Levine, MD, from Clinical Heart Disease, 1951: “Symptoms, as a rule, precede signs. Breathlessness is the most important and generally the earliest evidence of heart failure . . . it is necessary to rule out other causes, such as those of a functional and pulmonary nature, before regarding breathlessness as due entirely to the heart. In hypertension, aortic and coronary cases, dyspnea may first appear at night, while in other cases it is first noted on effort. Cheyne-Stokes breathing,
I will be the first to state I am not a cardiologist. For CDI/ Coding purposes, however, I personally feel that in order to report CHF as acute, one needs as much supporting evidence as possible in order to ensure compliant reporting. Positive JVD signs, SOB, elevated BNP that is due to CHF rather than some other process such as CKD, pulmonary edema on film, supplemental oxygen, INTRAVENOUS Diuresis.
Paul Evans, RHIA, CCDS
Yes, note bloat is an issue for may cases, unfortunately.
PE
We do quite a few planned CV procedures, and I concur with the thought expressed above that it should be rare to capture major (acute) organ failures in this population precisely because they are tuned up prior to the planned admission.
P. Evans, RHIA, CCS
My point is the Providers performing these procedures better make a good case as WEISHED has described or someone is going to be paying back medicare.
Richard D. Pinson, MD, FACP, CCS
Pinson & Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide
www.pinsonandtang.com
Exactly how "fine tuned" are they? Do they have to be so dry that they are practicality in AKI just so their lungs aren't wet?
If so, that is not sustainable. I would be interested in knowing what this population looks like at baseline. If they are NYHA classes 3 or 4 at baseline and just artificially and un-sustainably dry on admission, that is something I have been considering as an exception to the standard chronic vs acute definition as their baseline is acute and their clinical presentation pre-op is an artificial state. In other words, is "acute' still the clinical truth because their baseline is brittle and fairly decompensated?
If they are able to be sustained on medications without having constant congestive episodes and wet lungs...aka their baseline is good/manageable then that begs the question.....why the TAVR in the first place?
I suppose some will be found to be genuinely chronic while others may indeed be acute when viewed this way. You are talking about older patients who may be poor surgical candidates and have a diminished activity level and resp symptoms at rest in many cases...wet(ish) lungs (possibly somewhere between "insufficiency" and failure.) In some ways, we may be using "acute" as a surrogate for "severe" here. This presents a connundrum. Is "acute" a better surrogate for "chronic severe" than "chronic" which seems to incorrectly imply "chronic CONTROLLED" where clinical truth is concerned?
THIS is why we need ICD 10 codes for the NYHA and ACC stages and or terms such as "chronic severe" "chronic mild" or combos like "moderate chronic w acute congestion" but I digress.
You can temporarily prop up a Leukemia patients blood counts with transfusions and platelets but one would hardly be able to say they suddenly didn't have ALL or AML just because the counts were temporarily good??
Looks like some of you may need to write up a proposal to the ICD 10 coordination and maintenance committee for new codes!!
Just some thoughts, my mind isn't made up.
How are you all reporting this Any feedback is appreciated.