Heart Failure only documented in ED as Hx

ksaalmullerksaalmuller
in Clinical & Coding

We are looking for some guidance on the following scenario:

Patient comes into the ED for cellulitis. The ED provider documents HF as a history (ex: 65 year old male present to the ED today from home with c/o infected arm following a cat bite. History of HTN, TIA, CHF, and HLD.") No other mention of HF throughout the entire stay. No echo on record, no evidence of home diuretics, no symptoms of HF, etc.

Do you query for specificity of chronic HF? Do you query to validate HF?

Comments

  • dbutler@vidanthealth.comdbutler@vidanthealth.com

    From what you describe, seems like there was no reportability conditions met -- no monitoring, no home meds (was there any other meds than diuretics?), and no apparent impact on medical decision making -- unless there was a comment about careful fluid management.

    If that's the case, then would not query (or code) because in this case sounds like not reportable.

    Don

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