Opinion on documentation ?

tiffany.andrastiffany.andras
in CDI Talk Archive
I have a patient that nephrology consultant documented that the patient has volume overload/CHF. This patient is ESRD on HD.

The primary on the case never documents CHF, no history nor acute. He documents in his H & P: 1. pulmonary edema, secondary to endstage renal disease. He continues to document this through the documentation and the DC summary: patient was once again admitted to the hospital with volume overload secondary to end-stage renal disease. She received hemodialysis on multiple days with improvement in her overall condition.

What would you code as principal? I have reviewed again all the coding clinics, could I code the volume overload and not the CHF since the primary does not document the CHF anywhere and notes that the volume overload secondary to ESRD ?

Thanks

Tiffany Andras LPN CCS CCDS

Clinical Documentatoin Improvement
Thibodaux Regional Medical Center
602 North Acadia Road
Thibodaux, La. 70301
985-493-4593

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I think I would query to ask the primary if the patient has CHF and if verified, get the acuity/type. Then I would likely sequence the CHF (if confirmed) as a Sdx.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • tiffany.andrastiffany.andras
    edited April 2016
    I queried in house and he did not respond. I just have a hard time clinically with placing the diagnosis of the CHF as principal which is what the coder wants to apply.

    Tiffany

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    I agree, I would not use it as Pdx. Attending takes precedent over the consultant.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • jrileyjriley
    edited April 2016
    If you have fluid overload due to hypertensive ESRD with CHF then your PDX will be a combination code that captures all that information in a single code: 404.93. This groups to CHF. I would pursue the query to determine if in fact the CHF is present, and then if so, the type and acuity. You are right to question the coder, you currently do not have enough information in the chart to code CHF as a PDx.

    Judy

    Judy Riley, RHIT, CCS, CPC
    Coding/CDI Manager
    LRGHealthcare
    Lakes x 3315

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • angelisa.romanelloangelisa.romanello
    edited April 2016
    I agree with Katy.

    Another point you may want to make to the coder is that the intervention, "the multiple HD" treatments seem to assist the patient in improving. This leads me to believe the fluid overload related to ESRD is the principal.

    We struggle here with this a great deal. Our coders like to use CHF as the PDX on many occasions. I would sequence the CHF as a secondary.

    Lisa


    Lisa Romanello, RN,BSN,FNS,CCDS
    Manager, Clinical Documentation Improvement
    Quality and Compliance
    CJW Medical Center
    804-228-6527
    AHIMA Approved ICD-10 CM/PCS Trainer
    Angelisa.Romanello@HCAHealthcare.com

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Complicated topic with a multitude of Coding Clinic references....essence of issue is:

    MD should be asked if the fluid overload/edema associated with any CHF

    MD should be asked to distinguish NON-Cardiogenic Fluid Overload from any "CHF".

    MD should be asked if this is Non-Cardiogenic Acute Pulmonary Edema 2/2??

    MD should be asked if this is 'simply' fluid overload in a pt that missed dialysis

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • jrileyjriley
    edited April 2016
    Like your query form!

    Judy

    Judy Riley, RHIT, CCS, CPC
    Coding/CDI Manager
    LRGHealthcare
    Lakes x 3315

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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • kerryseekircherkerryseekircher
    edited April 2016
    That is a great query template!

    Kerry Seekircher, RN, BS, CCDS, CDIP
    Clinical Documentation Specialist Supervisor
    Northern Westchester Hospital
    400 East Main Street
    Mount Kisco, NY 10549
    Email: kseekircher@nwhc.net
    Phone: 914-666-1243
    Fax: 914-666-1013

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Thank you...we designed this specifically to address the scenarios subject of this CDI Talk Topic. "Often', the chart uses these clinical terms interchangeably, however, this can make the coding inaccurate.

    Bear in mind that the 'default' code (see C. Clinic) when a chart concurrently states 'CHF, pulmonary edema, and fluid overload' is the CHF unless the record states clearly o/w.


    PE

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

    [cid:image002.jpg@01CFD724.71098EC0]

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • mark.domineseymark.dominesey
    edited April 2016
    From what I can see, what admitted the pt to the hospital was the Fluid Overload - a manifestation of the ESRD. Fluid Overload is also a component/cause of Acute CHF. I do think a query is in order, because it is quite possible that the principal would be the 404.93 - Hypertensive Heart/Chronic Kidney Disease, Unspec, w/ Heart Failure And CKD, Stage V Or End Stage.

    The interesting thing about a principal of hypertensive heart/kidney disease is that it allows you to pick up Acute systolic/diastolic/combined HF as an MCC.

    Mark

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • jolene.filejolene.file
    edited April 2016
    Agree, Paul, we need to query to know if cardiogenic or non-cardiogenic fluid overload.   This will impact the principal diagnosis & DRG assignment. 
    I too like your query.
     
    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

    IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged.  If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else.  In such circumstances, please notify me immediately by reply email or by telephone.  Thank you.

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • tiffany.andrastiffany.andras
    edited April 2016
    I agree it is Good, I will try your template with the MD, I queried when the patient was in house and he did not respond to it, I will give it one more try.

    Thanks Tiffany
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    This is always a tough topic for CDI and coders.
    Hope the form can be useful to you.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

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    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • rmhosler1rmhosler1
    edited April 2016
    Paul I have been trying for years. You have made my day!

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    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Most welcome.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

    ---

    Copyright 2013

    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923
  • ch11287ch11287
    If the patient is admitted with fluid overload due to ESRD, compliant with dialysis and no documentation or history of heart failure. Is the principal diagnosis fluid overload like it is with noncompliance of dialysis, or does it go to the ESRD as the cause of the fluid overload?
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