Educate me on heart failure!

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Part of my job is to retrospectively review all Death Charts prior to them being finalized by coding. Yesterday I reviewed one that is confusing me.
We have a patient with underlying pulmonary fibrosis and pulmonary HTN who is admitted with AMS and syncope. Early on we have mention on CHF without specification. Cardiology is consulted and they statet eh syncope was multifactoria r/r "posture change in an elderly patient with pulmonary fibrosis with clinical signs of pulmonary hypertension". He states she has no overt signs of Right heart failure yet. That same day the attending sates "endstage pulmonary hypertension, cor pulmonale, secondary to pulmonary fibrosis". The pulmonologist states "cardiomegaly with evidence for congestive heart failure". The pulmonary fibrosis/HTN is consistently documented as the primary issue.

Currently the chart is coded with the Pdx as Cor Pulmonale. CHF is not coded.

This is where I am getting confused. It seems to me that she had R-sided heart failure. CHF is mentioned but never described as a primary issue, more mentioned off-hand. I am not sure where to go with this. Leave as is? Query for the significance and/or further specificity of the HF? Suggest the coder code the CHF with the current documentation?
Also, It is my understanding that Systolic/Diastolic CHF only refers to L-sided HF, right?

I don't know why I am finding this so confusing. I am tempted to "throw-up my hands" and leave it alone. But, I feel like something is being missed.

HELP!

Thank you,
Katy

Comments

  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    I don't look at adults (I do Peds) but I think I would query the
    cardiologist (or attending?) to clarify the CHF.


  • Unknown
    edited May 2016
    Was an Echo done?

    Tracey

  • robert.hodges2robert.hodges2
    edited May 2016
    End stage pulmonary hypertension and cor pulmonale with the pulmonary fibrosis almost sounds like chronic respiratory failure. If the patient was on continuous oxygen, scheduled nebulizers, and continuous steroid treatment and would decompensate quickly without all of these, it is a consideration.

    I also agree an echo (if present) would be helpful for CHF type specificity, but a cardiologist should also be able to specify based on clinical presentation.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
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  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes. Normal LV with EF 60-65%. Dilated RV with systolic function mildly reduced and Systolic pressure markedly increased. Cards states that the Echo has findings of pulmonary HTN and suggests a pulmonary consult. Also states No overt signs of R HF "YET". Pt did get the pulm consult. He confirms interstitial lung disease, pulm fibrosis/HTN but also suggests that there is evidence of "CHF".
    This was on day one of admission. Pt was moved to Comfort care on day 3 and passed away a few days later.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes. We have acute on chronic Resp failure documented as well, beginning on hospital day #3.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • Unknown
    edited May 2016
    Possible diagnosis based on information
    Acute cor pulmonale
    Chronic pulmonary heart disease
    Acute on Chronic respiratory failure
    I see it’s a death chart. What is the physician stating as the immediate cause of death?

    And I agree! query the cardiologist for CHF type and acuity if present.
    Tracey


  • Unknown
    edited May 2016
    Anything about diastolic function with that Echo

    Tracey
  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Were there clinical indicators for A/C resp failure at admit/POA? ABG's. SPo2 levels? Solumedrol?

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Unfortunately, the D/C summery is very "succinct". He states she was admitted with end-stage pulmonary disease as a result of interstitial lung disease and pulmonary fibrosis. She had acute on chronic respiratory failure and was made comfort care and passes when 02 was removed.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Diastolic function is not mentioned in the ECHO that I see.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • ddouthitddouthit
    Before you can assign acute cor pulmonale physician will need to document acuity. I too wonder if A/C resp failure indicators were present on admit. Pulmonary Fibrosis carries a higher weight than a/c resp. failure but Pulmonary fibrosis is a chronic condition.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Just chronic. H&P states she was at baseline on her home 02 on admission.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • Unknown
    edited May 2016

    From what you have said the left side of the heart seems to be ok and it is the right side that is concerning. Isn't right sided heart failure inherrent in the acute cor pulmonale code?


    Lisa McLuckie, RN BSN
    Clinical Documentation Specialist
    Wooster Community Hospital


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Right. Herein lies the secondary issue. A query was placed concurrently (not by me). However, I do not like the wording. The CDS quoted the dx "Endstage pulmonary HTN and cor pulmonale, secondary to pulmonary fibrosis/LD" and asks for acuity. The MD responded with "Acute on Chronic". However, I personally feel that this is unclear since there are 4 distinct diagnoses in that initial statement. I would have preferred that the cor pulmonale be queried on separately.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • Unknown
    edited May 2016
    Cor Pulmonale is the correct term for right heart failure only. If there is any left heart failure involved at all, then it goes to CHF (CHF is left heart failure or combined right and left heart failure). With cor pulmonale, I usually ask for specificity of chronic or acute.

  • ddouthitddouthit
    When the query asked for acuity did the question specifically state "acuity of cor pulmonale"?

    If a patient has right sided heart failure and an echo, we usually query for type and acuity systolic vs. diastolic.
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes. This is my understanding. CHF is mentioned twice in the record. By the attending on day#1 and by the pulmonologist after the ECHO. Cards never mentions it and also states there is "no signs of right heart failure, yet" after the ECHO.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • ddouthitddouthit
    There is great info on RT heart failure in Merk manual if you have access:

    "RV failure is most commonly caused by previous LV failure (which increases pulmonary venous pressure and leads to pulmonary arterial hypertension, thus overloading the RV) or by a severe lung disorder (when it is called cor pulmonale—see Heart Failure: Cor Pulmonale). "....;
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    No. She copied that diagnostic statement and asked for the acuity. She did not break the cor pulmonale out. That is what I wish she did. As it stands, to me, it appears as "acute on chronic" is applied to all diagnoses listed. However there is no option for acute on chronic for either cor pulmonale or pulmonary HTN. In the encoder (3M), If I attempt to code the cor pulmonale I end up with the options of "acute" "with pulmonary HTN" or unspecified. If I choose pulmonary HTN and denote that as acute, I still end up with "acute cor pulmonale".

    It is my understanding that R sided HF is cannot be described as diastolic/systolic. So, I am uncomfortable querying that way if we are really talking about R HF. However, CHF is mentioned twice and if it really was present then a query would be fine. I am not sure it was present though.

    Katy Good, RN, BSN
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


  • Unknown
    edited May 2016
    To take it through the 3m encoder
    Cor
    Cor pulmonale with pulmonary HTN
    Chronic
    Takes you to 4168



    Tracey


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Yes, but if the term "Acute Cor Pulmonale' is used the code should go to
    415.0 - an MCC, also. I echo all the previous messages regarding the
    need to separately query for the acuity of Cor Pulmonale and any
    possible consequences, such as a form of acute CHF associated with the
    Cor Pulmonale as it is known that one etiology of acute CHF is Cor
    Pulmonale.

    Paul Evans, RHIA, CCS, CCS-P

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

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