If you have been a CDI for a number of years, you likely have wished for a dollar for every time you have queries for “specificity of heart failure.” I often joked that I would be asking for differentiation of systolic versus diastolic on my death bed. The latest AHA Coding Clinic has offered us assistance in obtaining this differentiation.
AHA Coding Clinic, First Quarter 2016, pages 10-11, tells us that if the provider describes the ejection fraction with terms such as preserved EF (HFpEF), the coder may interpret this as meaning “diastolic heart failure “or reduced EF (HFrEF) is documented, the coder may interpret this as meaning “systolic heart failure.” It is always a good day when the coding instruction reflects the language used by our providers.
This new direction is effective for discharges after March 18th, 2016. I think it is a sure bet you might ask at least one less query in your record reviews this week based on this new guidance!