April 06, 2016 | | Comments 7
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BIG news for heart failure documentation

Prescott_Laurie_webIf 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!

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Filed Under: Clinical Documentation ImprovementCoding

Laurie Prescott About the Author: Laurie Prescott, MSN, RN, CCDS, is a CDI education specialist for HCPro., Inc., in Danvers, Mass. A former clinical documentation specialist at Morehead Memorial Hospital, she spent the majority of her nursing career in acute care, primarily medical surgical with experience in ICU, PACU, endoscopy, and one day surgery, as well as medical units. Prescott worked as a unit manager of MED/SURG and ICU units, as an adjunct professor for an ADN program, and then moved to onsite education and clinical support of nursing staff. Contact her at lprescott@hcpro.com.

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  1. Can this language be used in the ambulatory setting also?

  2. The physician documented Decompensated CHF documented —-can I get the type from the echo??? Without sending a query??

  3. Laurie Prescott

    Great questions ladies.
    Sheila, yes I would assume these definitions would also be suitable to use in the outpatient setting as well. there is nothing that would contradict any coding guidelines related to the outpatient setting.

    Gina, your questions has two answers… yes and no!
    Yes you could code form this terminology if documented in the echo if the physician interpreting the echo is providing hands on care as the attending or consulting provider.

    No, you can not use these terms for code assignment if the provider interpreting the echo has not provided hands on care and assessment to the patient.

  4. I’m using CHF as my pdx on a current patient. I’ve got physicians documenting CHF, Heart failure with preserved EF. Do I still need to Q for Acute? (same would apply if I was trying to use it as my mcc, does the acute/chronic part need to still be documented?

  5. Laurie Prescott

    Yes Carol we do need to differentiate if the heart failure is acute or chronic, this allows us to then differentiate the sytolic from diastolic.

  6. When documentaing CHF, our physicians have started documenting the NYHA classifications and stages. Are we able to assign codes using this classification system?

  7. Laurie Prescott

    Great question Michelle, and unfortunately the answer is no. but I do teach that knowledge of these classification can help you assure that you are capturing appropriate diagnoses. they can be used for clinical indicators to assist in obtaining missing or vague diagnoses.

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