Health Information Management

News: Need to query for acute CHF lessened, thanks to new Coding Clinic

CDI Strategies, October 30, 2008

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The third quarter, 2008 AHA Coding Clinic for ICD-9-CM contains valuable new guidance for CDI specialists regarding querying for congestive heart failure (CHF). Specifically, CHF exacerbation or decompensated CHF now equates to acute CHF.

Prior to 2007, the term ‘exacerbation’ did not automatically equal acute, so matching the code to the documentation often required additional steps, including querying the physician. But new ICD-9-CM codes for heart failure were split into two groups—acute and chronic. For a while, that left many CDI groups in a bind.

“We tried to figure out how to get more specific language into the documentation and developed an official, hospital specific, physician query form,” says Lynne Spryszak, RN coordinator, clinical documentation management program at Alexian Brothers Medical Center, Elk Grove Village, IL.

The clarification contained in the AHA Coding Clinic now reduces the need to generate a query but does not eliminate such queries altogether, she says.

Note: To read more about Coding Clinic and the need for continuing education for CDI specialists, check out Spryszak’s recent CDI Blog post at the ACDIS Web site.



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