Health Information Management

Q&A: Querying for type of heart failure

CDI Strategies, May 28, 2009

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Q:Last year a cardiologist provided an educational session for our coding auditor and the clinical documentation specialists. In this session he defined heart failure as:
“. . . a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.”
After that education and other articles I have read, I've always thought if a patient has heart failure, it has to be either diastolic or systolic.

Lately though, I've had charts that are telling me the echo showed "no diastolic HF, acute on chronic heart failure due to mitral regurg and afib," or "chronic decompensated HF due to afib and aortic stenosis." 

In cases such as these, when the physician is stating there is no diastolic or systolic dysfunction but there is heart failure, is it more appropriate to ask if this is acute pulmonary edema? Or should we just leave the documentation as-is and code the afib and/or valvular disease?

 
A: What you are experiencing is the difference between chronic heart failure and its modeling, chronic ventricular dysfunction with its acute exacerbations, and acute heart failure—which can be a very different animal.
 
In this instance, the cardiologist is sort of right, but slightly wrong, too. When a patient has acute heart failure (or CHF) due to atrial fibrillation with rapid ventricular response, the patient has acute diastolic heart left ventricular failure. It would be appropriate to make a request for clarification regarding the relationship between the documented tachyarrhythmia, the documented acute congestive heart failure, and the acute diastolic dysfunction that accompanies tachycardias.
 
Editor’s Note: Robert S. Gold, MD, provided this week’s answer. He is the founder of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement. Contact him at DCBAInc@cs.com.



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