Health Information Management

Clinically Speaking: Don’t rely solely on an encoder

Briefings on Coding Compliance Strategies, March 1, 2010

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Regardless of the scenario, codes reported should reflect clinical details. For example, a patient may develop acute diastolic heart failure from atrial fibrillation with rapid ventricular response. If the patient also has background hypertensive heart disease with chronic systolic or chronic diastolic dysfunction as the cause, the dysfunction must be coded separately. This patient does not have acute on chronic heart failure. The principal diagnosis would not be hypertensive heart disease with heart failure because the cause of the acute decompensation has nothing to do with the hypertension.

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