Health Information Management

Understand coding, core measures for heart disease

Briefings on Coding Compliance Strategies, March 1, 2008

I have always stressed the importance of proper documentation regarding heart failure and acute myocardial infarction. And physicians are finally listening. They are documenting heart failure when it exists, and many physicians are providing the necessary specificity, such as acute versus chronic or systolic versus diastolic. However, this more specific documentation has larger implications related to the core measures. There are clinical circumstances in which physicians properly identify the true severity of the patient and coders properly report these more severe cases, and yet the hospital's statistics may look worse-or at least appear that way on paper.

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