Health Information Management

Q&A: Querying for CHF using prior documentation

CDI Strategies, January 8, 2009

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Question: Part of our clinical support for determining the presence of congestive heart failure (CHF) includes referring to an echocardiogram performed during a previous admission. Using our electronic record, the physicians can access this same information to review it for mention of systolic or diastolic dysfunction in order to provide a link to exacerbation of CHF. Would using this prior documentation be considered "illegal" under the new American Health Information Management Association (AHIMA) final physician query practice brief?
Answer: I do not believe it would be illegal for query the physician for clinical information that is present in the old record so long as there are clinical indications and/or documentation supporting that the condition qualifies as a principal or additional diagnosis. Specifically regarding CHF, it would not be wrong if a physician documents that a patient has CHF and a query discusses a previously performed echocardiogram.  The question could be posed as follows:
Dear Dr. Jones,
Your progress note of XXXX date confirms that this patient has CHF. On XXXX date, the patient had an echocardiogram that was interpreted as having left ventricular dysfunction, impaired ventricular relaxation, and an estimated ejection of 45%. Please comment upon the nature and acuity of this patient’s CHF. Options may include:

Nature Acuity
 Systolic  Chronic alone
 Diastolic  Acute or acutely decompensated alone
 Both systolic and diastolic  Acute on chronic
 Other:  Other:
 Cannot be determined  Cannot be determined

Please also indicate the underlying cause of the patient’s CHF and any other condition that affected its stability during this hospitalization.

(James S. Kennedy, MD, CCS, director for FTI Healthcare in Atlanta, GA answered this question.)

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