Health Information Management

Understand clinical indicators of CHF before querying physicians

HIM-HIPAA Insider, July 6, 2010

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Congestive heart failure (CHF) is one example of a condition for which coders and clinical documentation improvement (CDI) specialists should understand clinical indicators before querying physicians, says Lynne Spryszak, RN, CCDS, CPC-A, a CDI educator at HCPro, Inc., in Marblehead, MA.

Be on the lookout for these specific clinical clues to provide clinical support for a CHF query, says Spryszak:
  • An echocardiogram that shows an ejection fraction (EF) of less than 50%, which is indicative of systolic heart failure, or an EF of greater than 50%, which generally indicates diastolic heart failure.
  • An echocardiogram that shows ventricular hypertrophy, an indicator of chronic heart failure. Look for evidence of decreasing EF and usage of home heart failure medications.
  • Increasing doses of diuretics (e.g., physician order of “Lasix 40 IVP now” or “Increase Lasix to BID”). These orders may indicate treatment of an acute or acute-on-chronic episode of heart failure.
  • Physician orders that reference cardiology consults, an echocardiogram, or a heart failure standing order set.
  • Other indicators, such as a CHF teaching form, CORE measures documentation form, or a nursing assessment that includes jugular venous distension, moist breath sounds, shortness of breath, or labored breathing.
Note: For additional tips, read the full article as printed in the June 2010 issue of Briefings on Coding Compliance Strategies.

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