Health Information Management

Tip: Understand clinical indicators of CHF before querying physicians

CDI Strategies, July 8, 2010

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Congestive heart failure (CHF) is one example of a condition for which coders and 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 clues to provide clinical support for a CHF query, says Spryszak:

  • An echocardiogram that shows an ejection fraction (EF) of less than 40%, which is indicative of systolic heart failure, or an EF of greater than 50%, which generally indicates diastolic heart failure.
  • An echocardiogram that shows LVH, accompanied with documentation of CHF, supports a query for chronic diastolic 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.
Editor’s Note: This article was excerpted from the June 2010 issue of Briefings on Coding Compliance Strategies.



Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Most Popular