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Q: Regarding CHF-In the past year or two, I am being told not to code CHF, unless somehow I determine it was active on the present admission. I thought CHF was a chronic ongoing condition that should always be coded. We try to get further data-acute/chronic/systolic/diastolic, etc., but in many cases I am being told not to code it, even when the patient is on Lasix or coumadin. No one can give me a simple explanation, or guideline I can use. Is there an answer to this?
A: The general guideline to determine a secondary diagnosis is if: a clinical evaluation is provided, diagnostic procedures may be performed and the patient may require an extended length of hospital stay or increased nursing care or monitoring. The UHDDS definition of a secondary diagnosis is: "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode that have no bearing on the current hospital stay are to be excluded."
Also, as per Coding Clinic, Volume 26, 1st Quarter, Number 1, 2009, page 8:
Question: The patient is documented as having systolic dysfunction with acute exacerbation of congestive heart failure (CHF). Can this be coded as acute systolic heart failure with congestive heart failure?
Answer: Assign code 428.0, Congestive heart failure, unspecified and code 428.23, Systolic heart failure, Acute on chronic. Acute exacerbation of a chronic condition (heart failure) is coded as acute on chronic.
ICD-9-CM's Alphabetic Index provides the following direction for systolic dysfunction with heart failure:
systolic 429.9 with heart failure-see Failure, heart
Additionally, congestive heart failure is not an inherent component of systolic or diastolic heart failure. When the diagnostic statement lists congestive heart failure along with either systolic or diastolic heart failure, two codes are required to report the specific type of heart failure: congestive, diastolic, and/or systolic. This advice is consistent with that published in Coding Clinic, Fourth Quarter 2002, pages 52-53 and Fourth Quarter 2004, page 140.
The key to determining if a diagnosis is reportable is following UHDDS guidelines and if the physician has documented the significance of this diagnosis. You cannot assign a secondary diagnosis just because the patient is on medication without supporting documentation by the attending. If one of more of the UHDDS criteria is met, then query the physician for the clinical significance.
- Arlene F. Baril, MHA, RHIA, CHC
Q: Per Coding Clinic, Second Quarter 1992, Page 13, "Assign a code from subcategory V10.6 only when the physician documents that the patient has been completely cured. A patient in remission still has leukemia." Therefore, pursuant to the above instruction you will typically code one of the leukemia codes unless the provider expressly states that the disease has been completely eradicated. Is multiple myeloma a chronic incurable condition as well as leukemia and do these "leukemia" rules apply to mm? If the MM dx is on the PMH, can I still assign code 203.00?
A: I would go strictly by physician documentation in these cases as the Coding Clinic you cited indicates. If the physician states leukemia or myeloma in remission, I would code using the 5th digit to indicate remission. But if the physician clearly documents that the condition is totally eradicated and does not refer to remission at all, I would use the past history V code. There is such a thing as these conditions being past history. They are not considered incurable chronics that will always be present like diabetes or hypertension.
- Christina Benjamin, MA, RHIA, CCS, CCS-P
Q: A MRI scan of the lumbar spine revealed "annular tear IN LUMBAR L4-L5" along with spondylosis of spine. Can we code 722.52 for annular tear on a 69 year- old patient?
A: Coding depends on the circumstance of the encounter: 1) Is it an outpatient or inpatient encounter? 2) Is the diagnosis documented by the physician as reason for the MRI scan?
For an outpatient encounter:
The coder must know what the intent was for the MRI scan.
- If the admitting diagnosis for the MRI is related to the findings documented within the Impression of the report, then codes 721.3 and 722.52 for the annular tear with spondylosis can be assigned. All other diagnoses documented within the body of the report are incidental findings and should not be coded. Per Official Coding Guidelines for Outpatient Services, Section IV, L, "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses." (Coding Clinic 2000 Q1 page 6 and Coding Clinic 1990 Q2 pg 15-16 address coding from diagnostic tests.)
- If the admitting diagnosis for the MRI is not-related to the findings documented within the Impression of the report, the annular tear is considered an incidental finding and should not be coded.
For an inpatient encounter:
The results of the MRI scan will have to correlated by the attending physician and documentation must be present within the record regarding the plan for treatment, further evaluation or significance of care per the Official Coding Guidelines for assignment of Additional Diagnosis.
- Jennifer Clements, RHIT, CCS