Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein...Read More »
by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS
Congestive heart failure (CHF) is a commonly diagnosed condition where the ventricles or the lower chambers of the heart do not work effectively. The heart serves as a pump to get blood in and then out of the...Read More »
To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit...Read More »
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and...Read More »
