Q: If the attending documented, “likely mixed cardiogenic and septic shock,” can I assign codes R57.0 and R65.21?
A: Refer to the documentation within the code book. If you open the book to the R57 code grouping (Shock not elsewhere classified) listed...Read More »
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 »
