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Documentation Tip of the Week: Heart Failure

Posted on Wed, Mar 18, 2015
Documentation Tip of the Week: Heart Failure

Heart Failure Documentation

Coding Clinic (a published guideline for coders) determined that

  • “Heart Failure with reduced Ejection Fraction” CANNOT be coded as “Systolic Heart Failure” AND
 
  • Heart Failure with preserved Ejection Fraction” CANNOT be coded as “Diastolic Heart Failure”

Documentation Awareness:
  • Physicians MUST at some point in the chart document systolic or diastolic to capture the specificity of heart failure correctly
 
  • Remember:  “Acute”, “chronic” or “acute on chronic” must also be documented

Timothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.

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