Q: Can you ask a yes or no question in a query based on clinical information from a previous echocardiogram report or other diagnostic result from a previous admission?
A: My gut response is no, because you can’t code from anything from a previous admission. But I think what you can do is include it as a clinical indicator for specificity. If you’re looking for something, I would probably feel that it would be more supportive in a multiple-choice or open-ended query.
Oftentimes when a patient has heart failure, one of the CMS core measures is that you have a left ventricular study. Well, it’s not reasonable for a hospital to do a left ventricular study every time the patient comes into the hospital. So there may have been one done within the previous six months, so I think that it would be important to be able to find that record, look at that information, and maybe use that clinical indicator to help the physician determine whether it’s a systolic or a diastolic heart failure. Again, I’m assuming we’re looking for that ejection fraction of less than 40% to support systolic.
But I don’t know that I would ask a yes/no because it’s not in this current episode of care. I would probably be more comfortable if that was included in a multiple choice where the physician has a little more latitude.
Probably the only caveat to that is oftentimes the physician will make reference to a previous study, and in that instance it is part of the health record. So for instance, I might say an echocardiogram six months ago did reveal an ejection fraction of 20%. So it’s in the record at that point.
But as far as bringing out old information and trying to bring it to the current record, you really can’t code from that. You can use it as one of your clinical indicators, but you certainly couldn’t code from this. I wouldn’t want to use that solely as a yes/no piece of information unless the physician specified that diagnosis in the current health record.
Editor’s note: Cheryl Ericson, MS, RN, CCDS, CDIP, CDI education director at HCPro., in Danvers, Mass, and William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, FL, answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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