Download Don`t fail to account for changes to CHF

Don’t fail to account for changes to CHF
Documentation of ‘acute’ and ‘chronic’ crucial in 2008
By Robert S. Gold, MD
As a writer for various HCPro publications for the
past six years, I want to welcome you to the Association of
Clinical Documentation Improvement Specialists (ACDIS).
Yours is, indeed, a very important job in today’s medical
practice—an age of medical informatix and statistics.
As you know, all severity-adjusted statistics come from
the codes that appear on CMS bills. If the chart has the right
words and the coders assign the right codes, the bill will
tell the story of the patient. Unfortunately, a bill that tells
the story is rare in facilities that don’t have a strong clinical
documentation improvement (CDI) program. Why? Young
doctors are influenced by their mentors, their textbooks,
their peers, drug reps, and the terminology “du jour”—
words taken from yesterday’s medical literature that have no
benefit whatsoever to help with the ability to assign proper
ICD codes. So, welcome to the club assigned with righting
these wrongs. Let’s use it as a springboard to mutual success.
Let’s share our information, our techniques, our successes,
and our failures, and help one another.
CHF and the need for specificity
For the past two years, CDI specialists and coders have
had to identify patients with heart failure based on the concepts of :
»Acute
»Chronic
»Systolic dysfunction
»Diastolic dysfunction
The information CDI specialists and coders provide is
supposed to help physicians identify patients with “heart
failure due to chronic systolic dysfunction,” the primary
reason for the existence of the CMS/Joint Commission
(formerly JCAHO) heart failure core measure initiative. The
American College of Cardiology (ACC) and the American
Heart Association (AHA) wrote an article in 2001, titled
“Guidelines for Identification and Management of Chronic
Heart Failure [CHF],” that identified the patients at risk
of sudden cardiac death as those with heart failure due to
chronic systolic dysfunction, which they defined as patients
having an ejection fraction under 40%. Unfortunately, CMS
and The Joint Commission have only asked us to identify
that a patient’s ejection fraction is under 40%, and do not
require physicians to include the terms “chronic” or “systolic.” Personal discussions with both the ACC and The Joint
Commission have led to promises that this will change.
Also, certain DRG assignments depend on physicians
to properly identify patients who have an acute myocardial
infarction (MI), heart failure, or shock as a principal diagnosis. These DRGs have a higher relative weight than the corresponding DRG assigned to patients without these conditions.
Under CMS’ Medicare Severity DRG (MS-DRG) system, which takes effect on October 1, secondary diagnoses
of acute diastolic or acute systolic (or acute diastolic and
systolic) heart failure are considered major complications/
comorbidities (MCC). CMS identifies secondary diagnoses
of chronic diastolic or chronic systolic (or diastolic and
systolic) failure as complications/comorbidities (CC). And
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October 2007
© 2007 HCPro, Inc.
many other descriptors, such as “CHF” won’t count for a
hill of beans—neither a CC nor an MCC.
This concept of severity and heart failure is of massive
importance from a quality and a reimbursement perspective.
If CDI specialists are to help the medical record truly reflect
what is wrong with patients with words that can be translated into the proper codes, they must be able to identify acute,
chronic, systolic, and diastolic conditions.
Important terminology to know
To identify these conditions in the patient’s chart and
ensure appropriate reimbursement under MS-DRGs, familiarize yourself with the following terms.
Left heart failure: This is a situation in which stroke
volume—i.e., the amount of blood leaving the left ventricle
with every contraction—cannot supply the body with sufficient nutrients to function normally. When the left ventricle
cannot meet this burden, the heart fails.
Left ventricular systolic dysfunction: This is a situation
in which the heart cannot supply enough stroke volume due to
contractility problems. During systole, the left ventricle is so
weak it cannot produce enough emptying to provide an acceptable stroke volume. If one has a left ventricular muscle that
has been weakened by ischemia, it can dilate and not be strong
enough to supply a good stroke with the next systole. This
occurs as a result of alcoholic cardiomyopathy, toxic effects of
adriamycin therapy, or other reasons that weaken or kill heart
muscle cells. Over time, the left ventricle dilates and ejects only
a small portion of what goes into it. This inability to empty
adequately during systole is called systolic dysfunction.
Left ventricular diastolic dysfunction: This is a situation in
which the left ventricle cannot fill with enough volume during
the relaxation phase. Despite the fact that it is strong, it doesn’t
have enough filling to put out enough volume with the next
contraction. If the left ventricle hypertrophies due to hypertensive
disease (i.e., working harder against higher pressures downstream
causes muscles to hypertrophy and become muscle-bound and
unable to relax when they should relax) or due to aortic valvular
disease (i.e., working harder against a narrower exit opening causing hypertrophy and inability to relax at the end of diastole), it
develops diastolic dysfunction—i.e., it cannot fill enough during
diastole because the volume of the left ventricle is smaller (with a
hypertrophied muscle), and it cannot relax at the end of diastole
to let blood into its smaller cavity.
Modeling: Chronic left ventricular systolic and diastolic
dysfunction develop over long periods of time. Dilation and
left ventricular hypertrophy are conditions called modeling.
This means that the shape of the left ventricle changes over
time due to chronic issues, either systolic or diastolic. When
the stroke volume is less than desirable, failure occurs. The
ACC/AHA article establishes a 40% ejection fraction as
being the lower level of normal systolic function. Therefore,
when a left ventricle has an ejection fraction under 40%, that
is systolic failure. When a CHF patient has a “normal” ejection fraction or a “sustained” ejection fraction, the patient
has diastolic failure. A patient with an ejection fraction
under 40% (i.e., systolic failure) can also have diastolic
dysfunction. In addition to downstream pressures or hypertensive disease or narrowing of the aortic valve, a heart may
be troubled with diseases that stiffen its muscle or deposit
abnormal chemicals between muscle fibers, making the left
ventricle stiff and unable to relax during diastole. Such
continued on p. 14
Chart courtesy Robert S. Gold, MD, Atlanta, GA.
CHF chart
Four phases of diastole: (1) isovolumic relaxation, (2) rapid filling, (3) diastasis, (4) atrial contraction.
Source: Chart courtesy of Robert S. Gold, MD, Atlanta, GA.
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© 2007 HCPro, Inc.
October 2007
13
Changes
continued from p. 13
conditions include amyloidosis of the heart or glycogen storage causing stiffness or chronic constrictive pericarditis causing
inability of the left atrium and the left ventricle to relax completely during diastole. The most common presentations of
patients with chronic diastolic failure are respiratory signs
and symptoms (e.g., dyspnea, cough), although they may be
minimal when things are otherwise stable and the patient is
controlled with medication. The most common presentations of patients with chronic systolic failure are fatigue and
weakness.
Acute diastolic dysfunction: This condition can occur
with a basically normal heart or with a heart that has
chronic systolic or diastolic problems. This is represented
by the patient who comes in with acute shortness of breath
and often with x-ray findings of pulmonary edema. Acute
diastolic dysfunction occurs due to an acute change in the
heart’s ability to fill the left ventricle during diastole.
The chart on p. 13 represents one heart cycle, starting
with left ventricular contraction on the left side of the chart
at a pressure of approximately 12–15 mm Hg. The pressure
change first closes the mitral valve. Then the pressure builds
until it exceeds the pressure in the aorta during diastole, and
“pop”—the aortic valve opens. Pressure builds in both until
the contraction of the heart is over and the pressure in the left
ventricle starts to drop. Then the aortic valve closes. Pressure
drops during Phase 1 of diastole until the pressure in the left
ventricle drops lower than the pressure in the left atrium and
the mitral valve opens. During Phase 2, there is rapid filling of
the left ventricle. Then a short period of rest (Phase 3) until
the left atrium contracts and the last little spurt of volume gets
into the left ventricle in Phase 4. This time period during diastole is necessary so that the left ventricle can fill.
If suddenly the heart rate rises to 140, 160, 220 beats per
minute, there is no time for diastole to take place. With no
time to fill the left ventricle during diastole, the patient instantly
develops massive decreases in stroke volume due to acute
diastolic dysfunction and experiences an acute diastolic heart
failure. Treatment must include dropping the heart rate. When
the rhythm is restored, the heart returns to where it was prior to
the acute event and there may be no chronic component at all.
Acute diastolic dysfunction is caused by acute volume overload, acute pericardial effusion, salt intake, not taking medication (noncompliance with treatment), or acute MI.
Acute diastolic failure: This condition occurs in a
patient that has:
»Symptomatic acute diastolic dysfunction
»Pulmonary edema
»Elevated serum brain natriuretic peptide levels
Acute systolic failure: This occurs due to an acute MI,
or an acute rupture of a chorda tendinae or papillary muscle
of the mitral valve. These conditions cause immediate mitral
regurgitation and inability of the left ventricle to empty itself
into the aorta and it backs up into the lungs.
Take-home points for CDI specialists
The following is a checklist you should run through for
every acute heart failure patient:
1. Find out the cause of the acute failure, or whether the
patient has any chronic conditions.
2. If a physician indicates any notation of left ventricular
hypertrophy, dilated cardiomyopathy, or history of CHF,
find out the cause of the patient’s CHF state. For example,
a patient may have acute diastolic failure due to ventricular
tachycardia on top of chronic systolic failure due to ischemic cardiomyopathy.
3. Require the physician to give you the reasons for the
acute and chronic conditions whenever they exist.
4. When forming a query or asking a question, talk the
physician’s language. Talk pathogenesis of disease.
5. Don’t forget. Patients with CHF states are at risk of
chronic kidney disease, especially if related to hypertensive disease. Patients with acute heart failure are at risk of
acute respiratory failure or acute renal failure. Don’t miss
those additional diagnoses when they exist as they can
affect severity.
Now, you be careful out there.
H
Editor’s note: Dr. Gold founded DCBA, Inc., in Atlanta, a consulting
firm that provides physician-to-physician programs in CDI. The goals are
data accuracy, profile management, and compliance, either in the inpatient or
outpatient arenas. He can be reached by phone at 770/216-9691 or by
e-mail at [email protected].
For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.
14
October 2007
© 2007 HCPro, Inc.