CHF (Congestive Heart Failure)

Heart failure, sometimes known as congestive heart failure (CHF) is a chronic complex clinical condition, which prevents filling or emptying of blood from the heart.

CHF is caused by either a structural anomaly (valvular or congenital) and/or certain conditions, such as narrowed arteries in the heart (coronary artery disease) or high blood pressure, gradually leaves the heart too weak or stiff to fill and pump efficiently.

CHF Symptoms: CHF Symptoms may include;

Shortness of breath (dyspnea) on exertion or at rest

Fatigue/weakness

Edema of legs (ankles and feet)

Rapid or irregular heartbeat

Exercise intolerance

Increased urination at night

Abdominal swelling (ascites)

Very rapid weight gain from fluid retention

Lack of appetite and nausea

Sudden, severe shortness of breath

Chest pain.

CHF Clinical Indicators:

Echo:  Ejection fraction (EF) of <40% = Systolic heart failure

 Ejection fraction (EF) of >50%= Diastolic heart failure.

Elevated BNP (B-type natriuretic peptide)

+Ve Chest X-ray for Pulmonary Vascular Congestion/Pulmonary Edema.

Medications:

IV or PO diuretics (Lasix, Bumex, Zaroxylin)

ACE Inhibitor/ARB

Betablockers, Coumadin, ASA (Aspirin), IV Dobutamine

Types of CHF:

Systolic heart failure: The left ventricle can't contract adequately, indicating a    pumping problem. HFrEF (Heart failure with reduced ejection fraction).

Diastolic heart failure: Also called HFpEF (Heart failure with preserved ejection fraction). The left ventricle will not relax or fill fully, indicating a filling problem.

Common Medical Specialists

A SPECIALTY is a branch of medicine that is focused on a defined group of  diseases, patients, or skills. 

Anesthesiologist:

Doctor who give drugs to patients to numb during surgery or procedures.  Monitors vital signs while the patient is under anesthesia.

Cardiologists:

Experts on the heart and blood vessels. Diagnoses and treats heart failure, a heart attack, high blood pressure, or an irregular heartbeat.

Critical Care Medicine:

They care for people who are critically ill or injured, often heading intensive care units in hospitals. You might see them if your heart or other organs are failing or if you’ve been in an accident.

Dermatologists:

Specialists in diseases of skin, hair and nails. Treats acne, moles, skin allergies etc.

Endocrinologist:

These are experts on hormones and metabolism. They can treat conditions like diabetes, thyroid problems, infertility, and calcium and bone disorders.

Emergency Medicine:

These doctors make life-or-death decisions for sick and injured people, usually in an emergency room. Their job is to save lives and to avoid or lower the chances of disability.

Family Physician:

They care for the whole family, including children, adults, and the elderly. They do routine checkups and screening tests, give you flu and immunization shots, and manage diabetes and other ongoing medical conditions.

Gastroenterologist:

They’re specialists in digestive organs, including the stomach, bowels, pancreas, liver, and gallbladder. You might see them for abdominal pain, ulcers, diarrhea, jaundice, or cancers in your digestive organs. They also do a colonoscopy and other tests for colon cancer.

Geriatrics:

These doctors care for the elderly. They can treat people in their homes, doctors' offices, nursing homes, assisted-living centers, and hospitals.

Hematologist:

Specialists in diseases of the blood, spleen, sickle cell disease, anemia, hemophilia, and leukemia.

Hospice and Palliative Care:

They work with people who are nearing death. They’re experts in pain management. They work with a team of other doctors to keep up your quality of life.

Infectious Disease (ID) Specialist:

Diagnose and treat infections in any part of your body, like fevers, Sepsis, pneumonia, tuberculosis, and HIV and AIDS. Some of them specialize in preventive medicine or travel medicine.

Nephrologist:

They treat kidney diseases.

Neurologist:

Specialists in the nervous system that includes the brain, spinal cord, and nerves. They treat strokes, brain and spinal tumors, epilepsy, Parkinson's disease, and Alzheimer's disease.

Obstetrician & Gynecologist:

Often called OB/GYNs, these doctors focus on women's health, including pregnancy and childbirth. They do Pap smears, pelvic exams, and pregnancy checkups. OB/GYNs are trained in both areas. But some of them may focus on women's reproductive health (gynecologists), and others specialize in caring for pregnant women (obstetricians).

Oncologist:

Cancer specialists. They do chemotherapy treatments and often work with radiation oncologists and surgeons to care for someone with cancer.

Ophthalmologist:

You call them eye doctors. They can prescribe glasses or contact lenses and diagnose and treat diseases like glaucoma. Unlike optometrists, they’re medical doctors who can treat every kind of eye condition as well as operate on the eyes.

Pathologist:

These lab doctors identify the causes of diseases by examining body tissues and fluids under microscopes.

Pediatrician:

They care for children from birth to young adulthood. Some pediatricians specialize in pre-teens and teens, child abuse, or children's developmental issues.

Plastic Surgery:

You might call them cosmetic surgeons. They rebuild or repair your skin, face, hands, breasts, or body. That can happen after an injury or disease or for cosmetic reasons.

Podiatry:

They care for problems in your ankles and feet. That can include injuries from accidents or sports or from ongoing health conditions like diabetes. Some podiatrists have advanced training in other subspecialties of the foot.

Psychiatrists:

These doctors work with people with mental, emotional, or addictive disorders. They can diagnose and treat depression, schizophrenia, substance abuse, anxiety disorders, and sexual and gender identity issues. Some psychiatrists focus on children, adolescents, or the elderly.

Pulmonologist:

You would see these specialists for problems like lung cancer, pneumonia, asthma, emphysema, and trouble sleeping caused by breathing issues.

Radiology:

They use X-rays, ultrasound, and other imaging tests to diagnose diseases. They can also specialize in radiation oncology to treat conditions like cancer.

Rheumatology:

They specialize in arthritis and other diseases in your joints, muscles, bones, and tendons. You might see them for your osteoporosis (weak bones), back pain, gout, tendinitis from sports or repetitive injuries, and fibromyalgia.

Sports Medicine:

These doctors diagnose, treat, and prevent injuries related to sports and exercise.

General Surgery:

These doctors can operate on all parts of your body. They can take out tumors, appendices, or gallbladders and repair hernias. Many surgeons have subspecialties, like cancer, hand, or vascular surgery.

Urologist:

These are surgeons who care for men and women for problems in the urinary tract, like a leaky bladder. They also treat male infertility and do prostate exams.

Frequently Used Medical Terms in In-patient DRG coding

Anti-inflammatory: Reduces swelling, pain, and soreness.

Body Mass Index (BMI): Body fat measurement based on height and weight.

Biopsy: A tissue sample for testing purposes.

Comminuted fracture: Broken bone that shatters into many pieces

Hypotension: Low blood pressure

Hypertension: High blood pressure

Lesion: Wound, sore, or cut

Benign: Non-cancerous

Malignant: Cancerous

Noninvasive: Non-surgical (No instrument to enter the body)

Inpatient: Plan to stay overnight for one or more days

In remission: Disease is not getting worse; not to be confused with being cured

Membrane: Thin layer of tissue that serves as a covering or lining or connection between two structures

Acute: Suddenly happening, but shorter duration (e.g., acute illness)

Angina: Pain in the chest related to the heart that comes and goes

Cellulitis: Inflamed or infected tissue beneath the skin

Compound fracture: Broken bone that protrudes through the skin

Epidermis: Outermost layer of skin

Edema: Swelling

Embolism: Blood clot

Sutures: Stitches

Polyp: Mass or growth of thin tissue

EHR: Electronic Health Record.

EMR: Electronic Medical Record.

OP Note: Descriptive note how the surgery has been performed. Illustrates how the surgeon entered the body (Laparoscopic or Open), body part operated, blood vessels ligated, instruments used(Hardware, tubings, catheters), body part removed or treated, type of sutures used etc.. 

ED Note: Emergency department note (The patient's first encounter to the hospital, where in-patient entry starts if required)

Lab Data: Logs all the tests performed on a patient while he/she stays in the hospital on daily basis.

Radiology Report: Important part of in-patient medical record. Contains information related to fractures, x-rays, Ultrasound, CT-scan, MRI, MRA. It also shows implants (Pacemaker, Stents, AICD, artificial body parts like joints, rods) central lines and tubes (PICC Line, Arterial lines, Endotracheal tube).

It also gives information of vital organs without the need to enter the body surgically.

Progress Notes: Records and represents the progression of health or condition of an admitted patient to the hospital.

Consult Notes: Records logged by the consultants (specialists) while the patient is admitted.

Query: Doubts raised by the In-patient Medical Coder to the treating physician to get clarification on inappropriate, insufficient  data.

                      (Let's discuss about !!!QUERIES??? in detail  in separate post)

                                                                                     .........

Sepsis

Sepsis/Septicemia:

It’s a medical emergency caused by the body's response to an infection and can be life-threatening. It involves the consequence of widespread swelling (inflammation) in the body.

Inflammation and blood clotting during sepsis can cause decreased blood flow to the limbs, vital organs, and can lead to organ failure and also death.

Sepsis Causes:

Bacterial infections are the most common cause of sepsis. Sepsis can also be caused by fungi, parasitic, or viral infections. The source of the infection can be any of a number of places throughout the body, like

Lungs: Pneumonia

Abdomen: Appendicitis, gastric and intestinal infections, peritonitis and gallbladder and lever infections.

Skin: Wounds, cuts, IV sites, catheter insertion sites. Cellulitis also can cause sepsis.

GU: Infections of the Urinary tract like urethra, urinary bladder and kidney

Signs and Symptoms:

·         Weakness

·         Fever and chills

·         Rapid breathing  (Tachypnea)

·         Rapid heart rate  (Tachycardia)

·         Low blood pressure (Hypotension)

·         Low body temperature (Hypothermia)

Treatment:

          IV Antibiotics

          IV Fluids

          Ventilation, if O2 levels are low

                                                                             ……how to code Sepsis

                                                                                             ….will continue

Present On Admission or POA

All claims submitted for in-patient admissions to general acute care hospitals or other health care facilities are required to report the POA indicator, which is assigned by the coder to the principal and secondary diagnoses and external cause of injury codes.

POA stands for Present On Admission, meaning, whether a condition was present at the time of In-patient admission or not.

CMS defines POA as PRESENT AT THE TIME THE ORDER FOR INPATIENT ADMISSION OCCURS.

POA Indicators

                 Y = Yes (Present at the time of inpatient admission)
                 N = No (Not present at the time of inpatient admission)
                 U = Unknown (Documentation is insufficient to determine if the condition was present at                             the time of inpatient admission)
                 W = Clinically undetermined (Provider is unable to clinically determine whether the                                      condition was present at the time of inpatient admission or not)

Issues related to inconsistent, missing, conflicting, or unclear documentation are resolved by the provider as a result of the physical query process.