Wiki CHF - Pleural Effusion

[Partha]

Should this be coded as CHF or Pleural Effusion?

X-RAY CHEST
REASON FOR EXAM: Male, 50 years old. Congestive heart failure.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: 11/23/14 ___________________________________
FINDINGS: Moderate lung volumes. Diffuse interstitial prominence which may be fibrosis and/or congestion and pulmonary edema. Bilateral small pleural effusions, right is larger than on previous studies. Faint focal pulmonary opacities in both upper lobes are seen unchanged with mass not excluded. CT scan recommended. Atelectasis in both lung bases. Normal size heart. Normal mediastinum and hila. Normal visualized pulmonary arteries. Normal visualized aortic arch and descending thoracic aorta.
Normal visualized thoracic spine. Normal visualized ribs, clavicles, and shoulders.

There is no demonstrated abnormality of the visualized soft tissue structures of the upper abdomen. ___________________________________

IMPRESSION: Congestion and pulmonary edema and/or fibrosis. Bilateral pleural effusions, increased on the right. Focal opacities in the upper lobes. CT scan recommended.

 

[mrupendra66@gmail.com]

Congestive heart Failure

Hi,
In this scenario we cant congestive heart failure. becouse X-Ray reports say congestion only may be it is due to the pulmanory edema, however the impressions also not concluded the congestive heart failure. provider concluded that bilateral pleural effusions in X-ray reports. So we can code Pleural Effusion.

 

[balamuruganm]

Hi Partha,

This is radiology report so Reason for visit itself CHF, That means Patient having CHF and this visit is follow up for CHF so better diagnosis is CHF and Effusion No need to code..

 

[Partha]

If we can corroborate with some guidelines, it will be helpful.