Wiki Heart Failure Principal Diagnosis

[jdevilla]

What is the PDx in this case?
- Discharge summary stated "patient was admitted due to acute on chronic systolic HF exacerbation.
- Other Diagnosis: DM type II
HTN essential
Mod Mitral Regurgitation
A fibrillation on Coumadin
-Hospital Course: The patient was admitted with signs of volume overload, serum BNP was elevated, LFEF 30% with severe DOE and orthopnea 2 pillow. The vital signs are within normal limits except for the tachycardia which was later controlled at the ED level... Lasix was administered, patient in O2 support, Digoxin, Beta blocker was continued throughout the stay....

Argument Points: This case was admitted normotensive and although he was on maintenance antihypertensive, no documentation that the antihypertensive medications was increased in dose nor an additional antihypertensive medication was given to control the hypertension. This patient was volume overloaded.

Possible Answer:
1. Hypertensive Heart Disease with Heart Failure
2. Acute on Chronic Systolic Heart Failure

 

[Munzueta]

I see this type of cases frequently. Pretty much a patient with hypertension and CHF will always receive treatment for both, especially during an exacerbation. Hypertension will always require treatment, even if its just monitoring of blood pressure. I am assuming you are doing DRG coding?

In other words, you will code both, and even though the patient was admitted for exacerbation, your coding guidelines for sequencing will guide you to code hypertension first followed by CHF.

1. I11.0
2. I50.23

hope it helps!