ࡱ> imh bjbjWW 4J==B#KK8t[LM$X MMMMMMMOLRtM-\u"\\MKK@M\LK8M\M6;<>PL=LVM0M7=RrR8>>R@4 LS6,MMffM\\\\R :  Request for Clarification Heart Failure/Edema/Overload Dear Physician/PA/NP: _________________________________________________________________________ or other responsible provider: For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected. On ___________ documentation in the ___________________________________________section of medical record states: MetricAdmissionDate:Date:Date:BNPCXRLVEF %Other  CDI Specialist/Coder: __________________________________________ Date:_____________ Time:_______________ PHYSICIAN/PA/NP PLEASE ENTER YOUR RESPONSE IN THIS SECTION Complete this Section if NO form of CHF is present  FORMCHECKBOX  No form of CHF (or other significant cardiopulmonary process) present  FORMCHECKBOX  Non-Cardiogenic Fluid Overload due to____________________________________________________  FORMCHECKBOX  Non-Cardiogenic Acute Pulmonary Edema due to____________________________________________ If CHF present, designate type If CHF present, Designate Acuity  FORMCHECKBOX  Systolic (LVEF <40%)  FORMCHECKBOX  Acute (decompensation)  FORMCHECKBOX  Diastolic ((LVEF >40%)  FORMCHECKBOX  Acute (decompensation) on Chronic  FORMCHECKBOX  Both Systolic & Diastolic Heart Failure  FORMCHECKBOX  Chronic  FORMCHECKBOX  Cannot be determined  FORMCHECKBOX  cannot be determined If CHF present, Designate Etiology  FORMCHECKBOX  Valvular Disease  FORMCHECKBOX  Cardiomyopathy, type___________________ Cor Pulmonale!  FORMCHECKBOX  Acute! FORMCHECKBOX  Chronic  FORMCHECKBOX  Hypertension  FORMCHECKBOX  Pericardial Tamponade  FORMCHECKBOX  Arrhythmia  FORMCHECKBOX  Cannot be determined  FORMCHECKBOX  Other_______________________ Physician/PA/NP Printed Name:______________________________________________________________________ Physician/PA/NP Signature: _____________________________________________Date: __________Time:_______ Created: 3/2011 Revised: 11/8/2011- 4/20/12 - 10/30/12 Heart Failure Definitions: Systolic Heart Failure For purposes of the CMS/TJC Heart Failure measure, LVSD is defined as chart documentation of LVEF less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction. (ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult) Diastolic Heart failure - definitive diagnosis of diastolic heart failure can be made when the rate of ventricular relaxation is slowed; this physiological abnormality is characteristically associated with the finding of an elevated LV filling pressure in a patient with normal LV volumes and contractility. In practice, the diagnosis is generally based on the typical symptoms and signs of HF in a patient who is known to have a normal LVEF and no valvular abnormalities (aortic stenosis or mitral regurgitation for example) on echocardiography. (American College of Cardiology/American Heart Association 2005 updated guidelines for the diagnosis and management of chronic heart failure in the adult) Cardiomyopathy - diseases of the myocardium associated with cardiac dysfunction; five types of cardiomyopathy: dilated, hypertrophic, restrictive, arrhythmogenic right ventricular, and unclassified (Cleveland Clinic: Current Clinical Medicine, 2nd ed., William D. Carey, 2010) Common etiologies of cardiomyopathy include: Alcohol-induced, drug toxicity, hypertension, diabetes, amyloidosis, ischemia, inherited, viral, transplant rejection) Right Sided Heart Failure /Cor Pulmonale - Most commonly, right-sided heart failure is caused by left-sided heart failure. Pure right-sided heart failure is infrequent and usually occurs in patients with any one of a variety of disorders affecting the lungs; often referred to as cor pulmonale. The common feature of these diverse disorders is pulmonary hypertension, which results in hypertrophy and dilation of the right side of the heart. The major morphologic and clinical effects of right-sided heart failure differ from those of left-sided heart failure in that pulmonary congestion is minimal, whereas engorgement of the systemic and portal venous systems may be pronounced. Clinical features include hepatosplenomegaly, peripheral edema, pleural effusions, and ascites. Organs that are prominently affected include the kidney and the brain. (Kumar: Robbins and Cotran Pathologic Basis of Disease, Professional Edition , 8th ed., 2009)     THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD Addressograph or patient sticker ,;<=>?DMSa {o{`T`{`H5CJOJQJaJ h3UhB5CJOJQJaJ hxhxOJQJhg <=>? 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