Wiki Coding heart failure

[TiffanySingh]

I have a general coding question about heart failure. i am coding from a hosp-admission discharge summary and the provider coded in the past medical history acute on chronic heart failure with a date as the same of admission date. The patient has prescribed medication, lisinopril as home medication. Can Heart failure be capture ?

 

[natashalage]

Hello, I am not an expert, but I will express my thoughts. We don’t code from a past medical history. And I don’t think we should Google the purpose for this medication so we can code the associated medical condition. We code the condition that was assessed, examined, evaluated , etc. by MD, or MD prescribed a medication for it. From the description above it is not clear if heart failure was stated as a current condition. I would query the provider. If MD documented that a prescribed medication for patient’s heart failure, then it will be a complete sentence qualifying for coding HF.