Keep in mind these coding tips to improve medical record documentation

In previous editions of The Record, we’ve reminded you of the importance of documentation and proper ICD-9 coding to ensure appropriate insurance reimbursement. This month we’ll focus on coding tips related to heart failure.

Heart failure: an overview
Heart failure is a challenge for all providers and affects all different specialties. Heart failure occurs when the heart muscle doesn’t pump blood to the body as effectively as it should. It can be an acute condition, but most of the time it occurs slowly and becomes a chronic condition. Heart failure often develops after other conditions have damaged or weakened the heart.

Congestive heart failure is a specific type of heart failure that occurs when blood backs up — and becomes congested — into other organs such as the liver, abdomen, lower extremities and lungs. CHF is often mistakenly used interchangeably with heart failure. Congestion is one feature of heart failure, but it doesn’t occur in all patients.

Causes of heart failure include coronary artery disease, cardiomyopathy and other arrhythmias, hypertension, myocarditis and faulty heart valves, and may contribute to kidney disease, diabetes, pulmonary embolism, endocarditis, anemia and other conditions

Heart failure can involve the left, right or both sides of the heart, but usually begins on the left side.

Symptoms of heart failure include:

• Shortness of breath
• Dizziness, fatigue and weakness
• Fluid and water retention
• Rapid or irregular heartbeats
• Cough or wheezing with white or pink blood-tinged phlegm
• Chest pain

Coding for heart failure
Coding and documentation of heart failure and congestive heart failure present additional challenges. The types of heart failure referenced above should be documented in order to correctly assign ICD-9 codes. Systolic heart failure uses codes in the 428.2x series, while diastolic heart failure uses codes in the 428.3x series. There’s also a category for combined systolic and diastolic heart failure: 428.4x. A fifth digit can be used to further specify whether the heart failure is unspecified, acute, chronic or acute on chronic.

When documenting only “congestive heart failure,” use ICD-9 code 428.0: congestive heart failure, unspecified.

Left heart failure is coded as 428.1 and includes associated conditions such as dyspnea, orthopnea, bronchospasm and acute pulmonary edema. Do not assign additional codes for these conditions. If both right and left heart failure exist, code only 428.0, which includes both conditions.

Systolic, diastolic and combined systolic and diastolic heart failure require a fifth digit, as indicated below:

• Systolic heart failure — 428.2x
• Diastolic heart failure — 428.3x
• Combined systolic and diastolic heart failure — 428.4x

The fifth digits for heart failure include:

Using the above information, you would code acute diastolic heart failure as 428.31.

When the diagnostic statement lists congestive heart failure along with either systolic or diastolic heart failure, two codes are required. For example, a diagnosis of acute combined systolic and diastolic congestive heart failure would be assigned two codes — 428.41 (combined systolic and diastolic heart failure, acute) and 428.0 (congestive heart failure, unspecified). Both codes are needed to report the specific type of heart failure — congestive, diastolic and systolic. Congestive heart failure is not an inherent component of systolic or diastolic heart failure, so CHF must be specifically documented.

If a patient has hypertensive heart disease with CHF, report a code for the hypertensive heart disease (402.01, 402.11 or 402.91). The code for CHF (428.0) should be added. However, a causal relationship between the two conditions must be documented by the practitioner in order to be coded. A coder can’t assume a cause-and-effect relationship, and the correct way to document a causal relationship is by stating “CHF due to benign hypertension.” A patient with congestive heart failure and hypertension without a documented causal relationship is assigned separate ICD-9 codes for CHF (428.0) and hypertension (401.9). Documentation simply stating “heart failure” codes to 428.9.

Documentation of diastolic or systolic dysfunction without mention of heart failure codes to 429.9: heart disease, unspecified. Do not assume that a patient is in heart failure if only “diastolic dysfunction” or “systolic dysfunction” is documented. Other terms for this code include “Heart disease, unspecified” and “Organic heart disease NOS.”

If you have any questions, please contact your provider consultant.

The information in this article is not intended to impart legal advice. If you have any legal questions about this information, you should consult your attorney or other professional legal services provider.