Coding corner update: Improve medical record documentation for heart failure

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. This article includes updated codes to align with the transition to ICD-10-CM.

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 locations such as the liver, abdomen, lower extremities and lungs. It’s 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, arrhythmias, hypertension, myocarditis and faulty heart valves. In turn, heart failure may contribute to the severity of other conditions such as 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 has its own challenges. The types of heart failure referenced above should be documented in order to correctly assign ICD-10 codes. Systolic heart failure uses codes in the I50.2 category, while diastolic heart failure uses codes in the I50.3 category. There’s also a category for combined systolic and diastolic heart failure: I50.4. A fifth character 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-10 code I50.9: heart failure, unspecified.

If a patient has hypertensive heart disease with congestive heart failure, report a code for the hypertensive heart disease with heart failure (I11.0). Use an additional code for heart failure (I50 category) to identify the type of heart failure. However, a causal relationship between the two conditions must be documented by the practitioner in order to be coded as such.

A coder can’t assume a cause-and-effect relationship, and the correct way to document a causal relationship is by stating “congestive heart failure due to hypertension.” A patient with congestive heart failure and hypertension without a documented causal relationship is assigned separate ICD-10 codes for congestive heart failure (I50.9) and hypertension (I10). Documentation simply stating “heart failure” codes to I50.9.

Documentation of diastolic or systolic dysfunction without mention of heart failure codes to I51.9: heart disease, unspecified. Don’t 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.”

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.