Coding corner: Congestive heart failure

More than a million people in the United States have congestive heart failure. It’s the most common diagnosis in hospitalized patients over the age of 65. One in 9 deaths has heart failure as a contributing cause.

Once CHF is diagnosed, it’s considered a chronic condition and should be evaluated and documented on a yearly basis. When patients with CHF are treated appropriately, however, they may experience minimal or no symptoms. In rare circumstances where it’s due to reversible causes, such as infection, arrhythmia or thyrotoxicosis, CHF may resolve after the underlying cause is treated.

Heart failure is often documented as compensated, decompensated or acute exacerbation. These terms can be confusing to coders, so please refer to these definitions for clarification:

• Compensated CHF indicates that because of ongoing treatment, the patient’s symptoms are controlled and they have no overt features of CHF, such as shortness of breath, lower extremity edema, fluid retention or pulmonary edema. They still, however, carry the diagnosis of CHF.
• Decompensated CHF or acute exacerbation of CHF indicates an acute flare-up of CHF symptoms. This requires intensification of treatment, often in an inpatient setting. When heart failure is documented as decompensated or exacerbated, it should be coded as acute.

Documentation tips

Document congestive heart failure to the highest level of specificity, using all applicable descriptors. The descriptors include:

• Acuity — acute, chronic or acute on chronic
• Type —
  • Systolic — heart failure with reduced ejection fraction HFrEF
  • Diastolic — heart failure with preserved ejection fraction HFpEF
  • Combined systolic and diastolic
• Cause — if known, using terms that clearly show cause and effect, such as associated with, due to, secondary to, or hypertensive.
• Status — stable, worsening, improved, compensated, exacerbated, decompensated.
• Don’t use history of to describe CHF in patients who are asymptomatic. As explained above, except in rare circumstances, CHF is a lifelong diagnosis, while history of implies that the condition has resolved.

Documentation of congestive heart failure should also include:

Clinical signs and symptoms

• Lower extremity edema
• Shortness of breath
• Fatigue

Diagnostic findings

• Echocardiogram showing abnormal ventricular function
• Elevated B-type natriuretic peptide, or BNP
• Chest X-ray or CT scan showing pulmonary vascular congestion or pulmonary edema

Treatment

• Lifestyle modification such as low salt diet, fluid restriction or weight loss as indicated
• Medications such as diuretics, beta blockers, ACE inhibitors or ARBs

Coding tips

Heart failure classifies to ICD-10 code category I50.XX. The fourth character specifies the type of heart failure, and the fifth character specifies the acuity of heart failure.

Examples of heart failure coding are shown in the chart below:

Sources:

• webmd.com**
• 2018 ICD-10-CM Professional for Physicians

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.