CCS Prep

Challenges for Coding Heart Failure

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Coding for heart failure continues to be a challenge to coders. With the proposed implementation of the Centers for Medicare and Medicaid Services (CMS) Medicare Severity (MS) DRGs, coding the specific type of heart failure will be more important than ever. An understanding of the disease process and the differences in clinical terms is necessary to code heart failure correctly.

Heart failure is a condition in which the muscle of the heart fails to pump blood through the circulatory system. This results in decreased blood flow to the kidneys, causing the kidneys to retain water and sodium. The water retained by the kidneys enters the circulation accumulating in the lungs, abdominal organs and the lower extremities. All codes for heart failure include any associated pulmonary edema; no additional code is assigned. The term congestive heart failure (CHF) is often mistakenly used interchangeably with heart failure. Congestion, pulmonary or systemic fluid build-up, is one feature of heart failure, but it does not occur in all patients.

Heart Failure Codes

428.0 Congestive heart failure, unspecified

428.1 Left heart failure

428.20 Systolic heart failure, unspecified

428.21 Systolic heart failure, acute

428.22 Systolic heart failure, chronic

428.23 Systolic heart failure, acute on chronic

428.30 Diastolic heart failure, unspecified

428.31 Diastolic heart failure, acute

428.32 Diastolic heart failure, chronic

428.33 Diastolic heart failure, acute on chronic

428.40 Combined systolic and diastolic heart failure, unspecified

428.41 Combined systolic and diastolic heart failure, acute

428.42 Combined systolic and diastolic heart failure, chronic

428.43 Combined systolic and diastolic heart failure, acute on chronic

428.9 Heart failure, unspecified

Heart failure is subdivided into two types: systolic dysfunction and diastolic dysfunction. Differentiating between systolic and diastolic dysfunction is essential because their long-term treatments are different.

Systolic heart failure (428.2x), which is more common, is the dilation of the left ventricle with impaired contraction of the heart muscle resulting in decreased outflow of blood from the heart. The heart contracts less forcefully and cannot pump out as much of the blood that is returned to it as it normally does. As a result, more blood remains in the lower chambers of the heart and accumulates in the veins. Coronary artery disease is a common cause of systolic dysfunction.

Diastolic heart failure (428.3x) occurs in a normal left ventricle with the impaired ability of the heart muscle to relax. The heart is stiff and does not relax normally after contracting. This results in the inability to receive, as well as eject, blood. As in systolic dysfunction, the blood returning to the heart then accumulates in the veins. Often, both forms of heart failure occur together.

Fifth digits for the identification of systolic and diastolic heart failure specify whether the heart failure is unspecified, acute, chronic, or acute on chronic. Acute on chronic refers to the patient having chronic heart failure and now experiencing a superimposed acute flare-up. Determination of whether the heart failure is acute, chronic or acute on chronic, is based upon physician documentation. Excludes notes in the ICD-9-CM tabular listing indicates that codes from categories 428.2 and 428.3 are not to be used with combined systolic and diastolic heart failure codes from category 428.4. When documentation indicates both systolic and diastolic heart failure, codes from category 428.4 are to be used.

Left-sided heart failure is due to the accumulation of fluid behind the left ventricle. Code 428.1 for left heart failure includes acute pulmonary edema, and no additional code is assigned. Right-sided heart failure is classified to CHF and coded to 428.0. Codes 428.0 and 428.1 are never used together because code 428.0 includes both left- and right-sided failure. Code 428.9 for unspecified heart failure is very vague, and every effort should be made to determine whether another code from category 428 is appropriate.

Heart Failure and Hypertension

Heart failure may be associated with hypertension. When this is the case a code from category 402 Hypertensive heart disease is assigned. Codes from this category are assigned only when a causal relationship is stated or implied. Category 402 includes a fifth digit of "1" that indicates whether heart failure is present. Use an additional code from category 428 to identify the type of heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and CHF. The cause and effect relationship between heart failure and hypertension should not be assumed. If the documentation states due to hypertension or hypertensive heart disease, then a causal relationship is established. When the documentation mentions both conditions but without a stated casual relationship, each is coded separately. Sequencing is determined by the circumstances of the admission and the supporting documentation. For example:

CHF due to hypertension: 402.91 and 428.0

CHF with hypertension: 428.0 and 401.9

Assign codes from category 404, Hypertensive heart and chronic kidney disease, when both hypertensive chronic kidney disease and hypertensive heart disease are documented by the physician. The relationship between hypertension and the heart failure must be stated, while the relationship between hypertension and chronic kidney disease is assumed. Fifth digits for category 404 are as follows:

0 without heart failure and with chronic kidney disease stage I through stage IV, or unspecified

1 with heart failure and with chronic kidney disease stage I through stage IV, or unspecified

2 without heart failure and with chronic kidney disease stage V or end-stage renal disease

3 with heart failure and chronic kidney disease stage V or end-stage renal disease

Assign an additional code from category 428 to identify the type of heart failure when assigning fifth digits of "1" and "3". More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and CHF. An additional code is also assigned to specifically identify the stage of chronic kidney disease based on the fifth digit selected.

Heart Failure and Pleural Effusion

Pleural effusion is commonly seen with CHF and should not be coded separately with code 511.9, unless it is specifically addressed by additional treatment such as a pleural tap or repeated chest X-rays. Pleural effusion should never be coded as the principal diagnosis when associated with CHF.

The coder must review documentation carefully to determine the exact circumstances of the heart failure and any related conditions. Complete documentation is the key to correct code assignment of heart failure.

Heart Failure and Proposed MS DRGs

CMS posted its proposed FY 2008 inpatient prospective payment system (IPPS) changes on its Web site on April 13. Included is the proposed implementation of MS-DRGs, which include a complete revision of the complication/comorbidity (CC) list as well as the addition of a major CC (MCC) list. This proposal significantly revises the CC list for codes in Category 428, Heart failure, as follows:

MCC

428.21 Systolic heart failure, acute

428.23 Systolic heart failure, acute on chronic

428.31 Diastolic heart failure, acute

428.33 Diastolic heart failure, acute on chronic

428.41 Combined systolic and diastolic heart failure, acute

428.43 Combined systolic and diastolic heart failure, acute on chronic

CC

428.1 Left heart failure

428.20 Systolic heart failure, unspecified

428.22 Systolic heart failure, chronic

428.30 Diastolic heart failure, unspecified

428.32 Diastolic heart failure, chronic

428.40 Combined systolic and diastolic heart failure, unspecified

428.42 Combined systolic and diastolic heart failure, chronic

Non-CC

428.0 Congestive heart failure, unspecified

428.9 Heart failure, unspecified

It is important to note above that code 428.0, which is currently one of the most commonly coded secondary diagnosis, may no longer be considered a CC in the MS-DRG system. Also note that acute and acute on chronic heart failure codes may be considered MCCs. If the final IPPS rule includes these changes it will be more important than ever to ensure that heart failure is documented and coded appropriately. Reimbursement may be affected as never before. Watch for information on the final FY 2008 IPPS final rule, which is expected to be published in August.

Before the certified coding specialist (CCS) exams, the coder may want to review the ICD-9-CM Official Guidelines for Coding and Reporting and all issues of Coding Clinic related to heart failure. After reviewing all coding guidelines related to heart failure, test yourself with the exercises below:

1. A patient is diagnosed with CHF due to diastolic dysfunction due to hypertension. The appropriate diagnosis code assignment is:

a. 402.91

b. 402.91, 428.0

c. 401.9, 428.30, 428.0

d. 402.91, 428.30, 428.0

2. A patient with a known past history of CHF is admitted to the hospital with severe shortness of breath, pulmonary congestion and edema. The patient is discharged from the hospital with the diagnosis of acute combined systolic and diastolic CHF. The appropriate diagnosis code assignment is:

a. 428.43

b. 428.43, 428.0

c. 428.21, 428.31, 428.0

d. 428.0

3. A patient is admitted with fluid overload and CHF. The appropriate diagnosis code assignment is:

a. 428.0, 276.6

b. 428.0

c. 276.6, 428.0

4. A patient is admitted CHF. The patient is also hypertensive and is on dialysis for end-stage renal disease. The patient is treated for CHF and discharged. The appropriate diagnosis code assignment is:

a. 428.0, 401.9, 585.6, V45.1

b. 404.93, V45.1

c. 428.0, 403.91, 585.6, V45.1

d. 404.93, 428.0, 585.6, V45.1

5. A patient presents to the hospital with shortness of breath and CHF and was intubated. She was admitted and subsequently diagnosed as having respiratory failure due to acute systolic CHF. The appropriate diagnosis code assignment is:

a. 518.81, 428.21, 428.0

b. 428.0, 428.21, 518.81

c. 428.21, 428.0, 518.81

d. 428.0, 518.81

This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic is published quarterly by the American Hospital Association.

CPT is a registered trademark of the American Medical Association.

 

Answers to ccs prep!: 1. d: You will need three codes to completely describe this diagnosis. Assign codes 402.91, Hypertensive heart disease, unspecified with heart failure; 428.30, Diastolic heart failure, unspecified; and 428.0, Congestive heart failure, unspecified. The two additional codes provide the specificity required to report that the heart failure was diastolic type and congestive; 2. b: Assign code 428.43, Combined systolic and diastolic heart failure, acute on chronic, as the principal diagnosis because the patient was known to have a history of CHF and was admitted to the hospital for an acute episode of his chronic condition. In addition, assign code 428.0, Congestive heart failure, unspecified, as a secondary diagnosis; 3. b: When the patient is admitted in CHF resulting from fluid overload, assign code 428.0, Congestive heart failure, as the principal diagnosis. Fluid overload is a component of CHF and should not be coded separately.; 4. c. 428.0 is the principal diagnosis because there is no indication that the CHF is due to the hypertension. Codes 403.91 and 585.6 are assigned to identify the hypertensive chronic kidney disease with end-stage renal disease. A cause-and-effect relationship is assumed unless the documentation indicates that the kidney disease is not due to hypertension. Code V45.1 is assigned to indicate kidney dialysis status; and 5. a: When a patient is admitted in respiratory failure due to or associated with an acute exacerbation of a chronic non-respiratory condition, the respiratory failure code 518.81 is assigned as the principal diagnosis. The CHF is documented as acute systolic heart failure with CHF, which is coded to 428.21 and 428.0 as secondary diagnoses.


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