Coding for heart failure has been a challenge to coders, especially since the creation of the new systolic and diastolic heart failure codes for FY 2003 and the related changes for coding hypertensive heart disease. 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,
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 an acute flare-up on top of it. 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 indicate 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 congestive heart failure 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.
Prior to Oct. 1, 2002, only one code was required to identify hypertensive heart disease and hypertensive heart and renal disease. Effective Oct. 1, 2002, references to congestive heart failure were changed to heart failure for category 402 and 403 codes. If heart failure is due to hypertension, sequence the hypertension heart disease first using the correct code from category 402. If there is also related renal disease, use the correct code from category 404 instead. In both instances, use an additional code to identify the type of heart failure with codes from category 428. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure.
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, heart failure with hypertension, but without a stated casual relationship, each is coded separately. Sequencing is determined by the circumstances of the admission and the supporting documentation.
CHF due to hypertension: 402.91 and 428.0
CHF with hypertension: 428.0 and 401.9
Care should be taken in sequencing when a patient with CHF is admitted in respiratory failure. When a patient is admitted in respiratory failure due to or associated with an acute exacerbation of a chronic non-respiratory condition, that condition is the principal diagnosis.
Example: Following dietary indiscretion, a patient with compensated congestive heart failure developed paroxysmal nocturnal dyspnea, orthopnea and pedal edema leading to increased respiratory distress. In the emergency room, the patient was found to be in cardiogenic pulmonary edema and respiratory failure and was subsequently intubated in the emergency room. The patient was admitted and treated for congestive heart failure. No myocardial infarction was found.
Principal diagnosis: 428.0 Congestive heart failure, unspecified
Additional diagnosis: 518.81 Respiratory failure
In this example, the congestive heart failure had become acute and required immediate hospital care. The associated development of respiratory failure in this case is an additional complicating factor, but it is not the condition that occasioned the admission and should not be designated as the principal diagnosis. The respiratory failure should be listed as a secondary diagnosis.
Pleural effusion is commonly seen with congestive heart failure and should not be coded 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 congestive heart failure.
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.
Before the CCS exams, coders may want to review the following references:
1. Coding Clinic for ICD-9-CM:
Fourth Quarter 2002, Heart Failure
Third Quarter 1991, Pleural effusion with congestive heart failure
Second Quarter 1991, "Sequencing of Respiratory Failure in Association with Nonrespiratory Conditions"
2. ICD-9-CM Coding Handbook, by Faye Brown: Chapter 24: Diseases of the Circulatory System
3..ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C7.A
After reviewing all coding guidelines re-lated to heart failure, test yourself with the exercises below:
1. A patient is diagnosed with congestive heart failure due to diastolic dysfunction due to hypertension. The appropriate diagnosis code assignment is:
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 congestive heart failure 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 congestive heart failure. The appropriate diagnosis code assignment is:
b. 428.43, 428.0
c. 428.21, 428.31, 428.0
3. A patient is admitted with fluid overload and congestive heart failure. The appropriate diagnosis code assignment is:
a. 428.0, 276.6
c. 276.6, 428.0
4. A patient is seen in the hospital for acute on chronic systolic congestive heart failure. The appropriate diagnosis code assignment is:
a. 428.23, 428.0
b. 428.21, 428.0
5. The patient is admitted with pleural effusion and treated with chest tube drainage. The diagnosis on discharge is pleural effusion with congestive heart failure. The appropriate diagnosis code assignment is:
a. 511.9, 428.0
c. 428.0, 511.9
6. 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 congestive heart failure. The appropriate diagnosis code assignment is:
a. 518.81, 428.0, 428.21
b. 428.0, 428.21, 518.81
c. 428.23, 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, manager of clinical HIM services, HSS Inc. (www.hssweb.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 congestive heart failure 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 congestive heart failure resulting from fluid overload, assign code 428.0, Congestive heart failure, as the principal diagnosis. Fluid overload is a component of congestive heart failure and should not be coded separately.
4. a: Assign code 428.23, Systolic heart failure, acute on chronic, as the principal diagnosis. Code 428.0, Congestive heart failure, unspecified, should be assigned as an additional diagnosis.
5. c: Pleural effusion is never the principal diagnosis when associated with congestive heart failure. 428.0 is always the principal diagnosis. In this instance, it is appropriate to also code the pleural effusion as an additional diagnosis with code 511.9 because the chest tube drainage was performed.
6. c: When a patient is admitted in respiratory failure due to or associated with an acute exacerbation of a chronic non-respiratory condition, that condition is the principal diagnosis. In this instance, the congestive heart failure had become acute, and the diagnosis is documented as acute systolic congestive heart failure, which is coded to 428.23 and 428.0. The respiratory failure, 518.81, is listed as a secondary diagnosis.