March 17, 2008
Coding for Heart Failure
Heart failure occurs when the heart cannot pump enough blood to meet the body’s needs, and it typically develops after other conditions have weakened or damaged the heart. Considered a chronic condition, it tends to develop slowly over time. However, patients may experience a sudden onset of symptoms, which is known as acute heart failure. Congestive heart failure (CHF) is defined as blood backing up into the liver, abdomen, lower extremities, and lungs.
• fatigue and weakness;
• rapid or irregular heartbeat;
• shortness of breath (dyspnea) during exertion or lying down;
• reduced ability to exercise;
• persistent cough or wheezing;
• white or pink blood-tinged phlegm;
• edema in the legs, ankles, and feet;
• abdominal ascites;
• sudden weight gain due to fluid retention;
• lack of appetite and nausea; and
• difficulty concentrating or decreased alertness.
Signs and symptoms of acute heart failure are similar to those of chronic heart failure but are more severe and start or worsen suddenly. Other symptoms of acute heart failure include the following:
• sudden fluid buildup;
• rapid or irregular heartbeat with palpitations that may cause the heart to stop beating;
• sudden, severe shortness of breath and coughing up pink, foamy mucus; and
• chest pain if caused by a heart attack.
Coders should not assign a code for chronic or acute heart failure based on the presence of the above signs and symptoms or based on the symptoms’ onset. The physician is responsible for documenting acute or chronic before the appropriate code can be assigned.
Heart failure is classified to ICD-9-CM category 428, and the following are the specific code assignments:
• 428.0, CHF that includes right heart failure secondary to left heart failure;
• 428.1, Left heart failure (includes left ventricular failure);
• 428.20, Unspecified systolic heart failure;
• 428.21, Acute systolic heart failure;
• 428.22, Chronic systolic heart failure;
• 428.23, Acute on chronic systolic heart failure;
• 428.30, Unspecified diastolic heart failure;
• 428.31, Acute diastolic heart failure;
• 428.32, Chronic diastolic heart failure;
• 428.33, Acute on chronic diastolic heart failure;
• 428.40, Unspecified combined systolic and diastolic heart failure;
• 428.41, Acute combined systolic and diastolic heart failure;
• 428.42, Chronic combined systolic and diastolic heart failure; and
• 428.43, Acute on chronic combined systolic and diastolic heart failure.
As always, code assignment is based on physician documentation of the diagnosis in the medical record and not on the signs and symptoms that are characteristic of a certain diagnosis. It may be appropriate to query the physician for clarification if the specific diagnosis is unclear.
Types of Heart Failure
Systolic heart failure is caused by a pumping problem that occurs when the left ventricle cannot contract vigorously. The ejection fraction is typically below 40%. Other common signs and symptoms of systolic heart failure include S3 gallop heart sound (also documented as “third heart sound”), cardiomegaly, and pulsas alternans, which is an alternation between weak and strong heart beats during sinus rhythm.
Diastolic heart failure is caused by a filling problem that occurs when the ventricle cannot relax or fully fill. Usually the ejection fraction is normal, and the patient has elevated end diastolic filling pressure with a normal filling volume, restrictive filling pattern, reduced compliance, increased passive stiffness, and abnormal diastolic distensibility.
Documentation of diastolic or systolic dysfunction with CHF in the medical record is assigned to two codes from category 428. One code will show the diastolic or systolic heart failure and code 428.0 to show CHF (AHA Coding Clinic for ICD-9-CM, 2002, fourth quarter, pages 52-53). ICD-9-CM assumes an association between the CHF and the diastolic and systolic dysfunction. It is important to identify the type of heart failure since the medication for each type may be different.
• angiotensin-converting enzyme inhibitors such as enalapril (Vasotec), lisinopril (Prinivil, Zestril), and captopril (Capoten);
• angiotensin II receptor blockers such as losartan (Cozaar) and valsartan (Diovan);
• digoxin (Lanoxin);
• beta blockers such as carvedilol (Coreg), metoprolol (Lopressor), and bisoprolol (Zebeta);
• diuretics such as bumetanide (Bumex) and furosemide (Lasix); and
• aldosterone antagonists such as spironolactone (Aldactone) and eplerenone (Inspra).
Coding and sequencing for heart failure are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.
— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.