Here’s What You Need to Know About Heart Failure Coding
Get into the nitty-gritty documentation to find the correct HF code to report. Heart failure (HF), also sometimes referred to as congestive heart failure (CHF), affects nearly 6.7 million people over the age of 20 in the U.S., according to the Centers for Disease Control and Prevention (CDC) and 2024 and 2019 reports from the American Heart Association, and cost an estimated $30.7 billion in healthcare service and medicine spending and missed days of work. As a cardiology coder, you will probably see patients with heart failure. Here’s what you need to know to code the condition. Know the Basics HF is a condition where the heart is unable to pump blood well enough to supply it to the entire body. This causes fluid to back up in the lungs and lower extremities over time. There are medications and other surgical therapies out there that can be prescribed when needed. Although the heart continues to work, over time it must work harder and harder and still cannot keep up with the supply and demand within the body. This can also lead to other conditions in the body becoming worse, as well as other conditions that can worsen the HF itself, such as hypertension and chronic kidney disease. These conditions have a causal relationship, which means that they are assumed as related, meaning without definitive documentation stating they are unrelated, they will always be considered related. Recognize Signs and Symptoms The most common signs and symptoms of congestive heart failure include shortness of breath; chest pain; swelling in the ankles, legs and abdomen; and heart palpitations. Other factors that can have a cause-and-effect relationship with HF are obesity, diabetes, coronary artery disease, and previous heart attack. We also need to address the complications of HF; these include but are not limited to cardiac arrest, heart valve issues, other organ damage, and pulmonary hypertension. There are four stages of HF: Become Familiar With Relevant Codes There are many facets of heart failure, and also many ways to report the conditions. Two examples: Systole is the contraction of any heart chamber. Systolic heart failure is broken down into the following four codes and is also known as reduced ejection fraction (EF) or abbreviated as HFrEF: Diastole is the relaxation of any heart chamber. Diastolic heart failure is broken down into the following four codes and is also known as preserved EF or abbreviated as HFpEF: Combined systolic and diastolic heart failure is also broken down into the following four codes. When billing combined heart failure, you will no longer assign the codes from subcategories I50.2- or I50.3-, because they are encompassed in the combined codes per Excludes1 notes: Other heart failure codes include: Follow the Guidelines Coding guidelines for congestive heart failure include order of the diagnosis codes when billed with both hypertension and chronic kidney disease as mentioned above. Hypertension has combination codes (I11-I13) that must be assigned when related to the congestive heart failure and sequenced based on the reason for the encounter. When billing with chronic kidney disease (N18.1-N18.6), these codes are also sequenced based on the reason for the encounter. Make sure to follow the coding guidelines in the Tabular List for Code also notes with these codes. As with all other coding, educating the provider that the documentation should meet the highest specificity known at the time of the encounter will allow you to assign the most accurate ICD-10-CM code. This affects multiple areas of coding and is always best practice. Cristin Robinson, CPC, CPMA, CCC, CRC, CEMC, AAPC Approved Instructor,
Education Coding Consultant, Bristol, Tennessee
