Cardiology Coding Alert

Steer clear of an all too common CHF mistake.

Millions of people in the U.S. have heart failure, requiring billions of dollars in medical care each year, according to the CDC. That adds up to a lot of patient encounters that require spot-on coding and a keen understanding of how terms like congestive, acute, and chronic affect your code choice.

First Focus on Congestive Heart Failure

You'll find codes for heart failure in the 428.x (Heart failure) range. The first code in the range applies when your patient has a diagnosis of congestive heart failure (CHF) unspecified: 428.0 (Congestive heart failure, unspecified), says Joan L. Usher, BS, RHIA, COS-C, ACE, president, of JLU Health Record Systems in Pembroke, Mass. This code is also appropriate for a diagnosis of congestive heart disease or right heart failure, including when the physician documents right heart failure secondary to left heart failure.

Definition: Patients with CHF have a heart that is unable to pump blood sufficiently to meet the body's needs. CHF may result from a heart attack, high blood pressure, high cholesterol, damaged heart valves, diabetes, obesity, or it may appear with advancing age, notes Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash. The key factor is that the poor circulation leads to congestion and edema (fluid accumulation/swelling) in the tissues. Symptoms of CHF can include fatigue, pulmonary and other edema, fluid retention, chest congestion (coughing/wheezing), pleural effusion, and shortness of breath.

Take Note of Additional Heart Failure Codes

Mistake: Coders often assume that "heart failure" is CHF, and that is not always true, cautions Sharon Molinari, RN, HCS-D, HCS-O, a consultant based in Henderson, Nev.

ICD-9 category 428.x (Heart failure) includes several additional codes for different types of heart failure:

• 428.2x, Systolic heart failure
• 428.3x, Diastolic heart failure
• 428.4x, Combined systolic and diastolic heart failure.

Systolic and diastolic heart failure involve the heart's lower chambers (ventricles), says Neighbors. Systolic heart failure essentially means that one or both ventricles don't pump as well as they should to get blood to the rest of the body. Diastolic heart failure means the heart's ventricles have become stiff and unable to relax enough to allow sufficient filling of blood. This builds pressure which then affects the lungs and intensifies symptoms of heart failure, she says.

Keep in mind: ICD-9-CM does not assume that a patient with diastolic or systolic heart failure automatically has CHF. According to AHA Coding Clinic for ICD-9-CM (1st quarter, 2009), "Congestive heart failure is not an inherent component of systolic or diastolic heart failure. When the diagnostic statement lists congestive heart failure along with either systolic or diastolic heart failure, two codes are required to report the specific type of heart failure: congestive, diastolic, and/or systolic."

So, if your CHF patient also has a diagnosis of systolic (428.2x), diastolic (428.3x), or systolic and diastolic (428.4x) dysfunction, you should list an additional heart failure code from 428.xx along with CHF code 428.0.

Ace Acute, Chronic, and Acute on Chronic

The systolic and diastolic codes all require fifth digits that indicate whether the heart failure is unspecified, acute, chronic, or acute on chronic.

Acute generally means the episode involves rapid onset and severe symptoms. You also can think of acute heart failure in connection with an exacerbation status, says Neighbors. Exacerbation is "an increase in the seriousness of a disease or disorder as marked by greater intensity in the signs or symptoms of the patient being treated," states Mosby's Medical Dictionary. "This means the CHF is uncontrolled," Neighbors says. So, when the word exacerbation is used, the CHF is in an acute state (see how this applies to acute on chronic below).

Chronic means the heart failure is less severe than acute and will continue to be present over a long period, Neighbors adds.

Acute on chronic can mean that the patient is having an exacerbation of a chronic condition, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. Or it can mean a patient with a known history of CHF is experiencing an exacerbation of a different heart failure, like diastolic heart failure, she adds.

Coding example: Your patient has a known history of CHF and was admitted with an exacerbation of diastolic heart failure. How would you code for her?

Answer: Assign code 428.33 (Diastolic heart failure, acute on chronic) and code 428.0 (Congestive heart failure, unspecified), Selman-Holman says.

Sequencing tip: Proper sequencing requires you to code any acute heart failure diagnoses before you code for chronic heart failure. According to ICD-9 Official Guidelines, Section I.B.10, "If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first."

Keep These 2 Additional Codes in Mind

To round out your heart failure coding education, be sure to review the codes for left heart failure and unspecified heart failure.

1. 428.1: Look to 428.1 (Left heart failure) for left ventricular failure due to acute pulmonary edema associated with acute myocardial infarction, acute or subacute ischemic heart disease, or coronary atherosclerosis.

2. 428.9: The 428.x category includes 428.9 (Heart failure, unspecified). It's best not to use this unspecified code because payers may consider it too vague to support medical necessity for the services you're reporting. Query the physician to get more information about the type of heart failure the patient has so you can list a more specific code.