Cardiology Coding Alert

End stage, right ventricular, ejection fraction, and high output are the ones to watch.

After a long freeze, ICD-10-CM will be open for changes going into effect Oct. 1, 2016. A number of the proposed changes involve coding heart failure.

Here’s a snapshot of the proposed changes from the ICD-10 Coordination and Maintenance Committee Meeting Sept. 22-23, 2015. You can review the Diagnosis Agenda at www.cdc.gov/nchs/data/icd/Topic_Packet_09_22_23_15.pdf. The meeting summary is posted at www.cdc.gov/nchs/data/icd/2015_09_23_2015_Summary_Final.pdf.

Note that the Committee does not make final decisions at the meeting. Stay tuned to Cardiology Coding Alert for updates about code changes as they become final.

Focus on Proposed End Stage Heart Failure Expansion

The Agenda includes proposed codes that would allow identification of end stage heart disease.

The proposed codes for end stage disease would help distinguish a specific patient population that falls into stage D of the ABCD classification from the ACC and American Heart Association. The patients are at high risk of rehospitalization, need specific types of interventions or hospice, and have a one-year mortality rate of about 50 percent.

The end stage heart failure changes, proposed by a cardiologist and presented by David Berglund, MD, include more than 15 new codes and 10 revisions to codes and subcategories between existing code I50.1 and proposed new code I50.439.

For instance: One example involves I50.32 (Chronic diastolic [congestive] heart failure). The proposed changes would expand the current code so that it would require a sixth character. The proposed I50.32- codes are:

• I50.320, Chronic (left ventricular) diastolic (congestive) heart failure without mention of end stage
• I50.321, End stage (left ventricular) diastolic (congestive) heart failure
• I50.329, Chronic (left ventricular) diastolic (congestive) heart failure, undetermined classification.

Shorter version? Sue Bowman of AHIMA suggested that instead of making such a large number of changes, revisions could be limited to options for “without mention of end stage” and “end stage” to avoid adding the proposed “undetermined” classification.

Recognize Reasons for RV Failure Proposal

Another group of proposed heart failure codes focus on chronic and acute (or decompensated) right ventricular failure.

The reasoning for the right heart failure revisions includes that pure right heart failure patients have different treatment requirements than left heart failure patients. For instance, left heart failure causes “backup into the lungs,” while right heart failure causes “backup into the venous circulation.” Additionally, right heart failure can lead to increased pulmonary embolism risk.

Expanding the options for coding right heart failure would also assist with distinguishing causes of both acute and chronic right heart failure.

A final reason for the change is that right ventricular failure currently falls under I50.9 (Heart failure, unspecified). The unspecified code is also appropriate for biventricular failure, meaning there is no way to differentiate these conditions.

The proposal creates a new subcategory (I50.5-, Right ventricular heart failure) with multiple new codes:

• I50.50, Right ventricular heart failure, unspecified
• I50.51, Isolated right ventricular failure 

Code also the causative disease if known

• I50.511, Acute isolated right ventricular failure
• I50.512, Chronic isolated right ventricular failure
• I50.513, Acute on chronic isolated right ventricular failure

Acute decompensation of chronic isolated right ventricular failure

Acute exacerbation of chronic isolated right ventricular failure

• I50.52, Right heart failure due to left heart failure

Right ventricular failure secondary to left ventricular failure

Code also the left ventricular failure (I50.1-I50.43)

• I50.53, Biventricular heart failure

Code also the left ventricular failure (I50.1-I50.43).

Clarify Heart Failure Coding for Reduced or Normal EF

Additional proposed changes would add ejection fraction inclusion terms to codes for systolic and diastolic heart failure.

The Agenda explains that “ejection fraction is a measure of the left ventricular function. In systolic heart failure, the ejection fraction is reduced. In diastolic heart failure, there is a normal ejection fraction, or preserved ejection fraction. In combined systolic and diastolic heart failure, there is a reduced ejection fraction, along with diastolic dysfunction.”

Berglund, who presented the changes, further explained that “the ejection fraction (EF) has to be either reduced (below the cut off), or normal (above the cut off).”

The proposed changes add the noted inclusion terms to existing subcategories I50.2- to I50.4-:

• I50.2-, Systolic heart failure

Heart failure with reduced ejection fraction [HFrEF]

• I50.3-, Diastolic heart failure

Heart failure with normal ejection fraction

Heart failure with preserved ejection fraction [HFpEF]

• I50.4-, Combined systolic and diastolic heart failure

Heart failure with reduced ejection fraction and diastolic dysfunction.

Hope for a High Output Heart Failure Code?

Yet another heart failure proposal relates to high output heart failure, which has causes that differ from most other kinds of heart failure. Examples the Agenda provides are “arrhythmias, anemia, fistulas, thyrotoxicosis, sepsis, carcinoid syndrome, polycythemia vera, and Paget disease of bone, among other things.”

Now: Currently you use I50.9 (Heart failure, unspecified) for this diagnosis.

Suggested update: The proposed change adds new code I50.81 (High output heart failure). Berglund also asked about adding another new code, I50.89, for heart failure not elsewhere classified.

The proposed high output heart failure code has a note to exclude septic shock (R65.21). The note generated some discussion, with Bowman suggesting a note is unnecessary because a coder would head to septic shock rather than heart failure for a patient with septic shock. Jeanne Yoder, with the military health system, suggested a code also or Excludes2 note option.

That’s not all: To see additional cardiology-related proposals, check out “See How ICD-10 2017 May Shake Up Coding for A-Fib and More,” also in this issue.