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Guest post: 2018 ICD-10 codes—when the heart needs a helping hand



by Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS

Congestive heart failure (CHF) is a commonly diagnosed condition where the ventricles or the lower chambers of the heart do not work effectively. The heart serves as a pump to get blood in and then out of the heart to circulate to the rest of the body. When any type of pump doesn’t work efficiently backups can occur.

The most common form of CHF is left ventricular failure, however left-sided failure can also lead to right ventricular failure as a ripple effect. There are two common types of CHF, one whereby the ventricle cannot contract normally, known as systolic heart failure, and one where the ventricle cannot relax normally due to stiffness, known as diastolic failure. Some patients may have a combination of both systolic and diastolic failure.

The causes of heart failure include hypertension, coronary artery disease, and valvular diseases, as well as cardiomyopathies. [more]

Q&A: Querying for CHF for systolic/diastolic specificity

Got a question? Ask us!

Got a question? Ask us!

Q: After reviewing Coding Clinic for ICD-9-CM, First Quarter 2014, p. 6, regarding heart failure and preserved or reduced ejection fraction the coding department began querying for a direct link between congestive heart failure (CHF) and the systolic/diastolic dysfunction that is often times noted in the medical record, but not directly linked to the CHF diagnosis.

For example, CHF is documented in the history of present illness as the reason for admission. The attending consults cardiology and cardiology’s progress note states severe systolic dysfunction. Our coders are now directed to query for the type of CHF and not just acuity in this example. Also going forward, if documentation in the electronic health record states acute CHF on line 1 and systolic dysfunction is on line 4, coding will query for systolic CHF.

Our coding department did submit a related question on this matter to AHA Coding Clinic for ICD-9-CM Editorial Board but they are no longer accepting questions related to ICD-9-CM since they have already transitioned to ICD-10-CM/PCS advice.

So we were hoping that you might have some advice as to whether such queries were actually necessary or whether the coders can go ahead and code for the type without a query.

A: There is no need to query when the chars states the type of dysfunction(systolic, diastolic, or combined) concurrently with a diagnosis of CHF, according to Coding Clinic for ICD-9-CM, First Quarter 2009, p. 8. If CHF is documented by a clinician in notes, history of present illness, consult, etc., and ‘systolic dysfunction’, as one example, is written in a similar fashion during the same episode of care, we do not query for linkage.

Editor’s Note: Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity at Sutter West Bay, in  San Francisco, answered this question in the ACDIS discussion forum CDI Talk.

Q&A: Sequencing pulmonary edema and congestive heart failure

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Q: What advice do you have for sequencing pulmonary edema and congestive heart failure when both appear to meet the definition of principal diagnosis?

A: The ICD-9-CM guidelines state that when a patient has two or more interrelated conditions that both meet the definition of principal diagnosis, coders may sequence either condition as principal unless the circumstances of the admission, the therapy provided, or the tabular list or alphabetic index indicate otherwise.
Interrelated conditions are those in the same ICD-9-CM chapter. They also include manifestations characteristically associated with a disease process.
Applying this guideline to pulmonary edema and congestive heart failure can be tricky and is often scenario-specific. Consider the following scenarios:
A patient is admitted for pulmonary edema. The physician documents pulmonary edema secondary to end-stage renal disease (ESRD). The patient also receives treatment for congestive heart failure. Code ESRD as the principal diagnosis.
A patient is admitted for pulmonary edema, congestive heart failure, ESRD, and pulmonary edema—all of which are listed as discharge diagnoses with no indication of the underlying etiology of the pulmonary edema. Query to determine the underlying cause of the pulmonary edema and the chronicity of the pulmonary edema.
A patient is admitted for acute pulmonary edema and congestive heart failure. Acute pulmonary edema is listed as a discharge diagnosis. Code congestive heart failure as the principal diagnosis.
A patient is admitted for pulmonary edema. The patient has a history of congestive heart failure. The history of congestive heart failure and pulmonary edema are both listed as discharge diagnoses. Query to determine the underlying cause of the congestive heart failure as well as the chronicity of the pulmonary edema.
A patient is admitted with a history of congestive heart failure and is taking medication. Code the congestive heart failure as a secondary diagnosis.
See the following Coding Clinic references:
  • Third quarter 1998, p. 5
  • Third quarter 1998, p. 3
  • Third quarter 1998, pp. 3-4
Editor’s note: Heather Taillon, RHIA, manager of corporate coding support services at Franciscan Alliance in Greenwood, Ind. answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Q&A: Driving the bus for DRG assignment

Q:If the principle diagnosis ICD-9 code is on the MCC list but there is no other diagnosis for the patient, is the DRG

A photograph of a sculpture created by Christopher Fennell in Athens, GA.

assigned with MCC or without?

For example, patient presents with heart failure but has no other diagnoses. So the ICD-9 code is 428.21, acute systolic heart failure. Would this fall into MS-DRG 291 or 293?

A: If a diagnosis is the principal diagnosis it can’t also be an MCC. It can’t drive the bus and be a passenger at the same time. In your example, if the heart failure is the principal diagnosis (the bus driver), you’d need to find another diagnosis to act as the MCC (a passenger) to group to DRG 291.  For example, any DRG that says “with” in the description (with CC, with MCC with CC/MCC) needs both a bus driver (principal diagnosis) and at least one passenger (CC, MCC, CC/MCC)

However, there is a little quirk about heart failure that is an exception to the rule. If the physician states “heart failure” or “congestive heart failure (CHF)” as the principal diagnosis your beginning ICD-9 code would be 428.0 (heart failure, unspecified as to type).

If the CDI specialist queries the provider to determine whether there is an association between “hypertension” (if appropriate) and “heart failure” (not an assumed relationship) and the provider documents “hypertensive heart disease”   what the coder would assign is a combination code as the principal diagnosis, 402.91 Hypertensive heart disease, unspecified, with heart failure (for example).  The instructional notes (in the code book) instruct the coder to assign an additional code from the 428* series of codes to describe the type of heart failure (e.g., 428.21, acute systolic heart failure).

In this scenario, the coding would include:

  • Principal diagnosis (bus driver): 402.91, hypertensive heart disease, unspecified, with heart failure
  • Secondary diagnosis (passenger): 428.21, acute systolic heart failure
  • MS-DRG: 291, Heart failure with MCC

If the patient also has hypertension (and or chronic kidney disease) it can be very important to query for the association between hypertension (and CKD, if appropriate) and heart disease, and the heart failure so one of these combination codes can be assigned (as the principal diagnosis). Then the patient’s specific type of heart failure may act as the MCC in certain cases.

Editor’s Note: This question was answered by Lynne Spryszak, RN, CCDS, CPC, Chicago-based Independent Healthcare Consultant. Email her at

How to handle multiple reasons for admission

When the physician directs medical treatment toward one condition, or when one condition is the only reason for the inpatient admission to the hospital, select that condition as the principal diagnosis (PDX). The PDX is the condition that the physician determines to be the primary reason for admitting the patient to the hospital.hands

Okay, let’s say Mrs. Happy Hinklebottom (yes, I just made that up) comes to the hospital complaining of a urinary tract infection (UTI) and exacerbation of congestive heart failure (CHF). The physician orders all sorts of tests and treats both conditions. The coder/clinical documentation specialist still needs to determine which condition justifies the inpatient admission. It could be the UTI. It could be the CHF. It could be both.

If the answer is truly both, then select the optimal DRG, writes Colleen Garry, RN, BS, clinical documentation improvement specialist at the New York University Medical Center in NYC, in The Clinical Documentation Improvement Specialist’s Handbook. However, if you are unsure as to which condition is the PDX you’ll need to query the physician. In Mrs. Happy Hinklebottom’s case, the CDI specialist should query about the type of CHF to determine if it is acute, chronic, systolic, diastolic, or both systolic and diastolic.

Editor’s note:This excerpt was adapted from the book The Clinical Documentation Improvement Specialist’s Handbook.

Questions from Brian’s Mailbox

Brian Murphy (our beloved ACDIS Director) routinely gets loads of e-mail and as much as he would love to be able to answer each message or question personally, the sheer volume can be overwhelming. So…he’s tossed a few questions my way and asked if I could address them.

The following are a few questions from his “in-box”:

Q: Should we document verbal queries in the record? Should we include paper queries in the record?

A: This is a matter for your facility to decide with collaboration from the CDS, HIM, and compliance departments. Let’s see what AHIMA had to say about this issue in the recently revised query brief Managing an Effective Query Process:

“Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query will be a permanent part of the patient’s health record. If it will not be considered a permanent part of the patient’s health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subject to health record retention guidelines.”

So, there’s no hard and fast rule about this. Our facility does both. First, I’ll address the second part of the above question.