Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
February is American Heart Month! Many heart conditions/diseases affect our patient population, but this blog post will highlight heart failure. Heart failure, also known as congestive heart failure? According to the CDC (Centers for Disease Control and Prevention), about 6.2 million adults in the United States have heart failure. Heart failure is a chronic, progressive condition in which the heart cannot pump enough blood to meet the body’s needs for blood and oxygen. Per the AHA (American Heart Association), the heart can’t keep up with its workload and may cause the following signs and symptoms listed by the Mayo Clinic:
- Shortness of breath with activity or when lying down
- Fatigue and weakness
- Swelling in the legs, ankles and feet
- Rapid or irregular heartbeat
- Reduced ability to exercise
- Persistent cough or wheezing with white or pink blood-tinged mucus
- Swelling of the belly area (abdomen)
- Very rapid weight gain from fluid buildup
- Nausea and lack of appetite
- Difficulty concentrating or decreased alertness
- Chest pain if a heart attack causes heart failure
Importance of Documentation
Provider documentation is crucial in diagnosing, treating, and managing heart failure. Often times documentation may only state “heart failure” with no mention of the type, acuity, status and treatment plan; this helps with proper diagnosis code assignment and supports the E/M (Evaluation and Management) level selected using MDM or Total time. Documentation should include some of the following:
- Type – systolic, diastolic, a combination of systolic and diastolic, left, right, right due to left
- Acuity – acute, chronic, a combination acute on chronic, unspecified
- Disease status – worsening, stable, improved
- Treatment plan – medicines, lifestyle changes, counseling, surgery, referral
Heart failure often does not come alone and may have other risk factors or associated medical conditions, such as hypertension, diabetes, obesity, coronary artery disease, chronic kidney disease and vascular heart disease. All of the above is an important part of selecting the appropriate code and coding it to the highest level of specificity and HCC (Hierarchical Condition Category).
In the outpatient setting, signs and symptoms can be used if a patient is still being worked up at the end of the visit with no definitive diagnosis. Per ICD 10 guidelines, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.” However, per guidelines, signs and symptoms can be coded until a confirmed diagnosis. A provider should be aware that coding guidelines are different in the inpatient setting as opposed to the outpatient setting when it comes to coding “probable, suspected, rule out, etc. If provider documentation is unclear and ambiguous, coders and/or CDI/CDIS(Clinical Documentation Integrity Specialist) should query the provider for clarification.
Sequencing & Diagnosis Coding
Per the ICD 10 guidelines, “the classification presumes a causal relationship between hypertension and heart involvement and between hypertension and kidney involvement, as the two conditions are linked by the “with” in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them unless the documentation clearly states the conditions are unrelated. For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with”, or “due to” in the classification, provider documentation must link the conditions in order to code them as related”.
Before a code is assigned, documentation and coding guidelines should be reviewed to understand the diagnosis codes’ etiology/manifestation convention and proper sequencing. When using combination codes, it is important to review which codes should be sequenced first, which requires additional codes. For example, I50 Heart Failure has a “Code first” followed by a list of conditions that should be sequenced first. Reviewing before a code assignment is essential, no matter how long someone has been coding. Remember October 1 of every year, new ICD 10 CM guidelines and codes are released. The following three sections are stated per the ICD 10 Guidelines:
Hypertension with Heart Failure (I11.0)
Hypertension with heart conditions classified to I50.- or I51.4- I51.7, I51.89, I51.9, are assigned to a code from category I11, Hypertensive heart disease. Use additional code(s) from category I50, Heart failure, to identify the type(s) of heart failure in those patients with heart failure. The same heart conditions with hypertension are coded separately if the provider has documented that they are unrelated to hypertension—sequence according to the circumstances of the admission/encounter.
- I50.1, Left ventricular failure, unspecified
- I50.2, Systolic (congestive) heart failure
- I50.3, Diastolic (congestive) heart failure
- I50.4, Combined systolic (congestive) and diastolic (congestive) heart failure
Hypertensive Heart and Chronic Kidney Disease (I13.0)
Assign codes from combination category I13, Hypertensive heart and chronic kidney disease when there is hypertension with both heart and kidney involvement. If heart failure is present, assign an additional code from category I50 to identify the type of heart failure. The appropriate code from category N18, Chronic kidney disease, should be used as a secondary code with a code from category I13 to identify the chronic kidney disease stage.
The codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. The Includes note at I13 specifies that the conditions included at I11 and I12 are included together in I13.
Pre-existing hypertension in pregnancy (O10)
Category O10, Pre-existing hypertension complicating pregnancy, childbirth and the puerperium, includes codes for hypertensive heart and hypertensive chronic kidney disease.
I10 -I16 also has instructional notes to use an additional code to identify the following; exposure to environmental tobacco smoke (Z77.22), history of tobacco use (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17-) or tobacco use (Z72.0).
Risk Adjustment & Hierarchical Condition Category (HCC)
Documentation of the severity of illness, prognosis, intervention and treatment is assessed when assigning a diagnosis to the highest level of specificity is very important for capturing and projecting treatment for the following year. Heart failure depending on provider documentation may fall under HCC 85 w/wo complications. Specialists such as cardiologists treating the patients know the severity of a condition after testing, evaluation and final diagnosis; unspecified codes should rarely be selected if documentation states the severity, type, acuity and status. Unspecified codes should only be assigned if documentation is not clear and insufficient.
Social Determinants of Health (SDOH)
SDOH are conditions in the environments where people are born, live, learn, work, play, worship, and age affect a wide range of health issues with patients and overall quality-of-life outcomes. Therefore, providers are encouraged to document any of the above factors affecting the patient and their ability to treat the patient. For example, maybe the patient has lost their job and insurance, is stressed out, not sleeping or eating properly and cannot afford the medication, so has not taken it in a few weeks, and their congestive heart failure has exacerbated, now requiring hospitalization. It is essential that the provider documents this for continuity of care, treatment, and resources, as well as capture the appropriate diagnosis Z55-Z65 codes that apply to the case.
Heart failure and other chronic conditions can be prevented or managed with lifestyle changes. Patients are encouraged not to diagnose and treat themselves but work with their providers and care team on management. The Mayo Clinic lists lifestyle changes that one can make to help prevent heart failure, such as;
- Not smoking
- Controlling certain conditions, such as high blood pressure and diabetes
- Staying physically active
- Eating healthy foods
- Maintaining a healthy weight
- Reducing and managing stress
To schedule training on documentation and coding guidelines for your organization or private practice providers or schedule a chart review email us today at email@example.com, schedule a call or visit the website and fill out the “contact us” form.