Q&A: Reporting right-sided heart
Q: If you have an acute exacerbation of a chronic right heart failure (CHF) with a preserved ejection fraction (EF)— above 55%—can you code it as heart failure with preserved EF? All the clinical symptoms are exemplifying right failure. For example, ascites, pronounced neck vein distension, swelling of ankles and feet, etc.
A: ICD-10-CM has codes associated with the documentation of right-sided failure and for left-sided failure. Each ventricle supplies different portions of the circulation, so heart failure can be described as either right or left depending on the symptoms. When the right ventricle fails, we call it right-heart failure. In this case, fluid backs up into the peripheral circulation, into the legs, head, and the liver. Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure.
Right-sided heart failure is coded in ICD-10-CM to the default code I50.9 heart failure, unspecified. This code is not affected by documentation of the acuity of the condition. The code maps to the MS-DRGs 291-293, Heart Failure and Shock.
Before we can code heart failure, though, we need to review the medical record to determine the underlying cause. I would suggest querying the physician regarding whether the “right-heart failure” is due to an underlying pulmonary process or right failure related to left-sided failure (CHF—systolic versus diastolic).
With left-sided heart failure or left ventricular (LV) heart failure, you may have either systolic and/or diastolic heart failure. Diastolic failure occurs when the muscle becomes stiff and loses its ability to relax normally. Documentation of heart failure with preserved EF(HFpEF), heart failure with preserved systolic function is also called “diastolic HF” or “diastolic dysfunction.” Documentation of “HF with reduced EF(HFrEF), HF with low EF, with reduced systolic function” or other similar terms also called “systolic HF.” The ventricle loses its ability to contract normally.
These terms can be used to clarify the type of heart failure for code assignment. Systolic (congestive) heart failure being coded to I50.2; with Diastolic (congestive) heart failure coded to I50.3 and I50.4 for combined systolic/diastolic heart failure in ICD-10-CM.
Now, having said all of this, there will be new codes in 2018 for heart failure, including a code for right-sided failure.
New heart Failure Codes
I50.8, Other heart failure
I50.81, Right heart failure
Unspecified, acute, chronic, acute on chronic, due to left heart failure
I50.82, Biventricular heart failure
I50.83, High output heart failure
I50.84, End-stage heart failure (code also type)
Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. Contact her at email@example.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.