Tip: Query for type, underlying causes, and/or stage of heart failure and CKD

It’s not enough to know whether heart failure is systolic or diastolic. Congestive heart failure (CHF), for example, isn’t an inherent component of systolic and diastolic heart failure, according to Coding Clinic, fourth quarter 2004. That means CHF, when present, requires a second code.

Also, many underlying conditions cause heart failure. Some require additional codes, some don’t. The following are a few conditions that CDI staff and coders see frequently:

Hypertensive heart disease, ICD-9 code 402.XX, where the fourth digit identifies the type of hypertension (i.e., benign, malignant, or unspecified), and the fifth digit identifies whether heart failure due to hypertension was present.

Unless a causal relationship exists between the heart condition and the hypertension—and the physician documents this relationship in the record—each condition requires its own code, according to Coding Clinic, fourth quarter 2008. If the documentation does not make that link, an HIM/coding professional must code the two conditions separately, using 401.X for the hypertension and a code from the 428.X series for the heart failure. If the documentation defines a causal relationship, he or she must select a combination code (i.e., a code from the 402.X category). Coding professionals must delineate the type of heart failure, when known, using an additional code (i.e., one from the 428.X category).

Hypertensive heart and chronic kidney disease (CKD), from ICD-9-CM code category 404.XX. This combination code denotes a patient’s heart disease and specifies that the CKD that is present directly resulted from the hypertension. For a patient who presents with both conditions, include a code for the type of heart disease, when known, and stage of the kidney disease (i.e., a code from the 585.X category).

Having the stage of the CKD could mean a difference in DRG assignment. “There is a clinical reason to document a stage,” said Shannon E. McCall, RHIA, CCS, CCS-P, CPC, director of coding and HIM at HCPro, Inc., in Marblehead, MA, during the April 9 HCPro audio conference, “Heart Failure Coding: Accurate Assignment to Reflect Patient Severity.”

She added that “the stages of chronic kidney disease are actually identified as being CCs.” If the physician doesn’t document the CKD stage, the CDI specialist should query for that information, she added.

• Coronary artery disease, ICD-9 code category 414.XX
• Myocardial infarction, ICD-9 code category 410.XX
• Ischemic heart disease (cardiomyopathy), ICD-9 code 414.8
• Alcoholic cardiomyopathy, ICD-9 code 425.5

In summary, coders and CDI staff must understand what type of dysfunction is occurring, where in the heart it occurs, and whether underlying conditions play a role. Capturing this specific information will better reflect patients’ severity and enhance the continuity of patients’ care, McCall said.

Editor’s note: This article was originally published in the newsletter Briefings on Coding Compliance Strategies. You can read the entire article on the ACDIS website’s Featured Article section. To purchase a recording of the audio conference, visit www.hcmarketplace.com/prod-7613.html.