how do i code heart failure and what are to be documented

April 07, 2022 Post a Comment

Partnering with special guest speaker Manasa Ranginani, MBBS, MPH, Clinical Documentation Improvement (CDI) Manager at Boca Raton Regional Hospital, ECLAT's team of experts tackled a perennial healthcare claiming: Congestive Heart Failure (CHF) Coding and Documentation. Selected from popular audition submissions, this topic is front end of listen for many in healthcare equally it is hard to overestimate the impact of one of medicine'due south most prevalent readmitted conditions (26.9% readmissions) and the loss in medicare reimbursements it causes. Not only is heart disease the leading cause of death for Americans 65 and older, but 42% of medicare beneficiaries in this range take at least 1 centre condition. Further, the recent shift in focus towards Social Determinants of Health (SDoH) has reframed the chat in an equity perspective. Mitigating SDoH risk is actually a key method of ensuring more positive outcomes for patients with CHF.

The Financial Touch on of CHF

Before delving into a consummate clinical breakdown of CHF, speaker Marie Thomas, MHA, RHIT, CCS, CCDS, COC, VP Revenue Cycle Operations, laid out in stark figures just how costly this condition really is. Looking at the result from a purely fiscal standpoint, heart disease (excluding strokes) is one of the most expensive wellness issues and reached an phenomenal $281 billion in 2015, and that figure may double by the year 2035. Marie explained that the toll of caring for a patient almost doubles when they have a single heart status, from approximately $9,000 to around $18,000 co-ordinate to the Centers for Medicare and Medicaid Services (CMS)¹.

A Clinical Overview of Congestive Center Failure

To continue creating a holistic understanding of Congestive Heart Failure, speaker Manasa gave a detailed clinical analysis of CHF. She detailed the 2 kinds of centre failure, Systolic and Diastolic, the specific breakdowns that crusade them, and why labeling these as Left and Right Sided Eye Failure doesn't fully capture their nature. Manasa further expounded on the telltale symptoms and signs that can indicate a CHF diagnosis is appropriate.

Every bit we can no longer lawmaking systolic and diastolic dysfunction, Marie established the importance of a medico linking the blazon of eye disfunction to the patient's CHF. If they do not, the code left bachelor to the coder is I50.nine. Nonetheless, she further identified this lawmaking for Heart Failure: Unspecified equally one that probably should non be left its non specific state, but is a flag for potential queries and requests for data to further analyze the state of the center failure.

Who Is At Risk For Congestive Eye Failure?

Only as the symptoms of Congestive Center Failure are recognizable, so too are many of its contributing factors. The next stage of Manasa'south overview involved a breakdown of what lifestyle choices and medical attributes put a person at greater hazard of a CHF diagnosis. Of the risk factors she detailed, many are easily preventable with a healthy lifestyle. Still, heart failure cannot be completely eradicated through healthier choices solitary. Still, the risks can be reduced, and our experts outlined both how patients can innovate prevention into their daily life choices and how hospitals can help mitigate the risks. Addressing this issue from both sides, the healthcare arrangement can reduce the national average LOS from half-dozen.2 days closer to the benchmark of iv.five days.

Diagnosing CHF

With a clinical breakup and knowledge of the associated take a chance factors established, nosotros and then addressed just how a medico assigns a CHF diagnosis as well as how to effectively treat the condition's short term symptoms and long term wellness impact.

With the condition diagnosed and the treatments begun, how do physicians arroyo CHF from a coding perspective? Further, how does a coder address the human relationship between center interest and hypertension? Manasa and our experts explained this in peachy depth, utilizing several case report examples. Farther, Manasa goes into details on dr. documentation and querying tips to establish coding accuracy, including the example below:

Physician Query Instance:

Clinical Indicators and/or Treatment: 80 yo M was admitted with SOB, CHF, Afib, and diabetes. Assessment/Plan-"Did receive furosemide 4 in the emergency department cardiology consulted"

Impression: "History of center failure with preserved ejection fraction syndrome." Assessment/Plan: "CHF (congestive heart failure) Received dose of furosemide in the emergency department with splendid diuresis. Resume torsemide continue spironolactone. Preserved systolic part history of PCI mitral valve prune x2 ASD repair"

Discharge Diagnoses: "CHF (congestive heart failure)"

proBNP: 3,092 (half dozen/29/21)

Echo: EF = 60-65%. LVH/BAE. Moderate MR and mild TR. (iv/17/21)

Treatment/Monitoring: IV Furosemide, PO Atorvastatin, PO Metoprolol, PO Spironolactone, PO Torsemide, PO Verapamil, Consistent Sugar Diet.

"CHF" has been documented in the medical record. If possible, can the diagnosis be further antiseptic past the post-obit?

Vigil of CHF- [ ] Acute [ ] Acute on Chronic [ ] Chronic

Type of CHF- [ ] Systolic [ ] Diastolic [ ] Combined

[ ] Other caption of clinical findings-_____________________________________

[ ] Clinically undeterminable.

CHF Health Disinterestedness

Like many common medical issues, Congestive Centre Failure is a office of the greater health equity word. One of the about subtle, but critical risk factors to place truly is a patient's contributing Social Determinants of Wellness, a thorough breakdown of which can be found in our previous webinar roundup web log. These include data well-nigh in what atmospheric condition the patient lives, if they take easy access to transportation, can they afford their medication, etc. Of all the SDoH factors affecting patient health, Marie and Manasa concord that the most impactful is non-compliance with medication regimens. This is true statistically and is besides observed by clinicians on the forepart lines of health.

In the webinar, our squad further details how, once identified with a trusted accountant like ECLAT Health Solutions, these factors can be easily addressed. The solutions are as numerous as they are readily available.

Poll Questions

Throughout the webinar, several audience polls were conducted as nosotros worked through doctor queries and instance studies together.

Poll Question #1:

Physician Queries

Clinical Indicators and/or Treatment: 89 yo Grand was admitted with syncope, aortic stenosis, dyslipidemia, history of CHF, and CKD.

Impressions: "Syncope Complete heart block Severe aortic stenosis status mail service TAVR Systolic congestive heart failure Hypertension Hyperlipidemia"

Impressions: "Syncope w/ facial trauma south/p recent TAVR, noted w/ bradycardia southward/p PPM now due west/ intermittent VT hypertension dyslipidemia chronic kidney affliction"

proBNP: 1,385 (6/29/21)

ECHO: LVEF:twoscore-45%. Moderate concentric LVH. Moderate, diffuse hypokinesis of the LV is present. Moderate MR, trace PR, and mild TR. Well seated bioprosthetic TAVR valve. (7/3/21)

Treatment: Iv Hydralazine, IV Phenylephrine, PO Metoprolol, PO Spironolactone, PO Bumetanide, PO Atorvastatin.

Results:

Poll 1 Results

Answer:

While the general audience consensus was to query for both acuity and type of heart failure, the case study did explain that the patient had systolic heart failure, eliminating the need to query for the type. Therefore, only the acuity of heart failure should be queried.

Poll Question #2:

Instance Written report #five:

71-yr-sometime male with a past medical history of COPD, hypertension, BPH, hyperlipidemia presents to the hospital with shortness of breath. His predominant symptom was shortness of breath, associated with a mild cough. He otherwise denies whatsoever frank fevers, chills, chest pain, overt sputum product. He did note that he had mild swelling in his lower extremities. In the ED, the patient was considered to accept pneumonia and given IV fluids and antibiotics. With the Iv fluids the patient condition worsened, Four fluids were stopped, patient was given Lasix. Labs remarkable for a WBC of 13.88, BNP 1123, c-reactive protein 7.02 and procalcitonin of 0.21. On exam, the patient was noted to take 2+ BLE edema. Patient was initially treated with BiPAP and improved with antibiotics and diuretics. Patient was DC dwelling with O2, po abx, po diuretic and weaning steroids
Initial chest x-ray noted interstitial edema with multifocal pneumonia, pneumonia slightly decreased in left midlung zone. Follow-up breast x-rays were clear without focal opacity or edema. Repeat noted Left ventricle: The crenel size is normal. Wall thickness is mildly increased. Systolic role is normal. The estimated ejection fraction is 55-60%. Wall motion is normal; there are no regional wall motion abnormalities. Left atrium: The atrium is mildly dilated

Coded Response:

I130 Hypertensive eye and chronic kidney disease
J189 Pneumonia, unspecified organism (MCC)
J9611 Chronic respiratory failure with hypoxia (CC)
N179 Acute kidney failure, unspecified (CC)
N184 Chronic kidney disease, phase four (astringent) (CC)
I509 Middle failure
MS DRG 291 Heart failure and shock with MCC
APR DRG 194 Heart Failure
SOI/ROM 4/4

Results:

Poll 2 Results

Answer:

Audience consensus in this poll was to query for the vigil of heart failure, which is the correct style to move frontward in these circumstances. Further, we can likely too query for the specific blazon of heart failure.

Poll Question #three:

Example Study #half dozen:

This is a 37-year-old female with a past medical history of vertigo, developmental delay (DiGeorge'south Syndrome), IBS, HTN and GERD who presents to the hospital for edema. The patient was noted to take worsening lower extremity edema likewise equally intestinal distention for the past week or so forth with increased fatigue. On admission, the patient was noted to have a BNP in 2000s, creatinine of 1.38 and EF of 40-45%. The initial chest x-ray noted an enlarged eye with balmy increment in pulmonary vascularity.
The Echo noted:
Left ventricle: Cavity size is normal, Wall thickness normal, Systolic office is mildly to moderately reduced, EF of forty-45%, moderate diffuse hypokinesis; Written report not technically sufficient to evaluate LV diastolic function
Right ventricle: cavity size is moderately to markedly increased, Wall thickness is normal, Systolic part is moderately to markedly reduced. TAPSE 1.ii, Systolic pressure is markedly increased. 90mmHG.
Right atrium: moderately dilated, Mitral valve: Moderate regurgitation, Aortic valve: Moderate regurgitation, Tricuspid valve: mild to moderate regurgitation
The patient was given Aldactone and Lasix, without adequate diuresis later 1 day of treatment, with a rising in the patient'southward Creatinine. The patient's congenital heart squad was consulted, and the patient was transferred to another facility for a higher level of intendance.

Coded Response:

130 Hypertensive heart and chronic kidney disease
I5023 Acute on chronic systolic (congestive) heart failure (MCC)
D821 DiGeorge's Syndrome (CC)
N179 Acute kidney failure (CC)
MS DRG 291 Center failure and shock with MCC
April DRG 194 Heart Failure
SOI/ROM 4/four

Results:

Poll 3 Results

Answer:

In this poll, the audience generally concluded that no md query and votes for each specific query were fairly depression and even across the board. Our team recommended a clinical human relationship query to found if the patient'south CHF is due to hypertension and chronic kidney disease or to her DiGeorge's Syndrome.

Q&A

The audience was extremely interactive, and many questions still remained at the close of the time slot. If you asked a question and are still awaiting the answer or if y'all want to larn more about CHF and what your peers desire to know, read below for viewer questions answered by our experts:

Question #ane:

For Polling Question-ane - History of systolic CHF - The answer was to place query for acuity of CHF. Can we consider a history of systolic CHF every bit chronic per AHA coding clinic, 2003?

Reply:

The circumstances of the admission also need to be taken into account. The history of CHF is chronic, but if we are giving the patient IV diuretics to treat it and that's the reason for their admission, and so we might need to query to come across if they have acute and chronic right now.

Question #2:

Is in that location a difference in causes and risks between systolic and diastolic centre failure?

Respond:

Conditions which directly touch the heart muscle similar myocardial infarction would likely crusade systolic heart failure. With increasing age or with HTN when the ventricles become stiff this leads to diastolic center failure. Once again information technology is helpful to think of the middle every bit a functional unit and systolic and diastolic heart failure are in the spectrum of the same disease.

Question #iii:

Is medical or surgical treatment for CHF used more often?

Answer:

Medical management of symptoms are most oftentimes used, when there is diuretic resistance or other need for surgery to assist in management of CHF symptoms such every bit aortic stenosis, treated with TAVR, so a surgical treatment may be used.

Question #4:

Is the causeless link betwixt hypertension and heart involvement ever authentic? Does it sometimes need to exist changed?

Answer:

When the md does not explicitly link a status to the center status, the guideline instructs coders to assume a link. When a condition is nowadays such as a congenital center condition or alcoholic cardiomyopathy as well every bit hypertension, and no link is made, and so a query may be needed to clarify the human relationship. Was it the hypertension related to the heart condition or was it the congenital heart condition or the alcoholic cardiomayopathy?

Question #5:

In your opinion, what Social Determinant of Health is the biggest correspondent to CHF?

Respond:

During out investigation, the biggest contributor is noncompliance with medication.

Question #6:

Do we demand to assume combination codes when HTN and CAD are documented?

Respond:

We tin can't assume a human relationship between HTN and CAD. In the ICD-x tabular nether category I11, there's an includes notation stating "any condition in I50.- (heart failure codes) or I51.iv-I51.seven (myocarditis, unspecified; myocardial degeneration; cardiomegaly), I51.89 (other ill-defined eye diseases), I51.nine (heart disease, unspecified) due to hypertension Coding Guideline Section I.C.9.a.ane Hypertension with Heart Disease also explains the presumed causal relationship betwixt hypertension and heart involvement specific to the higher up code classification. CAD (coronary avenue illness) falls nether category I25 therefore we can't assume a combination code when HTN and CAD are documented.ⁱⁱ

Question #7:

How is HTN coded with Hx of CHF i?

Respond:

Typically CHF is non a disease process that can exist "cured", intendance and treatment is given to save symptoms and deadening any potential damage due to CHF. If we run into "history of CHF" with documentation of treatment with diuretics or a procedure to assist with CHF direction, we would accept an opportunity to query to clarify a history of CHF vs. a chronic blazon of CHF. If the query is responded to as history of CHF with no chronic element, I10 for hypertension would exist appropriate.²

Question #viii:

Do y'all take any suggestions on how to get-go a program encouraging our facility physicians to document CHF types and vigil?

Answer:

To get doctor buy-in and encourage physicians to document CHF type and acuity it might be helpful to consider the following- (a.) Start with the specialists that is the cardiologists. Equally they ready a standard in the documentation and oft consult for CHF. (b.) Focus on quality, physicians will recognize the importance of documenting CHF blazon and vigil when nosotros focus on quality metrics particularly CORE measures and CMI. (c.) Make it a team effort, involve different care members in the plan including case managers, nurses, and residents.

Question #9:

In Case Written report #ane, Why would we report the NSTEMI and the CTO? Per coding edits, I21.4 and I25.82 are excludes 1 codes.

Answer:

With the NSTEMI, a left heart cath revealed astringent ischemic cardiomyopothy, left ventricular ejection fraction at 10%, and severe CAD with diffuse 99% illness in the LAD. The LAD was our culprit lesion for our NSTEMI. The patient has chronic total occlusion of the left circumflex and the RCA systems. Given this data, nosotros tin override the excludes 1 because that is not our culprit lesion. That'south the reason nosotros coded I21.iv and I25.82. Nosotros override an excludes one when they are not related, and that is how we took this particular aspect.

Question #10:

Case Study 2 - Was the S&D linked with the CHF?

Respond:

In this example we have the astute and chronic biventricular systolic and diastolic disfunction with decompensated middle failure. In this example information technology was linked.

Question #11:

When the EF is between 40-50%, our doctors similar to chart "HF with marginal EF," which of course doesn't have a code. How should this be queried?

Answer:

Every bit HF with marginal ejection fraction does not code to annihilation, it is of import to take a holistic view of the clinical presentation and patient profile. We should also notation the risk factors, handling, and focus of care while we are drafting the query. Sometimes physicians might compare current ejection fraction with the patient's ejection fraction from the past to help ascertain the type of heart failure.

Conclusion

Equally an interactive series, upon its conclusion, installments of the Experience The Brilliance Webinar Serial open into a Live Q&A forum, wherein our experts and guest speaker Manasa answered audience questions about Congestive Center Failure (CHF) Coding and Documentation.

If you missed out on the Live session or would like to revisit the case studies or any other data, watch the webinar replay here:

Watch The Webinar Replay

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Congestive Center Failure and other topics discussed across the Feel The Luminescence series are called from popular audience submissions. Make your phonation heard by submitting a topic here.

References:

ⁱhttps://www.cms.gov/Inquiry-Statistics-Data-and-Systems/Enquiry/MCBS/Downloads/HeartConditions_DataBrief_2017.pdf| Centers for Medicare & Medicaid Services

² https://www.cms.gov/files/document/fy-2022-icd-ten-cm-coding-guidelines.pdf| FY 2022 Coding Guidelines

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