Q&A: Sequencing pulmonary edema and congestive heart failure

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, answered this question. At the time of this article’s release, she was manager of corporate coding support services at Franciscan Alliance in Greenwood, Indiana. 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.