Q&A: Documentation for coding heart failure

Q: If the documentation states, “diastolic heart failure (HF) euvolemic” or “diastolic HF hypervolemic,” can we code chronic diastolic HF and acute diastolic HF, respectively?

A: Unfortunately, you may not like my answer, which is no, this documentation would not be acceptable to pick up either diagnoses of “chronic or acute” diastolic heart failure.

Code assignment is based on the physician documentation of the type and acuity of the HF. Euvolemic is a medical term that implies the patient appears to have normal circulatory or blood fluid volume. Hypervolemia or fluid overload is the medical condition where there is too much fluid in the blood, because not every patient is in fluid overload or hypervolemia at the time of admission, many physicians are now use HF (heart failure) versus congestive heart failure (CHF) in their documentation.

There are many types of HF, and CHF is just one type. There is a code in ICD-10-CM for fluid overload: E87.70, Fluid over, unspecified. This is also where hypervolemia would be coded.

Now, in AHA Coding Clinic, First Quarter 2016, it did state that HFpEF could be referred to as “diastolic heart failure” and that HFrEF could be referred to as “systolic heart failure.” This advice supersedes information previously given in Coding Clinic, First Quarter 2014. This is why it’s very important to keep up with the advice given by Coding Clinic.

Also, as a reference, see Coding Clinic, First Quarter 2017, p. 46, regarding the coding of acute congestive heart failure with diastolic or systolic dysfunction. I think you’ll find it helpful when looking at physician documentation requirements.

The question in this Coding Clinic asks how decompensated CHF with diastolic or systolic dysfunction would be coded in ICD-10-CM. Specifically, the question sites a patient admitted for acute CHF. The physician in this scenario documents “acute decompensated CHF with diastolic dysfunction.”

Coding Clinic’s answer was that if the “provider links acute CHF with diastolic dysfunction, assign code I50.31, Acute diastolic (congestive) heart failure, as the principal diagnosis. When the provider has linked either diastolic or systolic dysfunction with acute or chronic heart failure, it should be coded as ‘acute/chronic diastolic or systolic heart failure.’ If there is no provider documentation linking the two conditions, assign code I50.9, Heart failure, unspecified.”

Editor’s Note: Sharme Brodie, RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.