Q&A: Congestive heart failure coding

Q: In the past few weeks, we noticed physicians are documenting acute congestive heart failure with preserved ejection fraction (EF), instead of diastolic or systolic. In speaking with the physicians, they say the heart failure is not diastolic or systolic. What is the best way to approach this issue?

A: You are experiencing a very common frustration for both coders and CDI specialists. The term “preserved EF” in general equates to a diastolic heart failure. But, as you clearly understand, we cannot apply the code for the diastolic heart failure with the use of that verbiage.

The descriptions of diastolic and systolic in categorizing heart failure are older terms, and the code set has not yet “caught up” to the new wording. I encouraged my providers to state “diastolic heart failure with preserved EF.” This documentation gives coders what they need, and allows physicians to use clinically-accepted language.

AHA’s Coding Clinic for ICD-10-CM, First Quarter, 2014 speaks to this. It provides two examples. First, can heart failure with preserved EF or heart failure with preserved systolic function be coded as diastolic heart failure? Second, can heart failure with reduced EF, heart failure with low EF, or heart failure with reduced systolic function (or other similar terms) be coded as systolic heart failure?

Coding Clinic says “no” to these situations. The coder cannot assume either diastolic, systolic failure, or a combination of both, so CDI specialists need to query the provider to clarify the type of heart failure.

We cannot capture the acuity of heart failure without the descriptor of diastolic or systolic being stated. So, the last piece of advice is to educate providers about the importance of capturing specificity particularly in light of measuring severity of illness and risk of mortality, as this could influence their own quality scores. This may help to influence their cooperation with providing the needed clarification.  

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.