Q&A: Query for biventricular heart failure

Q: Our cardiologists like to document “biventricular heart failure.” Is a query needed to clarify systolic and/or diastolic?

A: A query should be issued for the chronicity and type of heart failure when the physician states only “biventricular heart failure.” Biventricular represents that both ventricles have mechanical problems, but it doesn’t specify which phase of the cardiac cycle (systole or diastole) is encountering a pumping/filling issue.

If you have access to an encoder and type in “biventricular heart failure” you will receive prompts to add in participating factors, and asked to choose what type of heart failure (systolic, diastolic, combined, etc). If you pick “unspecified,” you end up with code “428.0 Congestive heart failure, unspecified.”

Editor’s Note: Vicki Sullivan Davis answered this question. At the time of this article's original release, Davis was CDI manager at Cone Health Systel at Alamance Regional in Burlington, North Carolina, and a past speaker at ACDIS National Conference.