Coding for congestive heart failure

April 23, 2021 / By Rebecca Caux-Harry

I was reading an article the other day about a young man who developed severe biventricular heart failure after consuming a large quantity of an energy drink every day for 2 years. I remember my days as a college student and the need to be mentally alert for my classes and studies. We didn’t have energy drinks at that time, but there were, and still are, caffeine pills. I tried them once or twice and found myself so overwhelmed by the caffeine side effects that there was no benefit. I guess I was lucky in that way. 

While the young British student is expected to make a partial to full recovery with ongoing treatment, the article got me thinking about the ICD-10 codes for congestive heart failure (CHF). CHF is when the heart muscle doesn’t pump blood to the rest of the body as it should. The condition is usually progressive, meaning most people aren’t cured, but rather managed with medication and lifestyle changes.

There are multiple causes of CHF, coronary artery disease, high blood pressure and diabetes being the most common. The heart muscles can be damaged and become weakened, reducing their pumping ability, or the muscles can become stiff, unable to relax enough to allow the full amount of blood to enter the heart chamber and subsequently be pumped out to the rest of the body. Either way, this is a serious condition that will need life-long management. A measure of heart failure is based on ejection fraction (EF). This is the percentage of blood in the left ventricle that is ejected during contraction that sends oxygenated blood out to the body. Normal EF is 50 percent or higher. 

When I first started coding, we only had 3 ICD-9 codes for CHF: 428.0, 428.1 and 428.9. A few years later, those codes were expanded with specificity for acuity and type (acute, chronic, acute on chronic, systolic, diastolic, and combined). Now, with ICD-10 we have a wide variety of codes to choose from, but as always, selection of the most accurate and specific code depends entirely on the physician’s documentation.

When searching for an ICD-10 code for CHF, we start by looking under Failure/Heart to arrive at the unspecified code of I50.9 Heart Failure, unspecified. Make sure to read the Code First directions as well as the Excludes 1 and 2 sections. So, if we have the most minimal documentation, Heart Failure, I50.9 might be the right code. Since the term congestive appears in parentheses in the descriptor, the physician doesn’t need to state that term. 

The Code First section gives insight into cause and effect regarding heart failure. If there is documentation of heart failure due to certain conditions, we are instructed to code those first.  If the provider states hypertension and CHF, we can assume a causal linkage and select a code from category I11, Hypertensive Heart Failure with additional secondary codes for the specific type of heart failure. We can’t assume ‘failure’ with documentation such as heart disease, heart dysfunction, or LV dysfunction. This documentation leads us to the code I51.8x  Other ill-defined heart disease.

So, when educating providers about language specificity needed to accurately code heart failure, or simply looking for the correct language to use for code selection, we need several things. 

First, to start in the right code family, we need Heart Failure at a minimum. We also need the type of failure whether systolic, diastolic, or combined. We need to know if a specific chamber is most affected, left ventricle, biventricular or right heart failure due to left heart failure. Without this specificity, we can’t use the codes with acuity included. We also have a code for End Stage Heart Failure to be used either primary or secondary to the specified type of heart failure. For patients with neonatal cardiac failure, we are directed to a pediatric code, P29.0. 

As for the young student in the article, who cautioned others to consume energy drinks with care, the limited medical specificity in the article only supports codes I50.82 and T781XXA Other adverse food reactions, not elsewhere classified, initial encounter. Best wishes to the young man for a complete recovery!

Rebecca Caux-Harry, CPC, is a professional fee coding specialist with 3M Health Information Systems.

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