Documentation and Coding for Chronic Heart Failure in PACE

Documentation and Coding for Chronic Heart Failure in PACE

  • 17 Feb 1
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Documentation and Coding for Chronic Heart Failure in PACE

By: Sommer Huseman, RN, Risk Adjustment and Coding Specialist

Participants often enter PACE with limited understanding of their conditions and some have been treated for CHF without explicit awareness.  This treatment may be camouflaged by clinical setting – overlapping treatment of hypertension or renal conditions or a tendency for clinicians to downplay the diagnosis by referring to “pump problems” or other descriptions.  The astute practitioner will have a high index of suspicion for CHF when s/he recognizes key risk factors and/or treatments, even in the absence of unequivocal history.

Heart failure produces symptoms resulting in the accumulation of fluid in the lungs and other body tissues. Blood pools in the veins (vascular congestion) because the heart does not pump efficiently enough to allow it to return. It may vary from the most minimal symptoms to sudden pulmonary edema or a rapidly lethal shock-like state. Chronic states, of varying severity, may last years. Symptoms tend to worsen as the body attempts to compensate for the condition, creating a vicious circle. The patient has trouble breathing, at first during exertion and later even at rest. Treatment is directed toward increasing the strength of the heart’s muscle contraction, reduction of fluid accumulation, and repair or elimination of the underlying cause of the failure.

Below we are going to review different types of heart failure, contributing factors, treatment, and proper documentation and coding to the standards of the “official coding guidelines”.

Classification of heart failure (NYHA)

  • Class I- Patients with cardiac disease but without limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
  • Class II- Patients with cardiac disease with a slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
  • Class III- Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
  • Class IV – Patients with cardiac disease with inability to carry on any physical activity without discomfort.  Symptoms of heart failure or anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. Heart failure classification is used to determine follow-up recommendations and referrals to case management or palliative care, and for coding.

Stages of Chronic Heart Failure (ACC)

  • Stage A- increased risk factors w/o structural heart disorder or symptoms of HF- would not recommend capturing as a diagnosis as is just risk factors
  • Stage B- structural heart disorders without overt symptoms of HF — Previous MI, LVH, low EF, valvular disease
  • Stage C- structural heart disease with symptoms, previous or current
  • Stage D- refractory HF requiring specialized intervention  — Marked symptoms at rest despite therapies

Etiologies (Consider additional evaluations to identify potentially treatable causes of heart failure)

  • Alcohol or cocaine abuse
  • CAD
  • Collagen vascular disease
  • Endocrine disorders such as diabetes, hyperthyroidism or hypothyroidism
  • HIV
  • Obstructive sleep apnea
  • HTN

Documentation to Support CHF

In the asymptomatic patient, document the treatment that supports CHF (some treatment may overlap with other conditions, such as hypertension).  Consider that if a patient is on a combo of typical CHF meds, the patient may not have s/sx of CHF, even though the diagnosis exists.  Treatment is prima facie evidence of diagnosis.  Obviously, if symptoms are present (or were present) to confirm the diagnosis, such documentation is vital.

History and clinical findings  

If CHF is suspected, documentation of historical symptoms and disease progress from old records will give more support to the dx, but is not required. There is no single diagnostic test for CHF because it is largely a clinical diagnosis that is based on a careful history and physical examination and appropriate testing (Probability of volume overload and/or reduced ejection fraction is > 90% if 3 or more of the findings below are present.)

  • Jugular venous distension
  • Dyspnea, Orthopnea
  • Third heart sound
  • Rales in lungs
  • Edema
  • Pulse > 90 BPM, Systolic blood pressure < 90 mm Hg
  • Abnormal apical impulse, cardiomegaly
  • Prior infarction

Lab testing –to rule out treatable causes of heart failure:

  • Electrolytes
  • CBC
  • Albumin
  • BUN , Creatinine
  • AST
  • Calcium
  • TSH
  • EKG (wave MI or Left bundle branch block)
  • Chest X-ray (Radiographic cardiomegaly or redistribution or Pulmonary congestion)
  • Echocardiogram (consider radionuclide angiography if patient is obese (BMI > 35) or has severe COPD.) Evaluation for structural heart disease etiologies that can lead to heart failure – diminished motion, valves or Anatomic or functional changes — LVH, A-to-E reversal, diastolic dysfunction or Elevated PA pressure is coded as pulmonary hypertension which maps to the CHF HCC

Treatments for congestive heart failure

Lifestyle Modifications/Non-Pharmacologic Options.  Key self-management strategies for patients:

  • Check weight daily and report gains of more than 2 lbs in a 2- to 3-day period.
  • Limit sodium intake
  • Limit alcohol consumption completely (preferred) or to less than one drink per day
  • For stable heart failure patients, exercise training may improve survival and quality of life
  • Recognize and record symptoms

Patient monitoring signs and symptoms of a change in status

Assess the patient’s ability to:

  • Perform daily living activities
  • Recognize and document changes in weight and fluid levels that should be reported
  • Understand diet and sodium intake


  • Diuretic therapy: Used for clinical volume overload. Diuretic therapy improves symptoms, and exercise capacity in patients with heart failure.
  • ACE inhibitors:  is recommended for all patients with heart failure and ejection fraction < 35%, unless contraindicated or not tolerated. The benefit is greatest in those with low ejection fractions.
  • Beta blocker: Used to control heart rate and increase cardiac output. In addition to the above mentioned medications, used are aldosterone antagonist, calcium channel blockers, and cardiac glycosides.

Coding Chronic Heart Failure

  • Heart failure, Category 428, has expanded codes so that systolic heart failure, diastolic heart failure, or a combination have separate codes. These codes also have fifth digits to indicate whether the condition is unspecified, acute, chronic or acute on chronic. Assign a code for systolic and/or diastolic heart failure when they are present.
  • CHF unspecified, 428.0, is assigned if there is no further documentation into the nature of the CHF.
  • Acute pulmonary edema/CHF is assigned 428.1
  • Acute and chronic heart failure is assigned code 428.23 if it’s systolic, 428.33 if it’s diastolic and 428.43 if it’s both.
  • Acute pulmonary edema with mention of heart disease or failure is 428.1 (also left heart failure)
  • Combined systolic and diastolic CHF in a patient with a known history of CHF is assigned code 428.40, combined systolic and diastolic heart failure.
  • Fluid overload/CHF — A chronic renal failure patient who is on dialysis is admitted with volume overload the patient’s condition progresses to CHF. CHF is the principal diagnosis. Fluid overload is integral to CHF and should not be assigned a code.
  • Hypertension/CHF — If a patient has CHF and hypertension, the physician must state that CHF is due to hypertension before it is coded to hypertensive heart disease with CHF, 402.91.


*The information presented here complies with accepted coding practices and guidelines as defined in the ICD-9-CM coding book. It is the responsibility of the healthcare provider to produce accurate and complete documentation and clinical rationale, which describes the encounter with the patient and the medical services rendered, to properly support the use of the most appropriate ICD-9-CM code(s) according to the official coding  guidelines.

*The information presented herein is for general informational purposes for clinicians only and is not warranted that the information contained herein is complete, accurate or free from defects.