Transcript Module 5a: Documenting Heart Failure


At the conclusion of this module, the learner
will be able to:
1. Differentiate between systolic and diastolic heart
failure
2. Describe three clinical indicators of acute heart
failure
3. Define acute cor pulmonale




Heart, due to impairment of structure or
function, does not pump effectively
Because oxygenated blood is not effectively
pumped forward into the circulation, tissues
do not receive nutrients and oxygen
Fluid backs up within the circulatory system
leading to peripheral and pulmonary edema
(“congestive heart failure”),
Most common cause is coronary artery
disease





Documenting “CHF” is insufficient!
CMS guidelines require acuity and specificity.
Incomplete documentation of heart failure
has a significant impact on severity of illness,
risk of mortality, GLOS, and case mix index.
Incomplete documentation affects treatment
modalities, core measures, and
communication.
Incomplete documentation affects patient
care.

Documenting NYHA classifications is not
adequate documentation of heart failure for
CMS

Is it systolic, diastolic, or combined?




EF = % of blood volume pumped out with
each stroke
Usually refers to left ventricle, but right
ventricle EF may also be measured
Commonly diagnosed by ECHOcardiogram,
but may also be measured during stress test
or cardiac catheterization
Ejection fraction is a key clue as to type of
heart failure





Ejection fraction < ~ 50%
Result of impaired inotropic state – heart
can’t empty
Causes include dilated cardiomyopathy,
myocardial infarction
Treated with ACE-inhibitors or ARBs – core
measures; Digoxin, judicious use of βblocker
Core measure HF-3: pts w/LV systolic
dysfunction (EF < 40%) prescribed ARB or
ACE-i







Ejection fraction > ~ 50 %
1/3 of patients with symptomatic heart failure
have “normal” EF
Risk increases with age
Result of impairment in heart’s ability to relax –
heart can’t fill
May see elevated filling pressures “stiff ventricle”
Causes include restrictive and hypertrophic
cardiomyopathy, ischemia, HTN, senile cardiac
amyloid, constrictive pericarditis, myocardial
ischemia
Treatment differs from systolic HF – β-blockade



It is possible to have elements of both
systolic and diastolic heart failure
Physician should not write, “both,” or
“combined,” because the coders can’t code
from that
Physician needs to specify, “systolic and
diastolic”

Is it acute, chronic, or acute on chronic?






Usually – but not always – systolic
Develops suddenly without prior history
May have sudden reduction in cardiac output
May be hypotensive
May not show peripheral edema
Can be documented as “acute” or
“decompensated” heart failure




Develops slowly
May be seen in patients with dilated
cardiomyopathy, valvular heart disease
Often has normal blood pressure but with
peripheral edema
Patients coming from home with heart failure
medications – if you continue those meds, are
you treating a chronic condition?


Patient has pre-existing chronic condition
that worsens
Can be documented either as “acute on
chronic” or “exacerbation”



Check the BNP – is it elevated?
Check the ECHO results – what is the EF? How
does the cardiologist describe LV function?
What are the pt’s clinical signs/symptoms?
◦
◦
◦
◦
◦

Dyspnea, hypoxia
Rales/rhonchi
Peripheral edema
JVD
S3 gallop
How is the heart failure being treated?
◦ IV diuresis usually means an acute condition!
◦ No change in home HF meds usually means chronic

SI/IS for heart failure


Need documentation of diagnosis, physical
assessment to support diagnosis,
documented evidence of cardiopulmonary
instability, treatment per core measures
(unless contraindicated), evaluation of LV
systolic function, assessment of oxygenation
and treatment with supplemental oxygen, use
of cardiac monitoring
Heart failure can be monitored and treated in
an observation status – not an automatic IP

Severity of illness & geometric length of
stay



“CHF” does nothing to increase relative
weight and CMI
Acute heart failure, documented as systolic,
diastolic, or systolic & diastolic, is a major
co-morbidity that increases relative weight
and CMI
Two patients with the same presentation and
same treatment, documented differently, can
have dramatically different relative weights,
CMI, and geometric lengths of stay

Patient admitted with atrial fibrillation,
develops signs of acute heart failure, EF is
60%
◦ Physician documents AF, CHF
 DRG 310, GLOS 2.0 days, RW 0.5608
◦ Physician documents AF, acute diastolic heart
failure
 DRG 308, GLOS 4.0 days, RW 1.2283

Patient admitted with intracranial
hemorrhage, has been taking Lisinopril for
previously diagnosed heart failure, meds are
continued and patient placed on telemetry.
ECHO done in June showed EF of 30%
◦ Physician documents ICH, hx systolic dysfunction
 DRG 66, GLOS 2.6 days, SOI 1, RW 0.8105
◦ Physician documents ICH, chronic systolic heart
failure
 DRG 65, GLOS 3.8 days, SOI 2, RW 1.8555

Patient admitted with CAD, hx systolic HF,
undergoes CABG; postoperatively cannot
handle fluid resuscitation, requires extensive
diuresis and increased oxygen requirement,
spends extra 2 days in the hospital
◦ Physician documents CAD, fluid overload
 DRG 236, GLOS 6.0 days, RW 3.7720
◦ Physician documents CAD, systolic HF exacerbation
 DRG 235, GLOS 9.3 days, RW 5.9063

Getting acuity and specificity into the
medical record

Dr. Jones:
“CHF” is documented in the medical record.
The record indicates moderate dyspnea, bilateral rales
and rhonchi. BNP is 9400. ECHO shows ejection
fraction of 35%. Orders for oxygen, PO Lisinopril and IV
Bumex. CMS requires acuity and specificity in
documentation of heart failure. To establish the most
accurate severity of illness of your patient, please
specify the type (systolic, diastolic, or systolic &
diastolic), and acuity (acute, chronic, or acute on
chronic) of heart failure you are treating. For continuity
of the record, please document in the progress notes
and continue through to the discharge summary.



Type of right-sided heart failure
Acute cor pulmonale = acute lung disease
(e.g., PE, ARDS, COPD exacerbation) causing
acute right sided heart failure
Chronic cor pulmonale = right sided heart
failure resulting from pulmonary
hypertension, chronic lung disease, or
pulmonary valve stenosis
◦ Right ventricle dilates from chronic ischemia and
hypertension of the arteries in the lungs
◦ Ventricle unable to pump against the hypertension







Acute onset of dyspnea
JVD
Hypotension
Hypoxia
Tachycardia
Shock
S3/S4 on inspiration
Acute







Fatigue
Exertional dyspnea
Ascites
Hepatomegaly
Dependent edema
Cardiomegaly
Syncope
Chronic


CXR: RV and pulmonary artery enlargement
EKG: RV hypertrophy (R axis deviation, QR
wave in V1, dominant R wave in V1 to V3)
◦ Both CXR and EKG results may be skewed in COPD
patient due to realignment of the heart

ECHO: evaluate LV and RV function, likely to
see RV thickening and increased PA pressures
◦ Often limited by lung disease

Right heart catheterization
Cor Pulmonale, Merck Manual for Healthcare Professionals

Be aware of combination codes in ICD-10.
ICD-9
ICD-10
415.0 acute cor pulmonale
I26.01 septic pulmonary embolism
with acute cor pulmonale
415.12 septic pulmonary
embolism



Not coded as heart failure. There is no code in
heart failure DRGs for right sided heart failure.
As PDx, cor pulmonale goes to DRG 316, other
circulatory system diagnoses.
As SDx, acute cor pulmonale is a major comorbidity.


Can occur due to many causes
When found in patient with heart failure, is
considered integral to disease and is not
coded EXCEPT
◦ Physician can state that the pleural effusion is
clinically significant, apart from the heart failure, or
is not due to the heart failure (look for evidence of
different etiology for the pleural effusion)
◦ If treatment of pleural effusion is not the same as
that for heart failure (e.g., performing a
thoracentesis—not routine tx for HF!), then the
pleural effusion can also be coded
1.
Mrs. Gonzales is admitted with shortness of
breath, rales in the bases; CXR indicates bilateral
effusions, BNP is 12,400, EF is 28%; IV Lasix is
ordered. The physician documents CHF with
pleural effusion. Your most likely action is:
a. Code pleural effusion as PDx and query for
acute systolic HF as SDx
b. Query for acute systolic HF as PDx and do not
code the pleural effusion
c. Query for acute systolic HF as PDx and query
for transudative pleural effusion as SDx
d. Code CHF as PDx and query whether the pleural
effusion is related to the CHF
2.
On day 2, Mrs. Gonzales’s pulmonologist
decides to perform a thoracentesis of the
pleural effusion. Your most likely action is
to:
a. Code the pleural effusion as PDx because that is
the focus of the care
b. Not code the pleural effusion because it is
inherent in heart failure
c. Code the pleural effusion as SDx because the
treatment is outside the scope of heart failure
d. Query for acute respiratory failure due to the
thoracentesis.
3.
A good way to remember the difference
between systolic and diastolic heart failure
is:
a. Systolic means the heart can’t fill; diastolic means
the heart can’t pump
b. Systolic means the left ventricle is preserved;
diastolic means the right ventricle is preserved
c. Systolic means the heart failure is acute; diastolic
means the heart failure is chronic
d. Systolic means the heart can’t pump; diastolic
means the heart can’t fill
4.
Acute cor pulmonale:
a. Is usually caused by an acute lung injury or
disease
b. Is usually caused by acute systolic heart failure
c. Is best diagnosed by a left heart catheterization
d. Is never found in patients with chronic lung
disease