Cardiology Coding Alert

Cardiology coders are finding that the key to using the new congestive heart failure (CHF) codes correctly is to ensure that physicians use the same terms as those included in the codes to classify the particular type of CHF.

In response to the release of the 12 new ICD-9 codes that went into effect in October, coders have put together plans to help their practices use the codes more accurately. (For an overview of the new CHF codes, see the October 2002 Cardiology Coding Alert.)

"When these codes came out, I met with the physicians and the nurse practitioners in our practice to reinforce the importance of giving me specific information on the exact nature of the heart failure patients have," offers Karen Salowitz, RN, CPC, billing coordinator with Heart and Vascular Center of Arizona in Phoenix.

"I tell physicians that you might have to educate me on CHF, but Im also going to let you know that we need to use these codes accurately," Salowitz stresses.

"Were telling our billers that if a physicians CHF description is incomplete, the billers have to get in touch with the physician to fill in the missing information," instructs Rebecca Sanzone, CPC, billing manager for Midatlantic Cardiovascular Associates of Baltimore.

If coders persist in using 428.0 (Congestive heart failure, unspecified) and 428.9 (Heart failure, unspecified) instead of coding to the highest level of specificity with the new CHF codes, payers including Medicare carriers may respond by denying payment for CHF, coding consultants warn.

Coders will need a basic understanding of the differences between acute, chronic and acute on chronic heart failure. Moreover, physicians must specify in their notes not only the degree of severity but also whether the CHF is located in the systolic or diastolic areas of the heart, stresses Anne Karl, RHIA, CCS-P, CPC, a coding and compliance specialist with the St. Paul Heart Clinic in Mendota Heights, Minn. Even if the chart doesnt indicate the severity of the CHF, medication and histories can provide information that will help pinpoint whether the problem is acute, chronic or acute on chronic.

For instance, if a patient has acute heart failure, he or she is likely experiencing this condition for the first time, according to Sanzone. If the diagnosis is acute systolic heart failure, you would use 428.21; for acute diastolic heart failure, use 428.31.

If a patient already has chronic heart failure (428.22 or 428.32) and is taking medication for the condition, but the problem becomes more intense or starts "acting up," then the diagnosis would be acute on chronic heart failure. In this case, you would use 428.23, 428.33, or 428.43, depending on whether the problem is systolic, diastolic or combined systolic and diastolic.

Moreover, if hypertensive heart disease (402.xx) causes heart failure, you would use an additional code from the CHF group (428.0, 428.20-428.23, 428.30-428.33, 428-40-428.43) to specify the type of heart failure, Sanzone instructs. You would also use the new CHF codes with codes for fluid overload (276.6) if fluid build-up accompanies CHF, she adds.

Coders and physicians may have to rely on diagnostic test results to confirm CHF location and severity, Salowitz observes. She expects to see the new CHF codes linked to echocardiography codes (93303-93308, 93312-93318, 93320-93321, 93325, 93350).

In particular, cardiologists will use Dopplers with pulsed wave and color flows (93320-93325) as the definitive means for diagnosing whether CHF is systolic or diastolic, Salowitz and Sanzone observe.

Physicians also will use cardiac catheterization to determine the nature of CHF. Cardiologists would use right heart catheterization (93501) for determining the degree of CHF, Sanzone explains.