Home Health ICD-9/ICD-10 Alert

Don't over-code for heart disease symptoms.

Congestive heart failure code 428.0 is one of home health's most-reported diagnoses -- and a case-mix code to boot. Make certain you're listing this diagnosis correctly or risk missing out on reimbursement you deserve.

Definition: Patients with congestive heart failure (CHF) have a heart that is unable to pump blood flow that is sufficient to meet the body's needs. Symptoms of CHF can include fatigue, shortness of breath, pulmonary edema, fluid retention, edema, coughing/wheezing, pleural effusion, and heart palpitations.

You'll find the CHF code in the 428.x (Heart Failure) category, says Joan L. Usher, BS, RHIA, COS-C, ACE, president, of JLU Health Record Systems in Pembroke, Mass.

Look to 428.0 (Congestive heart failure, unspecified) when your patient has a diagnosis of CHF unspecified, Usher says. This code is also appropriate for a diagnosis of congestive heart disease or right heart failure secondary to left heart failure.

Sequencing tip: CHF is always considered chronic. If your patient has more than one kind of heart failure, code for them all, says Sharon Molinari, RN, HCS-D, HCS-O, a home health consultant based in Henderson, Nev. But if your patient has both CHF and left heart failure, don't code the left heart failure separately. And remember that proper sequencing requires you to code any acute heart failure diagnoses before you code for chronic heart failure.

Coding tip: Don't list diagnosis codes for integral symptoms in a heart failure patient, Molinari says. Coding for the heart failure itself is enough, so you should not add codes for dyspnea and edema.

Mistake: Coders often assume that "heart failure" is CHF and that is not always true, Molinari cautions. There are many different types of heart failure, including left, systolic, diastolic, and combined diastolic and systolic.

ICD-9 category 428.x (Heart failure) includes several additional codes for these different types of heart failure.

Coding tip: If your patient also has a diagnosis of diastolic or systolic dysfunction, you should list an additional code from the 428.x (Heart failure) category in addition to 428.0. ICD-9-CM does not assume that a patient with diastolic or systolic heart failure automatically has CHF.

The AHA Coding Clinic for ICD-9-CM 1st quarter 2009 states: "Congestive heart failure is not an inherent component of systolic or diastolic heart failure. When the diagnostic statement lists congestive heart failure along with either systolic or diastolic heart failure, two codes are required to report the specific type of heart failure: congestive, diastolic, and/or systolic." Look to the following 428.x subcategories to report these conditions when documented:

• 428.2x (Systolic heart failure);
• 428.3x (Diastolic heart failure); and
• 428.4x (Combined systolic and diastolic heart failure).

These codes all require fifth digits which indicate whether the heart failure is unspecified, acute, chronic, or acute on chronic. Acute on chronic can mean that the patient is having an exacerbation of a chronic condition, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. Or it can mean a patient with a known history of CHF is admitted with an exacerbation of a different heart failure, like diastolic heart failure, she adds.

Terminology tip: Dorland's Medical Dictionary defines "exacerbation" as an increase in the severity of disease or any of its symptoms. The terms "exacerbated," and "decompensated" indicate that there has been a flare-up (acute phase) of a chronic condition.

Coding example: Your patient has a known history of CHF and was admitted with an exacerbation of diastolic congestive heart failure. How would you code for her?

Answer: Assign code 428.33 (Diastolic heart failure, acute on chronic) and code 428.0, (Congestive heart failure, unspecified), Selman-Holman says.

Look to 428.1 (Left heart failure) for left ventricular failure due to acute pulmonary edema associated with acute myocardial infarction, acute or subacute ischemic heart disease, or coronary atherosclerosis.

Remember, codes 428.0 and 428.1 should never be used together, Usher says. Left heart failure is part of the inclusion note under 428.0 and you cannot have congestive heart failure without left heart failure.

Avoid: The 428 category includes 428.9 (Heart failure, unspecified). It's best not to use this unspecified code because it's too vague. The clinician should query the physician to get more information about the type of heart failure your patient has so you can list a more specific code.

Coding scenario: Your patient was admitted for exacerbation of CHF with pulmonary edema. Documentation notes that her ankles were 2+ pitting edema. How should you code for her?

Report her CHF with 428.0 -- that's the only code you need to list, Usher says. The other symptoms are inherent in her diagnosis. Remember, 428.0 is a case mix diagnosis.

Editor's note: This new column will feature coding tips for the most commonly reported home health diagnoses as determined by Seattle-based home care consultants OCS Homecare.