MDS Alert

Hint: Clinical knowledge will help you choose the right ICD-10 code.

Knowing how to navigate ICD-10 to code heart failure may prove especially important with the implementation of the Patient-Driven Payment Model (PDPM).

Cardiovascular disease is the largest diagnostic category for the estimated two million residents in skilled nursing facilities in the United States, say Corrine Y. Jurgens, PhD, RN, FAHA, and other authors, in a 2015 study for the Heart Failure Society of America. Heart failure, in particular, is a common occurrence in people older than 65, Jurgens says.

Look to these questions and answers for guidance on the nitty-gritty details of coding this common diagnosis.

Understand What Constitutes Heart Failure

Question: I’ve always thought when a resident has heart failure, his heart stops beating. Is that true?

Answer: No. That is actually not true. When a resident has heart failure, his heart will still beat. However, the heart of a person who has heart failure does not pump blood adequately to meet his body’s need for blood and oxygen.

““Heart failure occurs when the heart can no longer pump blood as it used to,” says Carol Hodge, CPC, CDEO, CCC, CEMC, certified medical coder of St. Joseph’s Cardiology in Savannah, Georgia. “This can cause blood and fluids to back up in the body such as in the lungs, hands, and feet.”

Remember ‘Code First’ Note for Category I50-

Question: How does the “code first” note under category I50- (Heart failure) relate to the ICD-10 sequencing rules?

Answer: When it comes to understanding sequencing rules, you want to make sure you pay close attention to the “code first” notes that appear in red under code categories like I50-.

Per the ICD-10 Official Guidelines for Coding and Reporting, “’Code first’ notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a ‘code first note’ and an underlying condition is present, the underlying condition should be sequenced first, if known.”

When you look in the tabular list under category I50-, you discover that the code first note tells you to sequence the following underlying conditions first, followed by the appropriate code from I50- identifying the specific type of heart failure:

• I11.0 (Hypertensive heart disease with heart failure)
• I13.- (Hypertensive heart and chronic kidney disease)
• I97.13- (Postprocedural heart failure)
• I09.81 (Rheumatic heart failure).

Note: There are other forms of heart failure listed that probably won’t be applicable to a nursing facility, including heart failure conditions relating to pregnancy.

Example: A resident has hypertensive heart disease with acute systolic congestive heart failure. You would code I11.0 and I50.21 (Acute systolic (congestive) heart failure).

Understand Common Heart Failure Acronyms

Question: I keep seeing the abbreviations HFrEF and HFpEF in the documentation for heart failure. Can you explain what these terms mean?

Answer: Take a look at two common acronyms you may see in the documentation for heart failure:

• HFrEF: The acronym for heart failure with reduced ejection fraction, which is also known as systolic heart failure. When a resident has systolic heart failure, the left ventricle of her heart is not able to contract normally, so her heart can’t pump with enough force to push enough blood into circulation.
• HFpEF: The acronym for heart failure with preserved ejection fraction, also called diastolic failure. When a resident suffers from diastolic heart failure, the muscle of her left ventricle has become stiff and won’t relax normally. This results in the heart not adequately filling with blood during the resting period between each heartbeat.

Systolic heart failure explained: If you look under category I50.2- (Systolic (congestive) heart failure), you will see two included conditions: heart failure with reduced ejection fraction (HFrEF) and systolic left ventricular heart failure. This is where your HFrEF acronym comes into play.

When you are reporting systolic congestive heart failure, look to the following code choices:

• I50.20 (Unspecified systolic (congestive) heart failure)
• I50.21 (Acute systolic (congestive) heart failure)
• I50.22 (Chronic systolic (congestive) heart failure)
• I50.23 (Acute on chronic systolic (congestive) heart failure).

Diastolic heart failure explained: If you look under category I50.3- (Diastolic (congestive) heart failure), you will see three included conditions: diastolic left ventricular heart failure, heart failure with normal ejection fraction, and heart failure with preserved ejection fraction (HFpEF). Notice that this category includes the HFpEF acronym.

When you are reporting diastolic congestive heart failure, look to the following code choices:

• I50.30 (Unspecified diastolic (congestive) heart failure)
• I50.31 (Acute diastolic (congestive) heart failure)
• I50.32 (Chronic diastolic (congestive) heart failure)
• I50.33 (Acute on chronic diastolic (congestive) heart failure).

Resource: To read more of the aforementioned study about managing heart failure in skilled nursing facilities, visit  www.hfsa.org/wp-content/uploads/2014/10/Heart-failure-management-in-skilled-nursing-facilities.pdf.