MDS Alert

Heart failure is not uncommon in residents of long-term care facilities, and under the Person-Driven Payment Model most presentations of the disease are covered under the Cardiovascular and Coagulations category.

Remember, the diagnosis of “heart failure” is not, in and of itself, specific enough to code on the MDS. Read on for tips to choose the most accurate code to describe the resident’s diagnosis.

Tip 1: Define Heart Failure

It’s a common myth that when a person has heart failure, their heart stops beating, but that is not actually the case.

Instead, when a person has heart failure, their heart will still continue to beat. However, the heart will not pump blood adequately to meet the body’s need for blood and oxygen. This can cause blood and fluids to back up in the person’s body in their lungs, hands, and/or feet.

Tip 2: Understand These Heart Failure Scales

“Oftentimes the provider will list a classification from one of two scales to indicate the severity or stage of heart failure,” says Robin Peterson, CPC, CPMA, manager of professional coding at Pinnacle Integrated Coding Solutions LLC. “These scales are from either the New York Heart Association (NYHA) or the American College of Cardiology (ACC)/American Heart Association (AHA).”

NYHA scale: The NYHA has a symptom-based scale and the person will be put into one of the four categories based on their symptoms, according to Peterson.

Class 1 – The person doesn’t experience any symptoms at any time.

Class 2 – The person can perform daily activities with ease but feels fatigued or winded when they exert themselves.

Class 3 – The person has difficulties completing daily activities.

Class 4 – The person feels short of breath, even at rest.

ACC/AHA scale: The ACC/AHA scale is a stage-based system, per Peterson.

Stage A – The person has one or more risk factors for heart failure, but they aren’t experiencing any symptoms.

Stage B – The person has heart disease but doesn’t have any signs or symptoms of heart failure.

Stage C – The person has heart disease and is experiencing signs or symptoms of heart failure.

Stage D – The person has advanced heart failure that requires specialized treatments.

“As always, query your provider if the documentation is unclear or if you are uncertain about whether the person is having an acute episode of heart failure,” Peterson adds.

Tip 3: Recognize These Heart Failure Acronyms

If you see the abbreviations HFrEF or HFpEF in the resident’s medical documentation, you should know these are abbreviations for heart failure.

For example, HFrEF is the acronym for heart failure with reduced ejection fraction, which is also known as systolic heart failure. When a person has systolic heart failure, the left ventricle of their heart is not able to contract normally, so their heart can’t pump with enough force to push enough blood into circulation.

On the other hand, HFpEF is the acronym for heart failure with preserved ejection fraction, also called diastolic failure. When a person suffers from diastolic heart failure, the muscle of the 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.

Tip 4: Use These Codes for Systolic Heart Failure

If you look under category I50.2- (Systolic (congestive) heart failure), you will notice this code also includes heart failure with reduced ejection fraction (HFrEF) and systolic left ventricular heart failure.

You should report the following ICD-10-CM codes for systolic congestive heart failure:

• 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)

Tip 5: Know These Codes to Describe Diastolic Heart Failure

If your cardiologist documents diastolic congestive heart failure, you should turn to category I50.3- (Diastolic (congestive) heart failure). Here are your 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)

Don’t miss: Under category I50.3-, 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).

Tip 6: Don’t Miss ‘Code First’ Guidance

When it comes to reporting the I50- ICD-10-CM codes, you always want to make sure to read the “code first” notes.

Per the ICD-10-CM 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.” So, when you look in the tabular list under category I50-, you discover this “code first” note tells you to sequence the following underlying conditions first, followed by the appropriate code from I50- to identify 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)

Coding note: There are also several codes pertaining to pregnancy and other obstetrical situations, but because those conditions aren’t common in SNFs and other nursing facilities, they are not included here.

Coding example: A person is admitted to the facility with postprocedural heart failure following cardiac surgery. The cardiologist documents the person’s heart failure as acute systolic congestive. You should report I97.130 (Postprocedural heart failure following cardiac surgery) and I50.21 (Acute systolic (congestive) heart failure).