Radiology Coding Alert
Remember Code First Guidelines for CHF and Heart Disease Diagnoses
Question: Following a computed tomography (CT) scan of a patient’s heart, the provider diagnosed the patient with hypertensive heart disease with acute systolic congestive heart failure (CHF). What codes should we report for the patient’s condition? Maine Subscriber Answer: You’ll report I11.0 (Hypertensive heart disease with heart failure) and I50.21 (Acute systolic (congestive) heart failure) for the scenario you presented. Start by searching in the ICD-10-CM code set Alphabetic Index for Hypertension > heart > with heart failure (congestive), which directs you to I11.0. When you turn to the Tabular List to verify the code, you’ll find instructions to use an additional code to identify the type of heart failure in the I50.- (Heart failure) code category. Return to the Alphabetic Index to search for Failure > heart > systolic > acute (congestive), which directs you to I50.21. You can then verify the code in the Tabular List. Under parent code I50.-, you’ll find “code first” notes in red text that help you correctly sequence multiple codes in scenarios such as the one you presented. According to the ICD-10-CM Official Guidelines, section I.B.7, “‘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.” The “code first” note under the I50.- code category instructs you to sequence the following underlying conditions first. Once the underlying condition codes are assigned, then you’ll assign an appropriate diagnosis code from I50.- that specifies the type of heart failure.
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