Documentation and Coding of Right and Left Heart Failure

by Dr. Richard Pinson, MD, FACP, CCS

Q: A patient was admitted for acute paroxysmal atrial fibrillation as principal diagnosis and what was initially thought to be acute on chronic combined systolic and diastolic heart failure, later determined to be right-sided heart failure and left ventricular (LV) dysfunction with advanced interstitial lung disease (ILD) and severe pulmonary hypertension.

Echocardiogram demonstrated a normal sized right ventricle with right ventricular systolic pressure of 62 mmHg and moderately dilated LV with mildly to moderately reduced systolic function (ejection fraction of 40%).

Would this be coded as right heart failure due to left heart failure (I50.814) along with systolic left ventricular failure, unspecified acuity (I50.20) or just acute on chronic right heart failure without mention of left heart failure (I50.813)?

A: Atrial fibrillation is the principal diagnosis. As for secondary diagnoses, the documentation doesn’t seem to make a connection between right heart failure and left ventricular dysfunction. Unfortunately, right heart failure (acute, chronic or acute on chronic) is assigned a code from I50.81- all of which are non-CCs

In addition, left ventricular “dysfunction” does not necessarily mean heart “failure”; with an ejection fraction of 40%, it clearly indicates reduced “systolic” function. This documentation only supports systolic LV “dysfunction” (code I51.9, unspecified heart disease) which is a non-CC.

Whether LV “dysfunction” represents LV (heart) failure needs to be clarified and then acuity specified. If documented as heart failure, the code assigned would depend on acuity: I50.21 (MCC) if acute; I50.22 (CC) if chronic.

Because ILD is documented assigned code J84.9 (CC), chronic LV heart failure would not change the DRG, but acute would by adding an MCC.

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About the Author

Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.

About the Author

Libman Education
Libman Education Inc. is a leading provider of training for the health care workforce offering self-paced and instructor-led online courses designed and developed by leading industry experts in Health Information Management (HIM) and Medical Record Coding. Our courses are specifically designed to improve individual skills and increase the efficiencies and competencies of health care providers and institutions. At Libman Education, we understand the needs and challenges of a well-trained workforce and offer the right-mix of online education to ensure that the health care professionals are prepared to meet the challenges of the changing workplace.

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