Heart Failure

Definition

(from Wikipedia)

Heart failure (HF) is a condition in which a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs.[1]

Common causes of heart failure include myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease and cardiomyopathy.[2] Heart failure can cause a large variety of symptoms such as shortness of breath (typically worse when lying flat, which is called orthopnea), coughing, ankle swelling and reduced exercise capacity. Heart failure is often undiagnosed due to a lack of a universally agreed definition and challenges in definitive diagnosis. Treatment commonly consist of lifestyle measures (such as decreased salt intake) and medications, and sometimes devices or even surgery.

Heart failure is a common, costly, disabling and deadly condition.[2] In developing countries, around 2% of adults suffer from heart failure, but in those over the age of 65, this increases to 6—10%.[2][3] Mostly due to costs of hospitalisation, it is associated with a high health expenditure; costs have been estimated to amount to 2% of the total budget of the National Health Service in the United Kingdom, and more than $35 billion in the United States.[4][5] Heart failure is associated with significantly reduced physical and mental health, resulting in a markedly decreased quality of life.[6][7] With the exception of heart failure caused by reversible conditions, the condition usually worsens over time. Although some patients survive many years, progressive disease is associated with an overall annual mortality rate of 10%.[8]

Description of disease process

1. Congestive heart failure is a condition in which the heart cannot pump enough blood in relation to the venous return and the metabolic requirements of body tissues.
2. Heart failure may be documented as due to ischemic heart disease, hypertension, cardiomyopathy, or valvular or pericardial disease.
3. Descriptive terms used by physicians may include low output heart failure, right sided vs left sided heart failure, compensated vs. decompensated heart failure, systolic vs. diastolic heart failure, or combined systolic and diastolic heart failure.
4. Congestive or “dilated” cardiomyopathy is a myocardial disease characterized by ventricular dilation, contractile dysfunction, and symptoms of congestive heart failure. In most cases treatment revolves around the management of the congestive heart failure (salt restriction, diuretics, and other drugs) and in those instances the heart failure, 428.0 or 428.1, is the principal diagnosis, with cardiomyopathy, 425.4, assigned as an additional diagnosis.
5. Acute on chronic refers to the patient having chronic heart failure and now has an acute flare-up on top of it.
6. The term congestive heart failure is often mistakenly used interchangeably with heart failure. Congestion, pulmonary or systemic fluid build-up, is one feature of heart failure, but it does not occur in all patients.
7. Common symptoms of heart failure are edema, fatigue, and dyspnea at rest or during exercise.
8. There are two main categories of heart failure: systolic and diastolic.
   1. Systolic heart failure occurs when the ability of the heart to contract decreases. The heart is unable to pump out adequate amounts of blood during contraction (systole). Blood coming from the lungs into the heart may back up and cause fluid leakage into the lungs causing pulmonary congestion. Treatment consists of ACE inhibitors, digoxin, diuretics and beta blockers.
   2. Diastolic heart failure occurs when the heart has a problem relaxing between contractions (diastole) to allow enough blood to enter the ventricles. The heart cannot fill with sufficient blood because the heart muscle is stiff and unable to relax. This may lead to fluid accumulation, especially in the legs, ankles and feet. Some patients may also have lung congestion. The treatment depends on the underlying cause. Beta blockers and calcium channel blockers are often used when diastolic dysfunction is due to ischemia or hypertension.
9. Congestive heart failure is not an inherent component of systolic or diastolic heart failure.

Findings and treatment

1. Heart failure triggers mechanisms to compensate in an attempt to preserve cardiac output. The patients may present with signs and symptoms of confusion, orthopnea, rales,

   productive cough and jugular vein distention.

2. Peripheral edema occurs in connection with right heart failure, and dyspnea in connection with left heart failure. 
3. The chest x-ray may demonstrate cardiomegaly, diffuse congestion and increased alveolar infiltrates. 
4. Congestive heart failure is a common manifestation of acute myocardial infarction, and may be a manifestation of hyperthyroidism, anemia, arteriovenous fistulas, beri-beri, or Paget's disease.
5. Respiratory failure may present as a manifestation of congestive heart failure. 
6. Treatment depends on the hemodynamic state of the patient. If the patient is not in shock, Digoxin may be used. When in shock, the patient may undergo placement of pulmonary arterial line and be placed in the ICU. The patient may be treated with diuretics and nitroglycerin (pre-load reduction), and sodium nitroprusside and dopamine (after load reduction.)
7. If the patient suffers associated respiratory insufficiency, treatment may include ventilator support and fluid and salt restriction. CHF may be precipitated by an acute anginal attack or by arrhythmia or abnormal heart rates (fast or slow.)

Documentation considerations

1. Discharge summary - What diagnosis does the physician give as his principal diagnosis? Does the report document diagnostic workup supporting the diagnosis of congestive heart failure?
2. History and physical examination - Was congestive heart failure documented as a confirmed or possible diagnosis in the impression of the H&P? Did the treatment plan support a diagnosis of congestive heart failure?
3. Consultations - Was a cardiology consultant referred to evaluate this patient? Was the consultant's diagnosis congestive heart failure? Did the documentation and treatment ordered following the consultation support a diagnosis of congestive heart failure?
4. Progress notes - In the first two to three days of the hospital stay, is congestive heart failure documented as the reason for admission? Do the progress notes state that the congestive heart failure has improved?
5. Other departmental documentation may be used by the coder to better clarify the treatment rendered. However, do not code solely from these types of documents. 

• Laboratory - possible increase in plasma volume (>5% of body weight.) 
• Nurses notes - frequent monitoring of vital signs and intake and output, low-sodium diet, oxygen therapy, daily weights, fluid restriction. 
• Procedures - echocardiography, cardiac blood pool imaging, pulmonary artery monitoring. 
• Radiology - chest x-ray that may demonstrate pleural effusion, Kerley B lines, cardiac hypertrophy or pulmonary venous congestion.

IDENTIFY THE SPECIFIC TYPE OF HEART FAILURE:

1. .. Left sided heart failure occurs when the left ventricle is failing to contract or pump

   efficiently and fluid backs up into the lungs. The etiology is usually a disease or

   damaged heart muscle (coronary artery disease or cardiomyopathy) or by aortic valve

   disease (which causes obstruction to outflow.) 

2. Right sided heart failure can be caused by high resistance in the lungs which blocks

   outflow. A common cause of high resistance in the lungs is left heart failure. An early

   sign of right heart failure is pedal edema due to fluid that backs up into the venous

   system. Right heart failure is the inability of the heart to pump blood from the right

   ventricle into the lungs. 

3. Systolic heart failure involves abnormal contractility of the heart - the heart is unable to

   pump out adequate amounts of blood during contraction. Blood coming from the lungs

   into the heart may back up and cause fluid leakage into the lungs causing pulmonary

   congestion.

4. .. Diastolic heart failure occurs from prolonged myocardial relaxation. The heart cannot fill

   with sufficient blood because the heart muscle is stiff and unable to relax. Fluid

   accumulation in the legs, ankles and feet is common and some patients may also have

   lung congestion.

5. .. Congestive heart failure is right heart failure secondary to left heart failure. Presenting

   symptoms include shortness of breath, paroxysmal noctural dyspnea, orthopnea, frothy

   copious sputum, rales, pedal edema and neck vein distension. A normal heart may fail

   due to prolonged demand such as in severe anemia or fluid overload.

6. .. Pulmonary edema can be of cardiac or non-cardiac origin. When pulmonary edema is of

   cardiac origin, it is a manifestation of congestive heart failure and is not coded separately.

   The physician would usually reference cardiac enlargement, presence of S-3 gallop,

   elevated pulmonary artery wedge pressure or associated cardiac diseases when acute

   pulmonary edema is of cardiac origin.

7. Patients with congestive heart failure often present with symptoms similar to those of

   pneumonia. The coder may see the diagnosis of congestive heart failure vs pneumonia as

   the admitting impression. It is important to remember that the documentation later in the

   hospital stay may eliminate one of the "vs" diagnoses, or confirm that both congestive

   heart failure and pneumonia are present on admission. The coder should then look for

   documentation to confirm the reason for admission. If the physician does not confirm the

   principal diagnosis in documentation, the coder must query the physician to clarify the

   presence or absence of congestive heart failure and if it was, indeed, the reason for admit.

    

Coding guidelines

(from ICD-9-CM official guidelines for coding and Reporting)

Currently there are no NCHS official guidelines for heart failure.

Other Coding Clinic/CPT Assistant References

List month/quarter, year and page # - may include summary in own words of guidance provided but do not cut and paste from these publications.