Combination coding of HTN heart disease with CHF and CKD

edited May 2016 in CDI Talk Archive
Please assist with some guidance re: the appropriateness of querying providers for the subsequent ICD-9 combination code of "HTN heart disease with CHF and CKD" 404-. We nurse CDS' as a group feel that such query is appropriate for inpatient admissions directed at the treatment of heart failure due to a diastolic or systolic dysfunction; however, we see it as problematic for patients who are treated for some other cardiac diagnosis. For example, it seems that the patient with a history of hypertension, CKD stage III, ischemic cardiomyopathy, and diabetes who is admitted with malignant hypertension for whom the plan of care includes IV antihypertensives, telemetry, and a 2-D echocardiogram. If we were to query in such case for "hypertensive heart disease," the subsequent DRG would assign to "Heart Failure & Shock," which doesn't seem to accurately describe the clinical picture, patient and/or plan of inpatient care. Consequently, core measures are also effected due to such code assignment leading one to question how even those measures could be accurately extracted during such a visit.

How are other facilities handling queries for this clarification/code when the patient does not have an acute exacerbation of CHF or impairment in systolic/diastolic dysfunction, in regards to HF readmissions and this code assignment?

Thank you,



Carol Canipe RN, BSN, CCDS
Clinical Performance Improvement
704-834-4980
Caromont Health
Gastonia, NC 28053

Comments

  • edited May 2016
    What a timely question. I don't know the answer but have an additional question.


    I just reviewed a record in which there is documentation from a physician office which reads
    "HCVD c CKD 404.12"
    The patient was admitted with acute on chronic right CHF with grade 3 diastolic dysfunction.

    Are we allowed to use the 404.91 code or does this require a query to hook the CHF to it?


    Charlene
  • edited May 2016
    I found one coding clinic that addresses the question. Nothing for
    heart failure per se, but if I read this correctly the linkage can be
    assumed. But reading the ICD-9-CM manual, you have to make sure that the
    chronic kidney disease with stage is coded along with the heart failure.

    I'll look forward to see what others say about this as well.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov

    "We are continually faced by great opportunities brilliantly disguised
    as insolvable problems." Benjamin Franklin
  • edited May 2016
    I believe you can connect the two as long as the relationship is stated or implied. My concern would be that the documentation came from a physician's office. Is it part of the in-house record? Did he state it elswhere in the hospital record or just in his office record?

    FROM 2007 Coding Guidelines
    Hypertension with Heart Disease

    Heart conditions (425.8, 429.0-429.3, 429.8, 429.9) are assigned to a code from category 402 when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category 428 to identify the type of heart failure in those patients with heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure.

    The same heart conditions (425.8, 429.0-429.3, 429.8, 429.9) with hypertension, but without a stated casual relationship, are coded separately. Sequence according to the circumstances of the admission/encounter.

    3) Hypertensive Chronic Kidney Disease

    Assign codes from category 403, Hypertensive chronic kidney disease, when conditions classified to categories 585-587 are present. Unlike hypertension with heart disease, ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease (CKD) with hypertension as hypertensive chronic kidney

    Sharon
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