Coding Right Heart Failure

angela.clayberg@mwhc.comangela.clayberg@mwhc.com
in CDI Talk Archive
Hello,

I could use some help Right Heart Failure.

Afib/RVR, with PMH: HTN, COPD. Echo EF 30-35% w/significant right heart failure (previous Echo EF 50% w/right heart failure. Documentation is Afib/RVR, Lower extremeity swelling 2/2 acute right heart failure...etc

What is your PDX, and what code do you used for the right heart failure?

I have read multiple resources on ACDIS website and on the web regarding Right Heart Failure - do you go to Cor pulmonale if there is no documentation of Pulmonary Artery HTN? Thanks in advance for the help!

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    I would query to clarify the 'right-heart failure' as Cor Pulmonale (R failure d/t underlying pulm process) vs Right failure 2/2 L heart failure (CHF- if they say this we need systolic vs distolic). The physician needs to say Cor Pulmonale if this is what it is.

    As for Pdx. What was the focus of care?

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Monday, August 31, 2015 1:18 PM
    To: Kathryn Good
    Subject: [cdi_talk] Coding Right Heart Failure

    Hello,

    I could use some help Right Heart Failure.

    Afib/RVR, with PMH: HTN, COPD. Echo EF 30-35% w/significant right heart failure (previous Echo EF 50% w/right heart failure. Documentation is Afib/RVR, Lower extremeity swelling 2/2 acute right heart failure...etc

    What is your PDX, and what code do you used for the right heart failure?

    I have read multiple resources on ACDIS website and on the web regarding Right Heart Failure - do you go to Cor pulmonale if there is no documentation of Pulmonary Artery HTN? Thanks in advance for the help!
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  • catladyrncatladyrn
    Right heart failure will default to left heart failure as generally it results from persistent left heart failure. Cor pulmonale is really only appropriate when right heart failure results from an acute or chronic pulmonary process, such as a COPD exacerbation or chronic pulmonary hypertension, causing strain on the right side of the heart from pumping against the pulmonary resistance.

    If there is no documentation of a pulmonary process that could account for the right heart failure, I would not pursue a diagnosis of cor pulmonale. I would, however, obtain further documentation of the left sided heart failure in accordance with heart failure documentation standards.

    Renee

    Linda Renee Brown, RN, MA, CCDS, CCS, CDIP
    Director, Clinical Documentation
    Tanner Health System
  • angela.clayberg@mwhc.comangela.clayberg@mwhc.com
    edited April 2016

    There was a Q&A by Dr. Gold on April 17, 2008 on the ACDIS website that
    states:

    "You can only report right sided heart failure using two codes - the
    chronic cor pulmonale code (416.9 and the acute or pulmonale code (415.0).
    If a physician documents these diagnoses as "CHF," all you have is code
    428.0. Never assign acute left heart failure codes in this instance."

    Our HF Program Manger interprets this to mean any right heart failure
    codes to 415.0 or 416.9. My understanding was that you had to say acute
    right HF 2/2 pulmonary HTN or say acute cor pulmonale to get to those
    codes otherwise it codes to 428.0. I understand that you don't specify
    the right heart failure for systolic/diastolic. I am trying to understand
    the instances that right heart failure can be moved out of the 428.0 code
    - is it just with underlying pulmonary disease? What about previous right
    side MI with no pulmonary history? I am sorry if this is confusing or too
    much but I need to make sure I understand. Thanks again for all your
    input!


    Respectfully,



    Angela Clayberg, BA, RN
    Clinical Documentation Improvement Manager
    1201B Sam Perry Blvd., Suite 210
    Fredericksburg, Virginia 22401
    angela.clayberg@MWHC.com
    540-741-4093




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