Hypertensive CHF and CKD with HF exacerbation
We recently had a case (a type frequently seen) with a patient who had hypertensive CHF and CKD who presented with a heart failure exacerbation. We have always coded the HF exacerbation (acute on chronic ____ CHF) as principal diagnosis, reasoning that the acute condition was responsible for the admission to hospital. My coding colleague tells me that the hypertensive CHF and CKD code has to be sequenced as PDx due to an instructional note under the I13 category; to wit, "Use additional code to identify type of heart failure."
Could you weigh in on this? I see her point about the instructional note, but I think it violates the PDx rule as you are sequencing an chronic condition before an acute one. Does anyone else have an interpretation of this note?
Help!!
Cathy Seluke
Could you weigh in on this? I see her point about the instructional note, but I think it violates the PDx rule as you are sequencing an chronic condition before an acute one. Does anyone else have an interpretation of this note?
Help!!
Cathy Seluke
Comments
Hi Cathy,
Good ole Coding conventions is what takes precedence on this one. The coder is correct to use the Hypertensive Heart and kidney disease I13.0 as principal dx and the acute on chronic CHF as a secondary diagnosis. To help explain further, if you have access to an older version of the CDI Pocket guide and look under DRG Tips section DRG 291, 292, and 293, it explains that it used to be a potential query opportunity if the patient had clinical indicators of hypertensive heart disease or if the CHF was due to the HTN, then it could have moved the DRG at that time from DRG 293 or DRG 292 to DRG 291. Now, with the updated Coding Guidelines for 2017 (in effect as of Oct 1 2016) it tells us that we are to assume because of the coding convention in the alphabetic index the word 'with' is an assumed link so now HTN with CHF is a combined code unless the CHF is stated as not related to HTN or if the CHF is due to another disease or disorder. If you have access to the 2017 CDI Pocket guide and you look on page 223, it will tell you the I13.0 is principal diagnosis for patients admitted for acute heart failure but also have hypertension and CKD.
I hope this helps. Have a great day!
Tammy Trombley
Also a significant CDI (defensive) strategy was to be aware of the clinical use of 'cardiorenal syndrom' when used to describe the development of AKI due to acute CHF -- unfortunately it also codes to htn heart & renal dz but the use in this clinical scenario is not to describe any sort of chronic renal dz. We'd query to clarify. There are several 'types' of cardiorenal syndrom, and one is htn heart & renal dz. As I recall, there was a nice Journal article on the subject, as well as other threads. This is something to continue to keep an eye out for.
One more comment -- even with the coding guideline changes, there will still occasionally be the opportunity to excercise this strategy when CKD clinically indicated but not documented.
Don