Coding Issue-Preserved left ventricular systolic function

alee2020

Our physician documents preserved left ventricular systolic function. Patient has no history of CHF. How is this coded? or Should the physician be queried for more specification? I researched what is preserved left ventricular systolic function and it is defined as HF with a normal ejection fraction, but should not be coded as diastolic heart failure. So, should I use ICD 10 code: I51.89 Other ill-defined heart diseases. Any suggestions would be appreciated.

rpinson@hcq1.com

Both from a clinical standpoint and according to Coding Clinic First Quarter 2016 page 10, preserved left ventricular systolic function is another term used to describe ventricular diastolic dysfunction. Heart failure is  a clinical diagnosis based on signs and symptoms, and many patient's with hypertension or other hypertrophic cardiomyopathies have ventricular diastolic dysfunction but without heart failure.  The ICD-10 Index indicates that ventricular dysfunction without heart failure is assigned code to code I51.9 (unspecified heart disease), not code I51.89.

However, I51.9 is a non-CC and a non-HCC so coding it really serves not particular useful purpose.  It ought to have a  specific cause which should be coded.

Richard D. Pinson, MD
Pinson&Tang
CDI Educators and Advisers
Authors of the CDI Pocket Guide

alee2020

Thank you for your clarification, Dr. Pinson.