How do you code for heart failure due to valvular disease only? Referring to valve replacement/repair and the heart failure is resolved post procedure.
1) Until Oct 1, you would break the link between heart failure and hypertension since the physician named a different cause of heart failure. This means you would not be using an I11 code but an I50. After Oct 1 you get to have the fun of placing a query to have the doctor specifically state that the heart failure is unrelated to hypertension or you will be stuck with hypertensive heart disease 2) Report the Standard I50 heart failure code and it's corresponding specificity 3) Report non rheumatic (I assume it is non rheumatic) valve disease to the appropriate valve code (stenosis, prolapse etc.) I34 to I37 Be careful. SOME coders may see this documentation and simply assign it to I51.89 "Other ill-defined heart disease" which i would fully disagree with. 4)Assign End stage heart failure if it was appropriate (but it probably wasn't if they were able to fix it with a valve). 5) You COULD (most don't) also assign the codes for either left ventricular failure or one of the new right sided heart failure codes (they aren't excludes 1s).
The determination of the acuity (acute vs chronic) is up to the MD's professional opinion and the corresponding indicators of such.
Is this a question of what should be coded as a principal diagnosis, or whether the code for the heart failure should be captured at all, considering that admissions for percutaneous valve replacements are usually short, there is often no evidence of medical treatment, and the heart failure is resolved after surgery? We discussed both questions with our Structural Heart department and came up with the internal guidance that the diagnosis of heart failure should be captured according to the documented level of acuity, since the surgery is actually an ultimate treatment, and that the heart failure should be coded as a secondary diagnosis, with the valvular disease coded as the principal. There are different coding guidelines that can be applied here, we select the principal diagnosis that correlates more with the procedure performed. Even if the patient is admitted in acute heart failure, the underlying cause of it is the valvular disease. The selection of principal in this situation defines whether your coding calculated to the base DRG, or the DRG with an MCC. We monitor our denials very carefully, and so far have not had any issues with our interpretation of coding guidelines.
I absolutely agree the valve problem should be sequenced first when they are admitting the pt for the valve repair.
If however they admit the patient with acute heart failure and then later decide to do the valve replacement, in accordance with the UHDDS, the heart failure would be pdx as the plan to replace the valve was not known. My understanding is that this is actually rare as the valve surgery is some what elective and usually occurs in a patent who has already been "tuned up" prior to admission and so isn't being admitted for acute heart failure itself.
Comments
After Oct 1 you get to have the fun of placing a query to have the doctor specifically state that the heart failure is unrelated to hypertension or you will be stuck with hypertensive heart disease
2) Report the Standard I50 heart failure code and it's corresponding specificity
3) Report non rheumatic (I assume it is non rheumatic) valve disease to the appropriate valve code (stenosis, prolapse etc.) I34 to I37
Be careful. SOME coders may see this documentation and simply assign it to I51.89 "Other ill-defined heart disease" which i would fully disagree with.
4)Assign End stage heart failure if it was appropriate (but it probably wasn't if they were able to fix it with a valve).
5) You COULD (most don't) also assign the codes for either left ventricular failure or one of the new right sided heart failure codes (they aren't excludes 1s).
The determination of the acuity (acute vs chronic) is up to the MD's professional opinion and the corresponding indicators of such.
We discussed both questions with our Structural Heart department and came up with the internal guidance that the diagnosis of heart failure should be captured according to the documented level of acuity, since the surgery is actually an ultimate treatment, and that the heart failure should be coded as a secondary diagnosis, with the valvular disease coded as the principal. There are different coding guidelines that can be applied here, we select the principal diagnosis that correlates more with the procedure performed. Even if the patient is admitted in acute heart failure, the underlying cause of it is the valvular disease.
The selection of principal in this situation defines whether your coding calculated to the base DRG, or the DRG with an MCC. We monitor our denials very carefully, and so far have not had any issues with our interpretation of coding guidelines.
If however they admit the patient with acute heart failure and then later decide to do the valve replacement, in accordance with the UHDDS, the heart failure would be pdx as the plan to replace the valve was not known. My understanding is that this is actually rare as the valve surgery is some what elective and usually occurs in a patent who has already been "tuned up" prior to admission and so isn't being admitted for acute heart failure itself.