Coding "New-Onset" heart failure

stephetccs@yahoo.comstephetccs@yahoo.com
in Clinical & Coding
We have received a denial for code I50.21 [Acute systolic (congestive) heart failure].  The only physician documentation that I can find in this record states, "New onset mild systolic congestive heart failure; left bundle branch block, mild left ventricular global hypokinesis."  Also, I do not see the term "new onset" listed in the ICD-10-CM Alphabetic Index for heart failure nor in the Tabular List for this code.  Am I missing something that the coder didn't?  Or should a query have been sent for clarification?
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Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    The application of the coding rules can be Draconian.  Even with the term ‘new onset’,  the chart must explicitly document the acuity of the HF.   However, you did not state ‘why’ the case was denied?  Does the 3rd party question the coding or the clinical validity?  Is the term systolic or HFrEF charted as well as acuity?   Did the patient have at least some of the traditional clinical findings expected and treated to support the condition of an acute form of HF?
  • stephetccs@yahoo.comstephetccs@yahoo.com

    paul_evans_90314 said:
    The application of the coding rules can be Draconian.  Even with the term ‘new onset’,  the chart must explicitly document the acuity of the HF.   However, you did not state ‘why’ the case was denied?  Does the 3rd party question the coding or the clinical validity?  Is the term systolic or HFrEF charted as well as acuity?   Did the patient have at least some of the traditional clinical findings expected and treated to support the condition of an acute form of HF?
    The denial letter states, "I50.21 cannot be validated as relevant to this admission."  What is your interpretation of this--coding or clinical validation denial?  If this is a clinical validation denial, we will not appeal the denial as there are no clinical indicators or treatments to support acute CHF.  However, if this is a coding issue, it goes back to the question of "Does 'new-onset' mean 'acute?'"  The term "systolic" HF is documented, but we cannot find the term "acute" HF, only "new onset" HF.  So based on your response and since there was no clarification query, I don't think we would have a successful appeal.  Thank you for your input.
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Lacking the actual chart, one can only speculate precisely ‘why’ this was denied; ‘sounds’ like a form of ACUTE HF was not clinically present, as you stated you will not appeal because there are no clinical indicators or treatment to support ACUTE CHF. If this is your stance, it seems the denial is valid.
  • afrady@blr.comafrady@blr.com
    In it's common usage "Acute heart failure" has evolved to be less about it's onset "new vs old = acute vs chronic" and more about it's severity.  Acute = Severe and Chronic  = Controlled.  Yes, i am aware that those are not technically the correct usages in the english language, but that is how heart failure is commonly related to.   

    Usually however, new onset or the initial diagnosis IS most often made in a patient who is presenting in a decompensated and wet state, meaning that in many cases you don't have this conflict as it is both new on set and acutely severe at the initial diagnosis.   

    If they just discovered a chronic heart failure, then the fact that it is a "new diagnosis" doesn't mean it is "new onset", and you could just have chronic in that instance.  

    "New onset" when talking about heart failure is sort of a misonomer anyway.  You could get acute new onset heart failure after a catastrophic event such as an MI, trauma, or maybe taksubo syndrome but those patients would almost always have clinical indicators for severity as well and you wouldn't be in this connundrum.

    The notion that you can be sitting around at 2:00 with no heart failure, and then get new onset heart failure at 4:00 but without symptoms is something that simply doesn't happen in the real world....although this discussion may give me new onset heart failure and prove me wrong....    :wink:

    Ooopp...i just got new onset heart failure (30 seconds ago)..  I'm fine though...really.  (sounds ridiculous right??)
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