esrd/chf/fluid overload

kimch73@yahoo.com

We are having a discussion with coding on how to code when patient's are admitted in fluid overload due to noncompliance with dialysis.  Physicians have documented CHF exacerbation due to noncompliance with dialysis and fluid overload due to noncompliance.  Coding is wanting to go with fluid overload, we are thinking the CHF exacerbation should be the principal diagnosis in this case since the patient was noted to be in exacerbation of heart failure.  

Any help would be appreciated.   We have found coding clinics but they all reference patient with no history of CHF or not in exacerbation.  

Thanks

vparent@emhs.org

In the past, we have gone with HTN heart and chronic kidney disease as the principle and the acute heart failure as a secondary as well as the ESRD and noncompliance.

evanspx@sutterhealth.org

I am on a pad and can’t reference the exact Coding Clinic, but if a patient with ESRD, HTN and CHF is admitted for a clearly documented exacerbation of the CHF, the CHF is the PDX and there is no sequencing choice.  
I13.0
Type of CHF, acute
N18.6

Paul Evans, RHIA, CCDS

vparent@emhs.org

https://www.aafp.org/fpm/2014/0300/p5.html

Hypertension, hypertensive heart disease, and chronic kidney disease: I13

To confuse matters further, if the patient has all three conditions (hypertension, heart disease, and chronic kidney disease), then you need to document the relationship between the hypertension and heart disease but assume the causal relationship between hypertension and chronic kidney disease. The documentation requirements are the same as what was outlined above.

The codes for the three-disease combination are numerically arranged by the degree of chronic kidney disease rather than the presence or absence of heart failure:

• I13.0, Hypertensive heart and chronic kidney disease with heart failure and with stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease,

• I13.10, Hypertensive heart and chronic kidney disease without heart failure with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease,

• I13.11, Hypertensive heart and chronic kidney disease without heart failure with stage 5 chronic kidney disease, or end-stage renal disease,

• I13.2, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end-stage renal disease.

As with the two-combination codes, all of the three-combination codes require additional coding from the N18 series to identify the stage of kidney disease. The three-combination codes that include heart failure also require additional coding from the I50 series to specify the type and acuity of the failure.

Example: The 55-year-old female in the above example presents to your office with some pedal edema, and on examination you also detect some mild crackles in the base of her lungs. You order an echocardiogram that documents mild systolic heart failure. Her eGFR has remained stable. You update her diagnostic codes to I13.0 (Hypertensive heart and chronic kidney disease with heart failure and with stage 1 through 4 chronic kidney disease, or unspecified chronic kidney disease), I50.21 (Systolic, congestive, heart failure, acute), and N18.3 (Chronic kidney disease, stage 3, moderate).

evanspx@sutterhealth.org

See also
Coding Clinic, 2001, pg 13, Second quarter
1996, pg6, 3rd quarter
These are dated, but still applicable.  

vparent@emhs.org

https://www.hcpro.com/HIM-275495-5707/QA-Proper-sequencing-of-heart-failure-with-hypertensive-heartkidney-disease.html

another reference

kimch73@yahoo.com

evanspx@sutterhealth.org said:

See also
Coding Clinic, 2001, pg 13, Second quarter
1996, pg6, 3rd quarter
These are dated, but still applicable.  

Thanks for your help,  did not see this coding clinic when I looked.  

kimch73@yahoo.com

vparent@emhs.org said:

https://www.hcpro.com/HIM-275495-5707/QA-Proper-sequencing-of-heart-failure-with-hypertensive-heartkidney-disease.html

another reference

Thank you for the information. 

bawolfy@yahoo.com

It seems this patient had 2 potential principal diagnoses based on the documentation. Volume overload due to HD noncompliance and acute HF.  If you apply the question of what condition required the most intense treatment . . . if the primary treatment was HD, I would select volume overload. I would code Acute CHF as a secondary if it was validated with clinical findings. Now if the patient was put on IV inotropes or had an MI in addition to HD, I would query the physician to determine which he/she considered the primary cause of the presenting symptoms mandating admission. 

This is a very important issue from a CMS quality reporting perspective. The principal diagnosis of HTNsive heart and CKD will qualify this patient to be judged in the CMS HF mortality and the HF readmission value-based purchasing programs. The goal of this program is to motivate Hospitals to improve HF care. 

I am going over cases just like this at ACDIS 2020 and talking about the stakeholders of coding, CDI, revenue and quality. Please come and offer your thoughts. The goal is to represent patients as accurately as possible, but sometimes the coding rules and guidelines tie our hands. 

Beth Wolf, MD, CPC, CCDS

evanspx@sutterhealth.org

Very brief response as am traveling and responding on a pad.  Salient points are that ‘volume overload’ and ‘pulmonary edema’ are integral to the stated ACUTE CHF, as such may not be used instead of the Acute HF as the PDX.

Paul Evans, RHIA, CCDS

However, different matter if we are dealing with acute NON-Cardiogenic HF.   Multitude of Coding Clinics on this complex issue -lacking my library as I respond, but a search for fluid overload and CHF should reference key references.

bawolfy@yahoo.com

I went back and read through the clinics.  Thank you Paul.  I reserve the right to change my answer.  :-)  
My clinical brain translated "due to missed HD" as non-cardiogenic.  When in fact, the provider does have to document that specifically in order to make the condition eligible as a principal diagnosis.  As documented, the index/guidelines/clinics force us to choose heart failure as principal. 
Please read closely and critique . . . 
If the documentation had stated the following:  "Acute HF and acute non-cardiogenic pulmonary edema (or fluid overload) due to dialysis non compliance", the option to sequence either first would exist.  
The Federal Registry indeicated that if 2 conditions equally meet the definition of principal, the coder can pick; and it is ok to pick the one that pays to the most.  The question we are now facing is whether up-front payment is more than  retrospective penalties.  
Beth Wolf, MD, CPC, CCDS