Coding Issue-Preserved left ventricular systolic function

alee2020alee2020
edited August 2017 in Clinical & Coding
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.

Comments

  • rpinson@hcq1.comrpinson@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
  • alee2020alee2020
    Thank you for your clarification, Dr. Pinson.
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