Documentation and Coding for Congestive Heart Failure

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

Documentation & Coding Tips  

Type of Heart Failure:  

• Systolic, Diastolic, or Combination Systolic and Diastolic 
  
• Left or right sided 
  
• End-stage 
  

Acuity/Status of the Condition:

• Acute (decompensated) 
  
• Chronic (compensated) 
  
• Acute on chronic 
  
• Historical condition only 
  

Causative Factors:

• Alcohol,
  
• Hypertension,
• Ischemia,
• Rheumatic, etc. 

Heart Failure Stages (1-4) Physical Activity:

• Stage 1: No signs & symptoms, treatment is lifestyle management. 
  
• Stage 2: Symptoms include SOB, fatigue, palpitations – monitoring required 
  
• Stage 3: Physical activity less than ordinary, may cause fatigue dyspnea, palpitations, or angina  
  
• Stage 4: Symptoms always present with rest and any physical activity 
  

Other:

• Documentation of systolic or diastolic dysfunction requires provider linkage to heart failure in order to code the appropriate heart failure code  
  
• Provide documentation for monitoring, evaluation, assessment, and treatment plan
  

Resources: 

• Merck Manual for Heart Failure