At the conclusion of this module, the learner will be able to:1. Differentiate between systolic and diastolic

heart failure2. Describe three clinical indicators of acute heart

failure3. Define acute cor pulmonale

Heart, due to impairment of structure or function, does not pump effectively

Because oxygenated blood is not effectively pumped forward into the circulation, tissues do not receive nutrients and oxygen

Fluid backs up within the circulatory system leading to peripheral and pulmonary edema (“congestive heart failure”),

Most common cause is coronary artery disease

Documenting “CHF” is insufficient! CMS guidelines require acuity and specificity. Incomplete documentation of heart failure has

a significant impact on severity of illness, risk of mortality, GLOS, and case mix index.

Incomplete documentation affects treatment modalities, core measures, and communication.

Incomplete documentation affects patient care.

Documenting NYHA classifications is not adequate documentation of heart failure for CMS

Is it systolic, diastolic, or combined?

EF = % of blood volume pumped out with each stroke

Usually refers to left ventricle, but right ventricle EF may also be measured

Commonly diagnosed by ECHOcardiogram, but may also be measured during stress test or cardiac catheterization

Ejection fraction is a key clue as to type of heart failure

Ejection fraction < ~ 50% Result of impaired inotropic state – heart

can’t empty Causes include dilated cardiomyopathy,

myocardial infarction Treated with ACE-inhibitors or ARBs – core

measures; Digoxin, judicious use of β-blocker

Core measure HF-3: pts w/LV systolic dysfunction (EF < 40%) prescribed ARB or ACE-i

Ejection fraction > ~ 50 % 1/3 of patients with symptomatic heart failure

have “normal” EF Risk increases with age Result of impairment in heart’s ability to relax –

heart can’t fill May see elevated filling pressures “stiff ventricle” Causes include restrictive and hypertrophic

cardiomyopathy, ischemia, HTN, senile cardiac amyloid, constrictive pericarditis, myocardial ischemia

Treatment differs from systolic HF – β-blockade

It is possible to have elements of both systolic and diastolic heart failure

Physician should not write, “both,” or “combined,” because the coders can’t code from that

Physician needs to specify, “systolic and diastolic”

Is it acute, chronic, or acute on chronic?

Usually – but not always – systolic Develops suddenly without prior history May have sudden reduction in cardiac

output May be hypotensive May not show peripheral edema Can be documented as “acute” or

“decompensated” heart failure

Develops slowly May be seen in patients with dilated

cardiomyopathy, valvular heart disease Often has normal blood pressure but with

peripheral edema Patients coming from home with heart

failure medications – if you continue those meds, are you treating a chronic condition?

Patient has pre-existing chronic condition that worsens

Can be documented either as “acute on chronic” or “exacerbation”

Check the BNP – is it elevated? Check the ECHO results – what is the EF? How

does the cardiologist describe LV function? What are the pt’s clinical signs/symptoms?

◦ Dyspnea, hypoxia◦ Rales/rhonchi◦ Peripheral edema◦ JVD◦ S3 gallop

How is the heart failure being treated?◦ IV diuresis usually means an acute condition!◦ No change in home HF meds usually means chronic

SI/IS for heart failure

Need documentation of diagnosis, physical assessment to support diagnosis, documented evidence of cardiopulmonary instability, treatment per core measures (unless contraindicated), evaluation of LV systolic function, assessment of oxygenation and treatment with supplemental oxygen, use of cardiac monitoring

Heart failure can be monitored and treated in an observation status – not an automatic IP

Severity of illness & geometric length of stay

“CHF” does nothing to increase relative weight and CMI

Acute heart failure, documented as systolic, diastolic, or systolic & diastolic, is a major co-morbidity that increases relative weight and CMI

Two patients with the same presentation and same treatment, documented differently, can have dramatically different relative weights, CMI, and geometric lengths of stay

Patient admitted with atrial fibrillation, develops signs of acute heart failure, EF is 60%◦ Physician documents AF, CHF

DRG 310, GLOS 2.0 days, RW 0.5608◦ Physician documents AF, acute diastolic heart

failure DRG 308, GLOS 4.0 days, RW 1.2283

Patient admitted with intracranial hemorrhage, has been taking Lisinopril for previously diagnosed heart failure, meds are continued and patient placed on telemetry. ECHO done in June showed EF of 30%◦ Physician documents ICH, hx systolic dysfunction

DRG 66, GLOS 2.6 days, SOI 1, RW 0.8105◦ Physician documents ICH, chronic systolic heart

failure DRG 65, GLOS 3.8 days, SOI 2, RW 1.8555

Patient admitted with CAD, hx systolic HF, undergoes CABG; postoperatively cannot handle fluid resuscitation, requires extensive diuresis and increased oxygen requirement, spends extra 2 days in the hospital◦ Physician documents CAD, fluid overload

DRG 236, GLOS 6.0 days, RW 3.7720◦ Physician documents CAD, systolic HF

exacerbation DRG 235, GLOS 9.3 days, RW 5.9063

Getting acuity and specificity into the medical record

Dr. Jones:“CHF” is documented in the medical

record. The record indicates moderate dyspnea, bilateral rales and rhonchi. BNP is 9400. ECHO shows ejection fraction of 35%. Orders for oxygen, PO Lisinopril and IV Bumex. CMS requires acuity and specificity in documentation of heart failure. To establish the most accurate severity of illness of your patient, please specify the type (systolic, diastolic, or systolic & diastolic), and acuity (acute, chronic, or acute on chronic) of heart failure you are treating. For continuity of the record, please document in the progress notes and continue through to the discharge summary.

Type of right-sided heart failure Acute cor pulmonale = acute lung disease

(e.g., PE, ARDS, COPD exacerbation) causing acute right sided heart failure

Chronic cor pulmonale = right sided heart failure resulting from pulmonary hypertension, chronic lung disease, or pulmonary valve stenosis◦ Right ventricle dilates from chronic ischemia and

hypertension of the arteries in the lungs◦ Ventricle unable to pump against the

hypertension

Acute Chronic

Acute onset of dyspnea

JVD Hypotension Hypoxia Tachycardia Shock S3/S4 on inspiration

Fatigue Exertional dyspnea Ascites Hepatomegaly Dependent edema Cardiomegaly Syncope

CXR: RV and pulmonary artery enlargement EKG: RV hypertrophy (R axis deviation, QR

wave in V1, dominant R wave in V1 to V3)◦ Both CXR and EKG results may be skewed in COPD

patient due to realignment of the heart ECHO: evaluate LV and RV function, likely to

see RV thickening and increased PA pressures◦ Often limited by lung disease

Right heart catheterizationCor Pulmonale, Merck Manual for Healthcare Professionals

Be aware of combination codes in ICD-10.

Not coded as heart failure. There is no code in heart failure DRGs for right sided heart failure.

As PDx, cor pulmonale goes to DRG 316, other circulatory system diagnoses.

As SDx, acute cor pulmonale is a major co-morbidity.

ICD-9 ICD-10

415.0 acute cor pulmonale I26.01 septic pulmonary embolism with acute cor pulmonale

415.12 septic pulmonary embolism

Can occur due to many causes When found in patient with heart failure, is

considered integral to disease and is not coded EXCEPT◦ Physician can state that the pleural effusion is

clinically significant, apart from the heart failure, or is not due to the heart failure (look for evidence of different etiology for the pleural effusion)

◦ If treatment of pleural effusion is not the same as that for heart failure (e.g., performing a thoracentesis—not routine tx for HF!), then the pleural effusion can also be coded

1. Mrs. Gonzales is admitted with shortness of breath, rales in the bases; CXR indicates bilateral effusions, BNP is 12,400, EF is 28%; IV Lasix is ordered. The physician documents CHF with pleural effusion. Your most likely action is:

a. Code pleural effusion as PDx and query for acute systolic HF as SDx

b. Query for acute systolic HF as PDx and do not code the pleural effusion

c. Query for acute systolic HF as PDx and query for transudative pleural effusion as SDx

d. Code CHF as PDx and query whether the pleural effusion is related to the CHF

2. On day 2, Mrs. Gonzales’s pulmonologist decides to perform a thoracentesis of the pleural effusion. Your most likely action is to:

a. Code the pleural effusion as PDx because that is the focus of the care

b. Not code the pleural effusion because it is inherent in heart failure

c. Code the pleural effusion as SDx because the treatment is outside the scope of heart failure

d. Query for acute respiratory failure due to the thoracentesis.

3. A good way to remember the difference between systolic and diastolic heart failure is:

a. Systolic means the heart can’t fill; diastolic means the heart can’t pump

b. Systolic means the left ventricle is preserved; diastolic means the right ventricle is preserved

c. Systolic means the heart failure is acute; diastolic means the heart failure is chronic

d. Systolic means the heart can’t pump; diastolic means the heart can’t fill

4. Acute cor pulmonale:a. Is usually caused by an acute lung injury or

diseaseb. Is usually caused by acute systolic heart failurec. Is best diagnosed by a left heart catheterizationd. Is never found in patients with chronic lung

disease