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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

ICD-10 

Description 

Example of when to use codes in this category  

I50.1  

Left Ventricular Failure 

 

I50.2X 

Systolic (congestive) heart failure 

Heart Failure w/Reduced Ejection Fraction, (HFrEF

I50.3X 

Diastolic (congestive) heart failure 

Heart Failure w/Normal Ejection Fraction (HFpEF

I50.4X 

Combined systolic (congestive) & diastolic (congestive) heart failure

 

I50.81X 

Other heart failure 

Right Heart Failure (acute, chronic, acute on chronic) 

I50.82 

Biventricular heart failure 

 

I50.83 

High output heart failure 

 

I50.84 

End Stage heart failure 

 

I50.9 

Heart failure, unspecified 

Congestive heart failure, unspecified (CHF

I13.X 

Hypertensive Heart & Chronic Kidney Disease 

 

I27.20 

Pulmonary Hypertension, unspecified 

 

I27.49 

Secondary pulmonary hypertension 

 

I27.81 

Cor Pulmonale (chronic)