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
