DRG 291, 293 Heart Failure

Heart failure is defined as the inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs such as the brain, liver, and kidneys. Heart failure may be due to failure of the right or left or both ventricles. The signs and symptoms depend upon which side of the heart is failing. They can include shortness of breath, pooling of blood in the general body (systemic) circulation or in the liver's (portal) circulation, swelling (edema), blueness or duskiness (cyanosis), and enlargement (hypertrophy) of the heart. 

There are many causes of congestive heart failure (CHF) including: 

1. Coronary artery disease leading to heart attacks and heart muscle weakness,
2. Primary heart muscle weakness from viral infections or toxins such as prolonged alcohol exposure,
3. Heart valve disease causing heart muscle weakness due to too much leaking of blood or heart muscle stiffness from a blocked valve, and 
4. Hypertension (high blood pressure). 

Rarer causes include hyperthyroidism (high thyroid hormone), vitamin deficiency, and excessive amphetamine use. 

General treatment of heart failure includes salt restriction, diuretics (to get rid of excess fluid), digoxin (to strengthen the heart), and other medications, such as spironolactone, which has been found to be successful in treating CHF. Its beneficial effects are additive to those from ACE inhibitors (angiotensin-converting-enzyme inhibitor), another class of drugs commonly relied on in treating heart failure. A pacemaker or implantable cardiac device (ICD) are also options to treat heart failure. The implantable device delivers synchronized electrical stimulation to three chambers of the heart, enabling the heart to pump blood more efficiently throughout the body.

When documenting on CHF, it is suggested that you:

• Describe clinical signs and symptoms (e.g., exertional dyspnea, orthopnea, peripheral edema, pulmonary rales or crackles, or jugular vein distention, etc.) in documentation.
• Document work-up (e.g., chest X-ray, EKG, Swan-Ganz, echocardiogram, etc.).
• Document treatment (e.g., diuretics, ACE inhibitors, digitalis, beta-blockers, O2, morphine sulfate, monitoring input and output, daily weights, etc.).
• Etiology (e.g., valvular heart disease, renal failure with volume overload, congestive cardiomyopathy, myocardial ischemia, new onset atrial fibrillation, etc.).
• Note LVEF (left ventricular ejection fraction), assessment for ACE inhibitor use, and contraindications for non-use of ACE inhibitors.

Typical Signs of CHF 

• Shortness of breath
• Orthopnea
• Paroxysmal nocturnal dyspnea
• Reduced exercise tolerance
• Fatigue 
• Tiredness
• Increased time to recover from an activity
• Ankle swelling

More Specific Signs 

• Distended jugular veins or elevated venous pressure
• Hepatojugular reflux
• Third heart sound
• Laterally displaced apical impulse
• Cardiac murmur

Documentation to Substantiate CHF 

• Medications 
• Diagnostics and lab tests (echocardiogram, BNP)
• Presence of dyspnea with mild exercise
• Presence of rales
• Paroxysmal nocturnal dyspnea
• Orthopnea
• Fatigue with exertion
• Jugular vein distention
• Pitting edema of the lower extremities

Helpful Hints

• Create a checklist to assure you have included all supporting documentation in the medical records.
• If another physician referred the beneficiary, be sure he or she signs and dates any orders that were written/given and that the referred physician is documented in the notes.

Resources

• National Coverage Determination (NCD) — Cardiac Rehabilitation Programs for Chronic Heart Failure
• Hospital Readmissions Reduction Program (HRRP)
• ICD-10-CM/PCS MS-DRGv33 Definitions Manual