Health Information Management

Q&A: Assessing physician documentation for diastolic heart failure

JustCoding News: Inpatient, February 17, 2010

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QUESTION: The pulmonologist documents “Diastolic heart dysfunction. There is coronary artery calcification and evidence of grade I diastolic dysfunction.” Based on this documentation alone, can I assume that this documentation indicates diastolic heart failure?

ANSWER: You are correct that “dysfunction” and “failure” are two different diagnoses. Diastolic heart dysfunction indicates that the ventricles of the heart are not relaxing properly after the contraction, causing increased pressure for the next heartbeat cycle (contraction [systolic] then relaxation [diastolic]). You would report the diastolic heart dysfunction with code 427.9 (Cardiac dysrhythmia, unspecified).

Diastolic heart failure, also known as cardiac insufficiency, indicates that the heart cannot adequately pump blood. For this, you would report code 428.9 (Heart failure, unspecified).

Coronary artery calcification, which you would report with code 429.1 (Myocardial degeneration) indicates that calcium salt deposits are hardening these vessels.

Of course, before submitting any of the codes above, check further into the patient’s chart, the physician’s notes, or query the pulmonologist. Third-party payers are mostly likely to set aside unspecified codes, delaying payment until you submit additional documentation.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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