Follow the MUSIC to ensure proper documentation

Association of Clinical Documentation Improvement Specialists, February 5, 2008

Now that Medicare Severity DRGs (MS-DRG) are in their fifth month, most physicians and hospitals can probably agree that no other diagnosis has been more misunderstood than congestive heart failure (CHF).

As we know, the American College of Cardiology (ACC) defines HF as a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ventricle's ability to fill with or eject blood. The ACC further emphasizes that HF is not synonymous with cardiomyopathy or left ventricular dysfunction, and that these latter terms describe possible structural or functional reasons for the development of HF. The ACC consensus statement is available at http://content.onlinejacc.org/cgi/reprint/46/6/e1.

Like the ACC, ICD-9-CM stipulates that physicians determine whether symptoms, such as pulmonary or peripheral edema, exercise intolerance, or orthopnea, are truly due to HF and, if so, the degree of severity, whether there are any underlying or precipitating pathologies, and to what extent any complications have ensued. Following the mnemonic MUSIC (manifestations, underlying cause, severity, instigating or precipitating causes, and consequences or complications) can help us improve our documentation and make our coders, case managers, and quality analysts happy.


When discussing CHF, consider whether the pulmonary or peripheral edema is indeed cardiogenic. Noncardiogenic pulmonary edema may result from pure fluid overload (e.g., dialysis noncompliance or acute renal failure), noxious gas inhalation, acute respiratory distress syndrome, or hypoalbuminemia. If the patient has heart disease, ICD-9-CM assumes that all pulmonary edema is cardiogenic unless explicitly stated otherwise. Likewise, peripheral edema can result from chronic or end-stage kidney disease, cirrhosis, hypothyroidism, or other endocrine disorders. When we describe the exact cause of noncardiogenic peripheral or pulmonary edema, explicitly stating it as such, this usually results in a higher relative weight.

Ventricular dysfunction is not HF unless the physician declares it as such. Should HF exist, ICD-9-CM subdivides it according to anatomy and muscle function. Right HF manifests as jugular venous distention, peripheral edema, and a hepatojugular reflux. Left HF presents with pulmonary edema and paroxysmal nocturnal dyspnea. Many physicians document left HF with pulmonary edema, but they fail to do so with right HF. Emphasizing right HF as the result of cor pulmonale, cardiac tamponade, or isolated right ventricular infarction adds severity.

Physicians must describe HF as systolic, diastolic, or both on every admission or visit to obtain maximum severity in risk adjustment and MS-DRGs. Characteristics of patients with systolic and diastolic HF are outlined in The New England Journal of Medicine, Vol. 348, pp. 2007-2018, which is viewable after a free registration at http://content.nejm.org/cgi/content/full/348/20/2007. Most HF patients have a combination of systolic and diastolic HF; thus, describing them as likely having such is clinically congruent.

Underlying cause

Coders must know the underlying cause of HF to assign the correct code. Typically, an underlying -congestive cardiomyopathy is present; however, diabetic, hypertrophic, hypertensive, ischemic, restrictive, or other combinations exist. Some physicians may describe temporary acute HF as myocardial "stunning" or "injury." In this circumstance, unless we describe its etiology, and the fact that acute systolic or diastolic HF is present, these terms have little effect on an MS-DRG. Likewise, we must use the word "cardiomyopathy" rather than "heart disease" if we are to increase severity in MS-DRGs.

As noted above, pericardial, endocardial, or great vessel disease can cause HF. Sleep apnea can result in respiratory failure and pulmonary hypertension, which leads to HF. Cardiac tamponade, cor pulmonale, and malignant hypertension are often not linked to the acute or chronic systolic or diastolic HF they cause; however, if our documentation links them, this will add severity.


For years, physicians have used ICD-9-CM code 428.0 (Congestive heart failure) to describe all of their patients with compensated and decompensated HF. As a result, MS-DRGs now assume that all patients with CHF (reported with code 428.0) are equal and do not require additional resources.

When a patient has compensated HF that incurs additional cost or risk, the physician must now explicitly document "chronic" HF, as well as its systolic or diastolic designation, to qualify as a complication/comorbidity (CC) under MS-DRGs. We must explicitly document decompensated HF as "acute" or "acute on chronic" systolic or diastolic HF to qualify as a major CC (MCC) under MS-DRGs. Omitting the systolic or diastolic designation results in a coder's assigning code 428.9 (Heart disease, unspecified) for the case. Unfortunately, code 428.9 has negligible severity under MS-DRGs.

Remember that documenting the term "dysfunction," or only documenting the ejection fraction (EF), such as EF of 20%, does not indicate that the heart has failed. We must specify that the heart muscle has failed, especially when diuretics, digoxin, beta blockers, and afterload reduction are used to prevent decompensation. Documenting in this way helps to ensure that we correctly capture patient severity.

Instigating or precipitating causes

HF is the most common reason for Medicare patient hospitalization. Ask yourself why the patient developed acute (on chronic) systolic or diastolic failure. Did he or she possibly have a non-ST segment elevation myocardial infarction, develop acute renal failure (a recent rise in serum creatinine of > 0.3 mg/dl), sustain a pulmonary embolus, mishandle his or her medication, or increase his or her salt intake? If the patient developed atrial fibrillation, was the reason for the admission primarily the arrhythmia, or the acute systolic or diastolic HF that it precipitated?

Consequences or complications

Many HF patients do not require inpatient hospitalization. However, hospitalization becomes necessary when the patient develops complications or consequences from that HF.

For example, does the patient have chronic respiratory failure that requires home oxygen or acute on chronic respiratory failure evidenced by significant hypoxemia or respiratory distress that is present on admission? Is there acute renal failure on top of chronic kidney disease (don't forget to stage it) due to renal hypoperfusion? Has the patient developed cardiac cirrhosis, venous stasis ulcers, or other chronic complications?

Warm regards,

James S. Kennedy, MD, CCS