Congestive Heart Failure (CHF) is a serious condition where the heart doesn’t pump blood as effectively as it should. Accurate diagnosis and coding are crucial for effective treatment, proper medical billing, and healthcare statistics. In the medical field, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is used to classify and code diagnoses. This guide provides an overview of diagnosis codes related to congestive heart failure, based on the ICD-10-CM/PCS MS-DRG v37.2 Definitions Manual. Understanding these codes is essential for healthcare professionals and anyone involved in medical coding and billing.
Understanding DRG Codes for Heart Failure and Shock
The Centers for Medicare & Medicaid Services (CMS) uses Diagnosis Related Groups (DRGs) to classify hospital cases and determine payment. For heart failure and shock, specific DRGs are assigned based on the severity and complexity of the case, indicated by the presence of Major Complication or Comorbidity (MCC) or Complication or Comorbidity (CC).
The DRGs relevant to heart failure and shock are categorized as follows:
- DRG 291: HEART FAILURE AND SHOCK WITH MCC
- DRG 292: HEART FAILURE AND SHOCK WITH CC
- DRG 293: HEART FAILURE AND SHOCK WITHOUT CC/MCC
These DRGs help differentiate cases based on their complexity, with DRG 291 representing the most complex cases (with MCC) and DRG 293 representing the least complex (without CC/MCC).
Principal Diagnosis Codes for Congestive Heart Failure
The following ICD-10-CM codes are listed as principal diagnoses for DRGs 291, 292, and 293, specifically related to heart failure. These codes cover a range of heart failure types, from rheumatic to hypertensive, and various classifications of congestive heart failure itself.
Rheumatic and Hypertensive Heart Failure
- I0981: Rheumatic heart failure – Heart failure due to rheumatic fever.
- I110: Hypertensive heart disease with heart failure – Heart failure caused by high blood pressure.
- I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease – Heart failure associated with both hypertension and chronic kidney disease (stages 1-4 or unspecified).
- I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease – Heart failure associated with both hypertension and stage 5 chronic kidney disease or end-stage renal disease.
These codes specify heart failure that originates from or is complicated by other underlying conditions like rheumatic fever, hypertension, and chronic kidney disease.
Systolic Congestive Heart Failure Codes
Systolic heart failure occurs when the heart muscle is too weak to pump blood effectively out of the ventricle. The following codes detail different presentations of systolic congestive heart failure:
- I5020: Unspecified systolic (congestive) heart failure – General systolic heart failure when not specified as acute or chronic.
- I5021: Acute systolic (congestive) heart failure – Sudden onset of systolic heart failure.
- I5022: Chronic systolic (congestive) heart failure – Long-term systolic heart failure.
- I5023: Acute on chronic systolic (congestive) heart failure – Worsening of pre-existing chronic systolic heart failure.
Diastolic Congestive Heart Failure Codes
Diastolic heart failure happens when the heart muscle becomes stiff and cannot relax properly, preventing the ventricle from filling with blood effectively. ICD-10-CM provides codes to classify diastolic heart failure:
- I5030: Unspecified diastolic (congestive) heart failure – General diastolic heart failure, unspecified as acute or chronic.
- I5031: Acute diastolic (congestive) heart failure – Sudden onset of diastolic heart failure.
- I5032: Chronic diastolic (congestive) heart failure – Long-term diastolic heart failure.
- I5033: Acute on chronic diastolic (congestive) heart failure – Worsening of pre-existing chronic diastolic heart failure.
Combined Systolic and Diastolic Congestive Heart Failure Codes
Some patients may experience both systolic and diastolic heart failure simultaneously, known as combined heart failure. The ICD-10-CM includes specific codes for these cases:
- I5040: Unspecified combined systolic (congestive) and diastolic (congestive) heart failure – Combined heart failure not specified as acute or chronic.
- I5041: Acute combined systolic (congestive) and diastolic (congestive) heart failure – Sudden onset of combined heart failure.
- I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart failure – Long-term combined heart failure.
- I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure – Worsening of pre-existing chronic combined heart failure.
Other and Unspecified Heart Failure Codes
The ICD-10-CM also provides codes for other specific types of heart failure and unspecified heart failure when the type is not further defined:
- I50810: Right heart failure, unspecified – General right-sided heart failure, not specified as acute or chronic.
- I50811: Acute right heart failure – Sudden onset of right-sided heart failure.
- I50812: Chronic right heart failure – Long-term right-sided heart failure.
- I50813: Acute on chronic right heart failure – Worsening of pre-existing chronic right-sided heart failure.
- I50814: Right heart failure due to left heart failure – Right-sided heart failure caused by pre-existing left-sided heart failure.
- I5082: Biventricular heart failure – Heart failure affecting both ventricles.
- I5083: High output heart failure – Heart failure where the heart pumps a higher than normal volume of blood but still fails to meet the body’s needs.
- I5084: End stage heart failure – Severe, advanced heart failure.
- I5089: Other heart failure – Heart failure types not classified above.
- I509: Heart failure, unspecified – General heart failure when the specific type is not documented.
Shock Codes Associated with Heart Failure
In severe cases, heart failure can lead to cardiogenic shock, a life-threatening condition where the heart suddenly can’t pump enough blood to meet the body’s needs. Also included is a general shock code for unspecified shock.
- R570: Cardiogenic shock – Shock caused by heart failure.
- R579: Shock, unspecified – General shock when the specific type is not documented.
Understanding and correctly applying these diagnosis codes is vital for accurate medical records, appropriate treatment planning, and proper billing and reimbursement in healthcare. This information is based on the ICD-10-CM/PCS MS-DRG v37.2 Definitions Manual and serves as a guide for navigating diagnosis codes related to congestive heart failure.
Alt text: CMS logo representing Centers for Medicare & Medicaid Services, a US government agency overseeing Medicare and Medicaid, relevant to healthcare coding and DRG classifications.
