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Cheryl Posted Wed 27th of March, 2013 11:22:48 AM

What code would you use for CHF most likely on the basis of right sided heart failure? Just 428.0? or do you query for diastolic or systolic?

SuperCoder Answered Thu 28th of March, 2013 17:46:53 PM

To ensure proper diagnosis coding for electrocardiography, you need to remember two things: specificity and medical necessity.

ECGs (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report; 93005, ... tracing only, without interpretation and report; and 93010, ... interpretation and report only;) are some of the most common diagnostic tests performed by ED physicians and cardiologists in the ED.

During the noninvasive procedure, a patient has electrodes placed on his or her chest, arms and legs to produce an electrical recording of the heart. Technically speaking, the ECG is a graphic tracing of the electrical activity caused by the impulses that travel through the heart that determine the heart's rate and rhythm as detected at the body surface.

ECGs are used in the diagnosis of disorders of cardiac rhythm, anatomy, coronary blood flow, myocardial function, and symptoms related to such disorders. They are also used as an adjunct to the diagnosis of certain drug toxicities and metabolic disorders.

Three Steps to Specificity

Proper payment for ECGs depends on whether you establish a credible medical necessity for the procedure by applying the correct diagnosis code. These codes tell the payer why the ED physician performed the ECG. And increasingly, carriers are denying payment if the ICD-9 codes are not specific enough.

You can ensure you are coding to the highest possible level of specificity by following a sound coding and assessment process, which has three steps:

1. Gather complete information. When you are translating the physician's encounter information into codes, you need complete information. You may not have enough information to code the services based on the ED physician's written notes. For example, if the doctor writes "heart failure" in the patient's record you may need more information. Heart failure (428) is an incomplete (truncated) code and will be denied because you did not carry it out to the highest degree of specificity. You need the data that will help you determine the type of heart failure and whether it is a confirmed or "rule-out" diagnosis.

Congestive heart failure (428.0) is a more specific code and will allow the EKG to be paid. A rule-out diagnosis may be clinically important to have in the chart, but it will not justify the procedure or service from the insurer's perspective, and it cannot be coded directly. Consequently, you will have to seek out more information on the specific symptoms from the patient's chart or by asking the physician. Specific diagnosis coding requires clear access to all the necessary information.

And, due to the nature of the clinical interaction in the ED, it is perfectly acceptable and common to use symptom-based codes. Codes such as unspecified chest pain (786.50) or shortness of breath (786.05) may be all the clinical information available during the ED doc's initial treatment.

Ideally, diagnosis information should come from the physician's clear, concise and specific diagnosis written in the patient's chart. But this kind of detail is often lacking in many practices.

"You may want to use an encounter form that lists the common diagnoses along with a clear indicator when more specificity is needed," says Heidi Stout, CPC, CCS-P, coding and reimbursement manager for University Orthopaedic Associates in New Brunswick, N.J. This will help educate the ED doctor about which ICD-9 codes require more information. For example, you can use a line after the code to indicate clearly that more digits are required, i.e., 786.__, Stout says.

2. Use the code with the highest specificity. No matter how well the ED physician communicates the patient data, you must ensure that you use the right code and that it is being carried to the highest digit possible. This involves not only noting any caution or warning symbols in the ICD-9 manual (some color-coded books use yellow for nonspecific codes and red for those with missing digits) but also having a good working knowledge of the terminology for electrocardiograms. If the physician sees a patient for heart failure, you will have to support the diagnosis codes by gathering enough information to know that, for example, the patient has congestive heart failure (428.0) or left heart failure (428.1)

The complete codes for this area are found in the ICD-9 manual under symptoms involving diseases of the circulatory system (390-459). The simple rule is: Assign three-digit codes only if there are no four-digit codes within that code category; assign four-digit codes only if there are no fifth-digit subclassifications for that category; and assign the fifth-digit subclassification code for those categories where it exists.

In this example, the specific code to report is 428.0 (Congestive heart failure). An example of fifth-digit specificity would be found in the group of codes describing symptoms involving the respiratory system and other chest symptoms (786). In the ICD-9 manual, there is a stop sign in front of 786.0 so you know you need greater specificity. The fourth and fifth digits delineate further symptoms of respiratory disorder such as hyperventilation (786.01), orthopnea (786.02), apnea (786.03), Cheyne-Stokes respiration (786.04), shortness of breath (786.05), tachypnea (786.06) and wheezing (786.07).

Although carrying out to the highest degree of specificity is mandatory, you occasionally have to use an unspecified code such as chest pain, unspecified (786.50) if no ICD-9 code exists that matches the ED physicians' documentation.

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