Scenario:
A patient is admitted for a cholecystectomy and during the medical clearance the patient is diagnosed with “Stage A heart failure”. The patient has hypertension, DM, and a family history of cardiomyopathy. How is the heart failure coded?
Answer:
Assign code Z91.89 Other specified personal risk factors for Stage A heart failure. Assign additional codes for the hypertension, DM and family history of cardiomyopathy as they are integral to Stage A heart failure.
Rationale:
The American Heart Association has identified four stages of heart failure:
| Stage A | Stage B | Stage C | Stage D |
| People at high risk of developing heart failure. Patients that have a family/personal history of high blood pressure (hypertension), diabetes, or heart problems as well as high fat diets, abuse alcohol or drugs, or smoke. | Patient has probably never experienced symptoms of HF, but has developed structural heart disease and has been diagnosed with the disease. There is clear evidence of heart failure during diagnosis but no clear symptoms. At this point a physician may prescribe medication such as ACE Inhibitors or Beta Blockers. There will be close monitoring of blood pressure. | Cardiac dysfunction is present, as are other symptoms: tiredness while performing simple activities like walking or bending over, are common symptoms. Shortness of breath and overall fatigue are present. | Exhibit signs and advanced symptoms of HF even though they are receiving optimum treatment and therapy. |
Patients in stage A failure have not been diagnosed with heart failure and are usually not receiving any treatment although some physicians may elect to treat prophylactically. Stage A heart failure should be viewed as a threatened or impending condition and per coding guidelines is not coded as a confirmed diagnosis. I50.9 should be assigned for heart failure described as Stage B-D.
Reference:
Coding Clinic First Quarter 2017 P. 45