CHF: A Clinical and Coding Perspective - HCPro

1 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at : A Clinical and Coding PerspectiveCarla A. Sueta, MD, PhD, FACCP rofessor of MedicineMedical Director, UNC Heart Center at MeadowmontUNC Center for Heart & Vascular CareUniversity of North Carolina at Chapel HillGarry L. Huff, MD, CCS, CCDSP resident/CEOHuff DRG Review Services, Eads, Objectives Define heart failure stages, etiologies, and related altered anatomy Recognize heart failure and types through documented physical exam and symptomsdocumented physical exam and symptoms in the health record Apply Coding guidance to Clinical scenarios Formulate compliant physician queries to clarify types of severity of heart failure3 Heart Failure Overview4 2013 HCPro , Inc. All rights reserved.

2 These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at None5 Outline Definition Stages Etiologies Anatomy Anatomy Symptoms, physical exam Types (systolic, diastolic) Diagnosing acute heart failure Treatment6 Heart Failure DefinitionHeart failure is a Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill (preserved EF/diastolic HF) or eject (systolic HF) cardinal manifestations are dyspnea and fatigue, which may limit exercise tolerance,and fluid retention, which may lead to pulmonary congestion and peripheral edema. 7 Hunt SA, et al. Circulation2005;112:1825 heart dzHigh riskHypertensionAtherosclerotic dzDiabetes. Obesity, Stage BStage AHeart Failure StagesStructural heart dz(-) SymptomsHx MILV systolic dysfunctionAsx valvular dzStructural dz(+) SymptomsSOB, fatigueEnd-stageNYHA INYHA II-IIINYHA IVmetabolic syndromeFH cardiomyopathyUsing cardiotoxinsStage CStage D8 2013 HCPro , Inc.

3 All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at at Risk forDeveloping Heart FailureStage A Hypertension Atherosclerotic disease Diabetes mellitus Obesity, metabolic syndrome Family history of cardiomyopathy Using cardiotoxins9 Structural Heart DiseaseBut No SymptomsStage B Previous MI LV remodeling including LVH, low EF Asymptomatic valvular disease10 Development ofDevelopmentofDevelopment of Symptoms11 DevelopmentofSymptomsStage CEnd-Stage HFMarked symptoms at rest despite maximal medical therapyStage D12 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at have a history of hypertensionyyp13 Etiologies of HFNonischemic Causes (1/3 1/2) Hypertension Cardiomyopathies-Dilated Idiopathic ChemotherapyCoronary ArteryDisease (1/2 2/3) Hx of MI CAD14 Chemotherapy Alcohol Cocaine Myocarditis Postpartum-Hypertrophic-Restrictive Amyloid, sarcoid Hemochromatosis Valvular disease Thyroid Congenital/shuntsTypes of Cardiomyopathies15 Definitions Left (most common) Systolic and diastolic Diastolic only Right due to left (combined)g() Cor pulmonale (right-sided only) Emphysema/COPD/obstructive sleep apnea pulmonary hypertension Primary pulmonary hypertension Thromboembolic disease Congenital heart disease with shunting16 2013 HCPro , Inc.

4 All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at Pathway of Blood Flow Through the Heart17 Symptoms and Physical Exam18 Symptoms and Physical ExamSymptoms Dyspnea at rest or exertion Reduced exercise capacity Orthopnea PND, cough EdemaLess specific Sx Early satiety Nausea, vomiting, abdominal discomfort Wheezing or cough FatigueEdema Chest pain or equivalentSigns BP, HR, dry wt, wt change Jugular venous pressure Rales, wheezes Displaced PMI, RV heave, murmurs, S3 Hepatomegaly, ascites, hepatojugularreflux Peripheral edema, scrotal edemag Confusion/delirium19 Define Heart Failure TypeSystolic ( EF) and preserved EF heart failure can present with the same Sx and signs: Dyspnea on exertion, orthopnea Paroxysmal nocturnal dyspnea pulmonary edema Jugular venous distension Rales S3, S4 Peripheral edema CARDIOMEGALY20 2013 HCPro , Inc.

5 All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at of Heart FailureDiastolic Heart FailureHFPEFS ystolic Heart vs. HF With PreservedEF (HFPEF) Heart Failure Acute Chronic Acute on chronic22 Diagnostic Criteria:HF With Reduced vs. HF With Preserved EFClinical evidence of HF: Clear Clinical presentation of HFor Framingham or Boston criteriaIf uncertain:Plasma BNP or chest x-ray or cardiopulmonary exercise testing23or cardiopulmonary exercise testingSupportive evidence:Eccentric LVH or remodelingSupportive evidence:Concentric LVH or remodeling Left atrial enlargement in absence of AFEcho Doppler or catheter evidence of diastolic dysfunctionExclusions:Non-myocardial diseaseExclusions:Non-myocardial diseaseAdapted from Yturralde FR. Prog Cardiovasc Dis 2005;47:314 19 Lindenfeld J, et al.

6 HFSA 2010 Comprehensive Heart Failure Guideline. J Card Fail 2010;16:e1-e194 LVEF < 50%LVEF 50%Heart Failure With Normal LVEF*Hypertension*CADR estrictive cardiomyopathyInfiltrative cardiomyopathyHypertrophic cardiomyopathyAdapted from Oh JK, et al. J Am Coll Cardiol 2006; 47:500. 12 Noncompaction cardiomyopathy*Valvular disease (severe valvular stenosis or regurgitation)Right heart failure (severe pulmonary hypertension, ASD,RV infarct, arrhythmogenic right ventricular dysplasia)Pericardial disease (cardiac tamponade, constrictive pericarditis)Intracardiac mass (atrial myxoma) pulmonary vein stenosisCongenital heart disease24 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at Heart Failure Symptoms Signs CXR Echo Echo Labs Treatment ( , intravenous furosemide)25 Framingham Criteria: 2 major or 1 major + 2 minor PND Orthopnea Peripheral edema Dyspnea on exertionMajor CriteriaMinor Criteria JVP Rales S3 CXR cardiomegaly CXR pulmonary edema Hematomegaly Pleural effusion HR > 120 Weight loss > kg/5 days with diuretic26 Chest X-ray Cardiomegaly pulmonary congestion or redistribution Pleural effusions most often bilateral Interstitial edema Interstitial edema pulmonary edema27 Echocardiography Ejection fraction(reduced/systolic vs.)

7 Preserved/diastolic) Valvular diseaseValvular disease Diastolic dysfunction Diastolic HF(symptoms and supportive evidence must be present)28 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at Elevated (pro) BNP Elevated troponin HyponatremiaElt d liftit t (AST ALT Elevated liver function tests (AST, ALT, alkaline phosphatase, bilirubin) Hypoxemia (low O2 saturation)29 Systolic Heart Failure RxMedication/Device Mortality Diuretic (furosemide, metolazone)NoACE-I (lisinopril, enalapril, ramipril, captopril)YesARB (losartan, candesartan, valsaratan)YesBeta blocker (metoprolol, carvedilol, bisoprolol)YesAldosterone antagonist (spironolactone, eplerenone)YesDigoxinNoNitrate (isordil) + hydralazineYesICD (EF< 35%)YesCRT (biventricular pacemaker)Yes30 HFpEFRx Underlying Risk Factors, ComorbiditiesHTN, CAD, DM, Obesity, CKDC ongestion DiureticsBP ACE-ITachycardia B-blockers Salt diet ARB CCB B-blockers Nitrates Verapamil Diltiazem Control Afib31 ACE-I/ARB: CVD, DMBB: Hx MI, HTN, AfibCCB.

8 Angina, Afib, HTNC ongestive Heart Failure: Breaking the Code !32 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at Failure DefinitionHeart failure is a Clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill(preserved EF/diastolic HF) or eject (systolic HF) cardinal manifestations are dyspnea and fatigue, which may limit exercise tolerance and fluid retention, which may lead to pulmonary congestion and peripheral edema. 33 Hunt SA, et al. Circulation2005;112:1825 riskHypertensionAtherosclerotic dzDiabetes. Obit Stage BStage AHeart Failure StagesStructural heart dz(-) SymptomsHx MILV systolic dysfunctionAsx valvular dzStructural dz(+) SymptomsSOB, fatigueEnd-stageNYHA INYHA II-IIINYHA IVObesity, metabolic syndromeFH cardiomyopathyUsing cardiotoxinsStage CStage D34 Ventricular Dysfunction Becomes CHFH eart dysfunction (structural/functional)+Onset of signs and symptoms++TreatmentCHF (Stage C or D )Acute Compensated35 ScenarioPatient with history of hypertension.

9 Patient has cardiomegaly on chest x-ray. EKG and echocardiogram reveal LVH. Current medication regimen includes beta blockers, ACE inhibitors, 36and diuretics. Physician documented LV diastolic dysfunction secondary to you query for hypertensive heart disease with compensated diastolic heart failure? 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc. For questions please contact HCProcustomer service at , a Query Is Appropriate ..Indicators for CHF: Has documentation of structural (cardiomegaly,LVH) and/or functional (diastolic dysfunction) On multiple drug therapyWhat we do not know from the documentation is: Has the patient ever had symptoms of CHF (stage C or D)?Patient does not require symptoms to make the diagnosis of compensated CHF(once a stage C or D, always a C or D)37 Left heart failure Combined Diastolic Heart failure with AnatomicalPerformanceTypes of Heart Failure(biventricular): Right heart failure due to left heart failure Right heart failure onlypreserved ejection fraction ( HFpEF ) Systolic Combined (diastolic and systolic)38 Diastolic Heart FailureAll congestive heart failure has a diastolic component (impaired ventricular filling) otherwise the patient would not have had congestive symptoms.

10 Elevated ventricular filling pressures, diastolic dysfunction, diagnosed by history and physical examination, can be nearly as accurate as non-invasive testing (Echocardiogram; NT-pro-BNP levels). Amer J Med 2011; 124:1051 S3 or S4 gallops (left-sided) Rales pulmonary venous ti Distended neck veins Ascites Swollen liverLeftRightClinical Definition of Diastolic Dysfunctioncongestion Interstitial edema (K-B lines) Pleural effusions Alveolar/ pulmonary edema Peripheral edema Peripheral edema (no other cause) S3 or S4 gallops (right-sided)Non-myocardial diseases of the heart such as constrictive pericarditis and mitral/aortic stenosis can result in diastolic heart failures. Additionally, high output failures such as severe anemia and thyroid storm can result in diastolic heart failure states. 40 2013 HCPro , Inc. All rights reserved. These materials may not be duplicated without the express written permission of HCPro , Inc.