December 14, 2015

Heart of the Matter: Cardiac ICD-10 Codes

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The newly supported ICD-10 code concepts for heart diseases, announced in a Nov. 13 letter from the American Health Information Management Association (AHIMA) to the National Centers for Health Statistics, will lead to tremendous improvement in data accuracy for these conditions.  

Physicians have been documenting many of these conditions properly for years, but as neither ICD-9 nor ICD-10 covered these entities, the conditions were lost to the patients’ databases. And being as many people supporting the physician documentation didn’t sufficiently understand the basic diseases, errors in assignment of the codes and relationships of the diseases to other patient presentations got lost.

Atrial fibrillation had one code in ICD-9. In ICD-10, we’ve seen an expansion to specifying paroxysmal, persistent, and chronic as options. These are based on definitions indicating length of time of the event and by response to treatment. The definitions are there. But these codes are specifically for the model of atrial fibrillation that is caused by the conduction system inherently and not related to episodes of atrial fibrillation that can occur as a reaction to an acute event, such as an acute myocardial infarction or acute myocarditis or other acute cardiac conditions that will affect the neuromuscular cells of the heart transiently (cardiac muscle cells act both as muscle cells and conduction system cells). So a patient with new onset atrial fibrillation or a first episode of atrial fibrillation may not have any further episodes for the rest of his or her life, once the inciting factor resolves. 

It would be inappropriate to ignore “new onset” or a “first episode” of atrial fibrillation because, truly, the definitions of paroxysmal and persistent (and chronic and longstanding and whatever they change it to from month to month) were originally defined for patients with inherent conduction disease. Next, we had been told by Coding Clinic that tachycardia should not be coded in addition to atrial fibrillation in ICD-9, as it is inherent in atrial fibrillation – but that was far from the truth. Now we will be told that it is important to pick up whether the current episode is associated with tachycardia or with bradycardia, as both of these can cause death in the face of atrial fibrillation, but by different mechanisms. That’s cool! Also, we are advised to pick up any identification of mitral valvular disease that may be associated with patients with atrial fibrillation because the treatment of patients with and without mitral valvular disease is different in the long run. Hooray! 

Heart failure codes had been specified in breakdown only for left heart failure. The systolic and diastolic nature of left heart failure had been defined by functional deficiencies in either systolic strength for emptying or in diastolic filling of the heart, both leading to reduced stroke volume from the left ventricle. But the codes in ICD-9 and in ICD-10 never indicated that this was for the left heart only, so patients with right-side heart disease or heart failure due to congenital heart disease were totally left out in the cold. There were no “acutes” or “chronics” in these patients. There were no codes to have acutes and chronics assigned to them. Now, there will be – and for biventricular failure as well.  

Also, even though we had stratification of ICD codes for worsening kidney disease leading to end-stage renal disease, a justification for dialysis or transplant, we have had no codes for end-stage heart disease. Heart failure centers throughout the United States that might use left ventricular assist devices had no way to distinguish their very sick populations from the hospitals that referred their sickest heart failure patients to the center. So the increased death rate associated with advancing heart failure remained an enigma. Now we will have the opportunity to distinguish end-stage heart failure patients – and statistics will be more appropriate for the physicians who treat the sickest.

Let’s look forward to working with our cardiologists and other doctors in the heart service lines and let them know that their patients will have codes for the diseases they actually treat – introduce them to the codes once they come out in final form.  

Great opportunities are coming down the pike, as the capabilities of ICD-10 now can allow us to demonstrate what’s wrong with our patients.

Robert S. Gold, MD

(1942-2016) The late Robert S. Gold, MD, was a nationally known physician, responsible for having championed clinical documentation with a peer-to-peer educational approach in hospital organizations. Dr. Gold was a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper data streams, proper communication within the medical records and proper reimbursement. Dr. Gold served on the ICD10monitor editorial board from 2011 through January 2016.

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