December 1, 2015

ICD-10 Heart Codes: Improvements Can’t Come Soon Enough

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Once in a while, the people who monitor the ICD codes actually listen to the providers of healthcare (rarely, but once in a while).

When ICD-10 first came to the fore as an upcoming entity, the major non-trauma issue everybody noted was that code I10, hypertension, eliminated identification of benign essential hypertension, accelerated hypertension, and malignant hypertension. 

One code hit them all. Why did this happen? Because so many clinical documentation improvement (CDI) programs bullied their docs to identify “accelerated hypertension” for any tiny rise in blood pressure that everyone had accelerated hypertension and its significance went away. You know who you are. Well, I was quite upset. Accelerated hypertension or malignant hypertension (without or with papilledema) kills people, and there’s no way to identify this event in ICD-10. I had telephone conferences with the past and current presidents of the American Society of Hypertension and we submitted a model of how to code Hypertensive Crisis with its subdivisions of Hypertensive Emergency (significant hypertension in the range of 220/110 in adults and not so high in children with organ involvement) and Hypertensive Urgency (same level of dangerously elevated blood pressure without target organ damage—yet). 

These were discussed at the Coordination and Maintenance Committee and will probably be adopted in the I16 category. Be sure that the target organ damage gets documented and coded as well, whether it’s a hypertensive stroke or hypertensive seizure or acute kidney injury or acute pulmonary edema or demand [ST1] non-ST elevation acute myocardial infarction. And, if that dangerously elevated hypertension is due to another process, identify that process, too, such as hyperthyroid crisis or eclampsia or pheochromocytoma.

Next, having been grilled by a couple of cardiologists who knew a lot about cardiac arrhythmias, it became obvious to me that the model of atrial fibrillation codes in ICD-10 is inadequately categorized. First of all, there is no code available for a patient’s first episode of atrial fibrillation. What we have are categories of paroxysmal, persistent, and chronic atrial fibrillation, and when a patient first appears, it is impossible to determine if the episode is one of these three.

According to the American Heart Association and American College of Cardiology, we have definitions of paroxysmal, permanent, longstanding, and chronic atrial fibrillation. But for the first time a patient appears with atrial fibrillation, whether symptomatic or not, it will or will not require treatment. If it requires treatment, then it is important to know if it is caused by some acute event, such as acute myocardial infarction or myocarditis or the patient just had an aortic valve replaced. It may be a single event that never recurs or it may progress to one of the chronic groups. We need a code for that first episode because everyone starts with the first episode. And is it related to mitral valve disease or not? Because the ACC/AHA Guidelines for treatment is different for each of these subgroups, so it’s important to have that patient data available.

Finally, left heart failure is left heart failure, whether it’s acute or chronic or systolic in nature (with reduced ejection fraction) or diastolic (with preserved ejection fraction). But there are no codes for right heart failure, whether acute or chronic, at all.  

And children with congenital heart disease and shunting can develop heart failure, but it’s not represented by any of the existing codes in the I50 series at all. So kids are left out again. Yes, left ventricular failure can occur from other conditions and they are represented in the I50 series, but not when due to congenital heart disease.  

Regarding stratification, only the kidneys have disease that is stratified into severity as far as coding goes. There are a few ways of stratifying severity of heart failure in the literature (like New York Heart Association Classes of Heart Failure), but no codes for that. And end-stage heart failure? Forget it. Well, the current model in consideration will answer all of these questions if they adopt them. And I have the support of the American College of Cardiology. 

Plus—we need a fix for Cardiorenal Syndrome, because the current code(s) is ludicrous, and for Types of Acute Myocardial Infarction other than rupture of a coronary plaque, because that’s all we have in coding at this time.

Stay tuned.

 

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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