Unspecified Codes Associated with CHF Could Lead to Denials

Posted on Thursday, December 8, 2016 9:59 PM

New data has been released to confirm that agencies continue to struggle with coding congestive heart failure (CHF) under ICD-10. This is a huge concern due to the use of the unspecified code associated with heart failure, which could lead to additional documentation requests and ultimately denials.

The issue lies in part on a lack of specificity within information coders are provided and in part on clinicians or coders not fully reading the entire record to identify greater specificity that already is included, says Brandi Whitemyer, an independent home health and hospice consultant in Canton, Ohio.

During the first two quarters of 2016, I50.9 (Heart failure, unspecified) was used 49.5% of the time agencies used codes beginning with I50, according to data Minneapolis-based ABILITY Network. In reality, I50.9 should be used less than 10% of the time, says Trish Twombly, Senior Director for DecisionHealth in Gaithersburg, MD.

Note that the non-specific code for heart failure remains on the case-mix list, but CMS has warned that assigning nonspecific codes in ICD-10 will come at a cost, Twombly says.

While agencies continue to struggle with coding CHF, the good news is they have shown drastic improvement from the fourth quarter of 2015 — when they used I50.9
about 94% of the time they used I50, Twombly notes.

Part of why I50.9 is being used is because of a code in ICD-9 — 428.0 — that translated to CHF and mapped out to I50.9 in general equivalency mappings (GEMs), Twombly

The following strategies are used to improve CHF coding:
• Look beyond the patient’s history and physical (H&P)
• Scrutinize the echocardiogram report
• Make sure coders don’t settle when they don’t have enough information

Coders must speak up if the information they’re presented isn’t detailed enough. In some situations, documentation provided at referral is vague and coders/clinicians aren’t taking time to obtain clarification regarding the type of heart failure patients have or the time to get additional medical records that would identify this information, Whitemyer says.

Corridor’s Coding Services offers ICD-10 coding, multi-level OASIS reviews, clinician documentation review, as well as trends and reporting. Contact us to learn more.

For the full article, please see the December 12, 2016 Home Health Line Edition.

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