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Heart failure: The importance of precision

From the August ACP Hospitalist, copyright © 2010 by the American College of Physicians

By Richard D. Pinson, FACP

Sidebar: Ask Dr. Pinson

The diagnosis and treatment of heart failure have progressed rapidly over the past several years, and for coding purposes, it is no longer enough to say that patients have “CHF” or “congestive heart failure.” Since not all heart failure is “congestive,” the term is misleading and needs qualification.

First, the medical record should clearly indicate whether a patient's heart failure is “chronic” (“stable,” “baseline”), even if asymptomatic, or if an acute exacerbation has occurred. Also, to manage patients correctly and select the most effective medications, a physician needs to know whether the failure is systolic or diastolic failure—or both. This can sometimes be clinically determined, but the best test is an echocardiogram.

Systolic or diastolic

Systolic heart failure is characterized by:

• dilated, weak heart and/or thin ventricular wall,
• decreased outflow of blood from the heart (impaired ventricular pumping function), and
• ejection fraction (EF) less than 40%.

Systolic heart failure is more common than diastolic failure, and the usual cause is ischemic coronary artery disease. If at all possible, these patients must be treated with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB), as these drugs prolong life, reduce complications and lower hospitalization rates for patients with any component of systolic heart failure.

Diastolic heart failure is characterized by:

• thickened myocardium/hypertrophic ventricle,
• low-capacity ventricular chamber,
• an improperly relaxing ventricle,
• impaired filling with blood (during diastole),
• strong ventricular contraction, and
• normal (55% to 70%) or elevated (“preserved”) ejection fraction.

Common causes of diastolic heart failure are aortic stenosis, uncontrolled hypertension and end-stage renal disease. ACEIs or ARBs may be prescribed, but they do not have the same benefits in patients with pure diastolic heart failure as in patients who have any component of systolic failure.

Treatment

To eliminate or reduce fluid retention, physicians often give loop diuretics like furosemide (Lasix) before giving thiazides. If a patient is already taking stable doses of ACEI and digoxin (Lanoxin), spironolactone (Aldactone) should be prescribed to reduce mortality risk in patients with New York Heart Association (NYHA) class III or IV heart failure (i.e., moderate or severe heart failure).

Beta-blockers slow the heart rate, lower blood pressure, reduce cardiac oxygen consumption and lessen the cardiac workload. They are generally prescribed for most patients with heart failure, but are typically first-line therapy for diastolic failure. Three beta-blockers have been shown to improve survival in heart failure: carvedilol (Coreg), metoprolol (Lopressor, Toprol-XL) and bisoprolol (Zebeta).

Nitrates are venous and coronary artery vasodilators that reduce cardiac work, increase coronary blood flow and improve cardiac performance. Digoxin (Lanoxin) is used for rate control when a patient has atrial fibrillation, and improves cardiac function when a patient has symptomatic left ventricular systolic dysfunction despite treatment with an ACEI and diuretic. It does not, however, benefit diastolic heart failure.

Richard Pinson, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This content is adapted with permission from HCQ Consulting.

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Ask Dr. Pinson

I am a practicing nephrologist and I admit all my dialysis patients. Can I still bill for the admit history and physical (H&P) each time the same patient is admitted for different reasons, or is this considered an established patient visit?

Venugopal Govindappa, ACP Member
Florence, S.C.

Hospital inpatient services are classified as “initial” (including, for example, admitting H&P) or “subsequent” hospital care without the distinction of “new” or “established” status. When admitting a patient as the attending physician of record, one would bill the appropriate initial hospital care code for the first inpatient hospital encounter regardless of the reason for admission. All evaluation and management (E/M) services provided by the physician in conjunction with the admission on the same day at another site of service are considered part of the initial hospital care.

Got a documentation or coding conundrum? Let us help you. Each month in this space, Dr. Pinson will respond to selected questions from readers. Please e-mail your questions, including your name, city and state, and professional credentials.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated