Documentation Tips – Session 1: Congestive Heart Failure and Myocardial Infarction

Dr. Keith Stokes provides a detailed overview of the evolving terminology and documentation needs for heart failure, focusing on the distinction between heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). He emphasizes that these terms replace the older labels of systolic and diastolic heart failure, respectively. Dr. Stokes explains how clinicians must document not only the type of heart failure (HFpEF, HFrEF) but also the acuity (acute or chronic) to accurately reflect the severity of illness and support appropriate treatment decisions.

He underscores the importance of documenting underlying causes of heart failure exacerbation, such as medication noncompliance, excessive salt intake, myocardial infarction, infections, or other conditions, to provide context for the patient’s symptoms and treatment plan. Specific physical findings and diagnostic tests that point to heart failure, such as elevated venous pressure, hepatomegaly, or left ventricular function abnormalities, are also highlighted.

Dr. Stokes then discusses coding guidelines, including specific ICD-10 codes for heart failure based on its type and whether it’s acute or chronic. He provides coding examples and clarifies that nonspecific heart failure documentation is inadequate for reflecting the patient’s true condition.

Lastly, he delves into myocardial infarction (MI) documentation, explaining the different types of MI, including Type 1 MI (due to coronary artery disease) and Type 2 MI (due to an imbalance between oxygen supply and demand without a thrombus). He stresses the need to document symptoms, EKG findings, and any imaging results to properly classify MIs and ensure proper coding. Dr. Stokes concludes by reiterating the necessity of documenting all relevant diagnoses and secondary conditions that impact patient care.