ICD-9-CM Coding for Heart Failure

Coding a heart failure diagnosis can be a challenge. In the current Medicare risk adjustment environment, it is critical for physicians to code these types of diagnoses accurately and to the highest level of specificity. The tips below are designed to help providers better understand the distinctions between the various heart failure diagnoses codes and use of the required fourth and fifth digits.

Congestive heart failure

• The only ICD-9-CM code for congestive heart failure is 428.0, congestive heart failure, not otherwise specified. This code should only be used when there is combined left and right failure.
  • Left heart failure alone (428.1) is not congestive heart failure; codes 428.0 and 428.1 should not be used together.
  • 428.9 is not a code for congestive heart failure.
• Other ICD-9-CM codes can be used in conjunction with 428.0 to specify whether the congestive heart failure is systolic (codes 428.20 through 428.23), diastolic (428.30 through 428.33), or combined systolic and diastolic (428.40 through 428.42); but the 428.0 code is still required to indicate that it is congestive heart failure.
• Congestive heart failure (428.0) should be coded as a secondary diagnosis whenever it is present, even if treatment is no longer required.

Heart failure in conjunction
with hypertensive heart disease

• 402.11 is the code for benign hypertensive heart disease with heart failure. An additional code is required to specify the type of heart failure (Codes 428.0-428.43) if known.
• 402.91 is the code for hypertensive heart disease, unspecified, with heart failure. Use this code when hypertension is considered a cause of heart failure. Note: The documentation should support a cause and effect relationship between the hypertension and the heart failure. Use an additional code from the 428 series to specify the type of heart failure, i.e. 428.0 for congestive, 428.20 through 428.23 for various types of systolic, 428.30 through 428.33 for various types of diastolic, or 428.40 through 428.42 for various types of combined systolic and diastolic.

Heart failure in conjunction with hypertensive
heart disease and chronic kidney disease

• Category 404 encompasses combination codes for hypertensive heart disease and chronic kidney disease. This category includes a fifth digit that indicates if the patient has heart failure. (See chart on page 20.) For example, 404.03 represents malignant hypertensive heart disease and renal disease with heart failure and renal failure.
• When heart failure is indicated by the fifth digit in the 404 category, an additional code from the 428 category should be used to specify the type of heart failure. For example, 404.03 might be used with 428.0 to indicate that the heart failure is congestive.

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