from "Rust Out" by Dr. Royce Bailey, page 64

What Happens During Normal Heart Function?

The heart has four chambers that fill and empty (contract) blood in a coordinated fashion.  Your heartbeat is controlled by the heart’s electrical system.  The pumping activity is controlled by the heart muscle.  The right side of the heart receives deoxygenated blood from your body and then sends it to the lungs to pick up oxygen.  The left side of the heart receives oxygenated blood from the lungs and then sends it to the rest of the body, where the oxygen is delivered to your organs and brain.  The heart adjusts to the body’s exercise and stress need of oxygen and nutrients.  This is done by changing the heart rate and the amount of blood squeezed or pumped through the body.  An average person has approximately 120,000 heartbeats a day, that’s seven billion in a life time!

What Is Heart Failure?

Heart failure doesn’t mean the heart has stopped working.  Heart failure, in general, is a treatable condition.  It means that the heart is weak and doesn’t work (or pump blood) as well as it should.  Because the heart is not pumping blood adequately to the organs such as the kidneys and brain, they receive less oxygen.  Therefore, fluid collection tends to build up in the lungs, abdomen and legs, resulting in congestion and edema in all the body’s tissues.  The heart enlarges and becomes “baggy.”
We now have all kinds of new required codes (428.??-five digits required) to explain the type of heart failure we see in each patient.

What Are The Symptoms Of Heart Failure?

Symptoms that may occur with heart failure include: Shortness of breath (SOB), swelling of the feet and legs, chronic lack of energy, difficulty sleeping at night due to breathing problems, cough with frothy sputum, swollen or tender abdomen with loss of appetite, increased urination at night and confusion and/or impaired memory.

How Is Heart Failure Diagnosed?

To help diagnose whether someone has heart failure, a health care professional will take a thorough medical history, including: family history, lifestyle and symptoms.  A physical examination checks the heart, lungs, neck, abdomen and legs, looking for signs of heart failure.  A S3 heart sound usually means the patient has systolic “baggy” heart failure.  A S4 heart sound is consistent with diastolic (stiff pump) heart failure.   A chest x-ray shows a “silhouette” (or outline) of the heart size and shape.  In heart failure the x-ray of the heart is typically enlarged and shows signs of fluid in the lungs.  An echocardiogram uses: sounds waves (sonar), to see the heart chambers and valves; doppler, to evaluate the chamber pressures and narrowing or leakage of the valves in the heart; and “m” mode, to measure the chamber sizes of the heart.  An exercise stress test or treadmill test evaluates the heart’s function when you are active.  An electrocardiogram (ECG) records the electrical activity of the heart, which may provide evidence of an old “heart attack,” chamber enlargement, abnormal heart rhythms and decreased blood flow to the heart muscle.  A new blood test (Brain Naturetic Protein, “BNP”) can differentiate between heart failure and other causes of fluid collections in the body.

How Common Is Heart Failure?

Over five million people in the United States have some form of heart failure.  Nearly 700,000 new cases are diagnosed each year.  The risk of developing heart failure increases with age, and it is estimated that 1,000 out of every 100,000 people who are over the age of 65 have heart failure.

Treatments For Heart Failure
Lifestyle changes: eat less salt, get enough rest, exercise in moderation (cardiac rehab. program).

Medication: diuretics, ACE inhibitors or ARBs (angiotensin receptor blockers), digoxin (digitalis-purple foxglove flower) and beta-blockers.  These meds are typically used to increase the heart’s pumping ability, manage swelling (fluid retention), and to treat other symptoms associated with heart failure.

Surgery: When heart failure is caused by muscle damage that has occurred as a result of blocked coronary arteries, coronary bypass surgery (CABP) may be an option.  When defective or diseased heart valves cause muscle damage leading to heart failure, heart valve surgery to repair or replace the valve may be an option.

Enhanced External Counter Pulsation (EECP): Using sequenced blood pressure cuffs on the legs and abdomen (is like a “mast suit"), EECP unload the weak heart, stimulates beneficial hormonal action of the heart and improves the forward pumping action of the heart.

Heart Transplantation: Some patients have severe, progressive heart failure.  Their symptoms cannot be helped with medications and lifestyle changes.  In such cases, a heart transplant may be the only remaining treatment option.

Cardiac Resynchronization Therapy: This is a three lead (wires) heart failure pacemaker (can be combined with a cardioverter/defibrillator-ICDs).  This therapy causes both ventricles (lower chambers of the heart) to beat together again in a more synchronized pattern contributing to an increased pumping action of the heart.

What Kind Of Heart Failure Is My Doctor Trying To Have Me Code???
428.2 Systolic Heart Failure: is when the motion of contraction of the heart is reduced.  We some times call this Left Ventricular (LV) Heart Failure.  There is a reduce forward flow of blood, through the heart; the blood in the heart has to go somewhere and backs up into the lungs.
428.20 Unspecified-1) the doctor doesn’t have a clue, 2) I can’t read his handwriting, 3) he forgot to tell me, 4) this stuff gives me a headache, so I’m going to use this code.
428.21 Acute-The reduced pumping function has happened suddenly.
428.22 Chronic-The patient has been dealing with this problem for a long time.
428.23 Acute on chronic- Has been diagnosed with a reduced pumping function that has worsened.
428.3 Diastolic Heart Failure: this type of patient has a normal contracting heart but continues to be short of breath, fatigued, has a dry cough and may even have body swelling.  This is from the left ventricle (LV) being too stiff or rigid.  In order to maximally fill the LV, the inside blood pressure of the heart, between beats or contractions, needs to be between 6-12 mmHg.  In diastolic heart failure (abnormal pump muscle relaxation) this pressure is often measured greater than 20 mmHg, thus preventing the adequate filling the LV, therefore, the LV pumps half empty and again the blood backs up into the lungs.
428.30 Unspecified-As above.  These “unspecified” codes should be avoided.
428.31 Acute-A sudden rise in the resting internal heart pressure sufficient to cause hearty failure symptoms.
428.32 Chronic-The patient continues to be plagued with heart failure symptoms while having a normal heart pump and elevated resting heart pressures.
428.33 Acute on chronic-Sudden worsening symptoms of failure, despite longstanding diagnosis and treatment for a stiff LV and elevated end diastolic pressures (increased LVEDP).
428.4 Combined Systolic And Diastolic Heart Failure: This code combines 428.2 and 428.3 heart failure causes and symptoms.  Both a diminished pumping action of the heart muscle and a unyieldingly rigid heart walls contribute to this set of codes.
428.40 Unspecified-As above for 428.20 and 428.30.  These unspecified codes are the most likely to be denied.
428.41 Acute-Sudden impaired squeeze of the LV and stiff LV symptoms.
428.42 Chronic-Continued management of failure symptoms, both contraction and resting dysfunction.
428.43 Acute on chronic-A worsening of existing failure symptoms, including reduced contraction of the LV pump and non-compliant LV dysfunction.

References:
2003 ICD-9-CM, October 2002, Vol.I:115
Medtronic, “Understanding Cardiac Resynchronization Therapy For Heart Failure,” Patient education; 2002.
AMA 2001, Heart and Stroke Update