Q&A: ICD-10-CM documentation for congestive heart failure

Q:  When it comes to conditions not related to hypertension, is it sufficient to attribute the diagnosis to another etiology or does the provider need to specifically document that the congestive heart failure (CHF) is not due to hypertension?

A: Yes. If the doctor uses the term “with,” then of course we know to use it, but otherwise, if CHF caused by something else, you would certainly want the physician to document that other cause. If the doctor does not specifically document that other condition, you would need to query for that.

Editor’s Note: Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, answered this question in the recent HCPro webinar Cardiovascular Coding: Achieve Success with the Latest ICD-10-CM/PCS Codes.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment. Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.