From the Guidelines
To document congestive heart failure (CHF) effectively, begin by clearly stating the diagnosis, including the specific type (systolic vs. diastolic) and severity using the New York Heart Association (NYHA) classification (Class I-IV) or American College of Cardiology/American Heart Association (ACC/AHA) stages (A-D), as recommended by the most recent guidelines 1.
Key Components of Documentation
- Document the ejection fraction percentage from recent echocardiograms or other cardiac imaging.
- Include current symptoms such as:
- Dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Fatigue
- Edema
- Their severity
- Note vital signs with particular attention to:
- Blood pressure
- Heart rate
- Respiratory rate
- Oxygen saturation
- Document physical exam findings including:
- Jugular venous distention
- Lung sounds (crackles/rales)
- Heart sounds (S3 gallop, murmurs)
- Peripheral edema
- Hepatomegaly
- List all current medications with dosages, particularly:
- Diuretics (furosemide, spironolactone)
- ACE inhibitors/ARBs (lisinopril, losartan)
- Beta-blockers (metoprolol, carvedilol)
- SGLT2 inhibitors (empagliflozin, dapagliflozin)
- Include recent lab values such as:
- BNP/NT-proBNP
- Electrolytes
- Renal function
- Any changes from baseline
Treatment Plan
- Document the treatment plan including:
- Medication adjustments
- Fluid restrictions
- Daily weight monitoring
- Follow-up timing This comprehensive documentation is essential for tracking disease progression, ensuring appropriate treatment adjustments, facilitating communication between healthcare providers, and supporting medical necessity for interventions and insurance purposes, as emphasized in the guidelines 1.
From the FDA Drug Label
In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention In one of the studies, the combination of lisinopril, digitalis and diuretics reduced orthopnea, presence of third heart sound and the number of patients classified as NYHA Class III and IV; and improved exercise tolerance.
To document Congestive Heart Failure (CHF), the following signs and symptoms should be recorded:
- Edema
- Rales
- Paroxysmal nocturnal dyspnea
- Jugular venous distention
- Orthopnea
- Presence of third heart sound
- NYHA Class
- Exercise tolerance 2
From the Research
Documenting Congestive Heart Failure (CHF)
To document CHF, the following steps can be taken:
- A thorough physical examination and basic, noninvasive evaluation are essential for establishing the diagnosis of heart failure and for designing an optimal, individualized treatment regimen 3.
- The measurement of serum brain natriuretic peptide and echocardiography have substantially improved the accuracy of diagnosis 4.
- Echocardiography is an essential tool for the diagnostic work up in patients with AHF, and no individual parameter reliably detects congestion, thus the physician must integrate several measurements from the right and left heart 5.
- Lung ultrasound (LUS) is particularly helpful in assessing congestion, and it has demonstrated diagnostic, therapeutic, and prognostic value in AHF 5.
Key Components of Documentation
The documentation of CHF should include:
- A careful history and physical examination 4.
- Characteristic chest-radiograph findings 4.
- Results of echocardiography and LUS 5.
- Measurement of serum brain natriuretic peptide 4.
- Assessment of the severity of heart failure, including exercise tolerance and clinical class 3, 6.
Utilization and Medical Coding
The documentation of CHF should also include: