Heart Failure vs. Dysfunction

The most recent diagnostic trend among cardiologists is a “new” type of heart problem known as heart dysfunction. When heart dysfunction becomes severe, heart failure can occur. Heart failure means that the heart isn’t pumping properly in order to deliver oxygen and nutrients to the body. This can lead to lack of cells delivered through the blood which would in turn cause the patient to experience symptoms of fatigue, shortness of breath and even coughing. Heart failure is a progressive chronic condition that eventually can’t keep up with the body demand. Symptoms begin with enlargement of the heart, muscle mass increases and pumps faster. The body tries to help by also narrow of vessels and stops delivering blood to less important tissues and organs. All these accommodations only work for a brief time as the progression of heart failure eventually becomes too much.  Cardiology tests that can measure include the ejection echocardiogram, MUGA scan, CAT scan nuclear stress test, and heart catheter.

Below are the types of heart failure that can occur in a patient:

• Left side heart failure – the most common type of heart failure; occurs when the left ventricle does not pump efficiently, leading to lack of oxygen -rich blood in the body
• Systolic heart failure (reduced ejection fraction) – also documented as HFrEF; the left ventricle is not able to contract normally to deliver blood
• Diastolic heart failure (preserved ejection fraction) – also documented as HFpEF; left ventricle cannot relax, allowing it to fill with blood causing the muscle to stiffen
• Right side failure – Also known as right ventricular failure. Blood backs up in the body’s veins due to the pressure of increased pressure from the left side heart failure. Symptoms include swelling in abdomen, legs and ankles and leads to damage on the right side.
• Congestive heart failure- Causes fluid buildup within the body that leads to edema. Patient should see medical attention as soon as possible.

The term ejection fraction refers to the measurement that the pumps blood through the left ventricle. It is a percentage that measures the total amount of blood pumped throw the left ventricular with each heartbeat. Normal ejection fraction is between 50 and 70 percent; however, you can exhibit normal ejection fraction and still have a diagnosis of heart failure if the muscle is thick and stiff. If your EF measures below 40%, this could indicate the presence of failure or cardiomyopathy. Anything higher than 70% EF is most likely hypertrophic cardiomyopathy.

And so, if the provider calls out dysfunction or refers to ejection fraction, can you bill heart failure?

The answer:

No, diastolic dysfunction without mention of heart failure is indexed to 429.9, Heart disease, unspecified. It is not appropriate to assume a patient is in heart failure when only “diastolic dysfunction” or “systolic dysfunction” is documented.” Diastolic or Systolic Dysfunction without Heart Failure (2009 Vol.26 No.1). Therefore, unless a provider specifically documents ‘heart failure,’ dysfunction is not an appropriate definitive diagnosis.