How Do I Code Heart Failure? Type, Acuity, and the Hypertension Combination Codes

Category I50 classifies heart failure by type and acuity. I50.2- is systolic heart failure — inclusion term “Heart failure with reduced ejection fraction [HFrEF]” — with I50.20 unspecified, I50.21 acute, I50.22 chronic, I50.23 acute on chronic. I50.3- is diastolic (“Heart failure with preserved ejection fraction [HFpEF]”), I50.4- combined systolic and diastolic, each with the same acuity characters; I50.2 and I50.3 carry an Excludes1 for the combined code, so combined failure is one I50.4- code. I50.81- is right heart failure. I50.9 carries the inclusion terms “Congestive heart failure NOS” and “Cardiac, heart or myocardial failure NOS.” I50.2-, .3- and .4- each carry a Code Also for end stage heart failure (I50.84), if applicable.

Category I50 opens with a Code First note whose second and third lines matter most: “heart failure due to hypertension (I11.0)” and “heart failure due to hypertension with chronic kidney disease (I13.-).” Section I.C.9.a.1 supplies the presumption: “Hypertension with one or more heart conditions classified to I50.-, Heart failure, I51.4, Myocarditis, unspecified, I51.89, Other ill-defined heart diseases, or I51.9, Heart disease, unspecified, is assigned to a code from category I11, Hypertensive heart disease. Use additional code(s) from category I50, Heart failure, or I51 … to identify the heart condition.” The same conditions “are coded separately if the provider has documented they are unrelated to the hypertension.”

1. Type from the documentation: systolic / HFrEF → I50.2-; diastolic / HFpEF → I50.3-; both → I50.4-; right → I50.81-; “CHF” or “heart failure” with no type → I50.9.
2. Acuity for I50.2-, .3-, .4-: 0 unspecified, 1 acute, 2 chronic, 3 acute on chronic — one code, not an acute code plus a chronic one.
3. Hypertension documented? Then I11.0, Hypertensive heart disease with heart failure, leads and the I50 code follows as its Use Additional code — unless the provider documents the two as unrelated, in which case I10 and the I50 code are reported separately.
4. Chronic kidney disease as well? I13.0 (CKD stage 1–4 or unspecified) or I13.2 (stage 5 / ESRD) replaces I11.0 and I12 together, with two Use Additional codes: the I50 type and the N18 stage (I.C.9.a.3).
5. End stage heart failure documented: add I50.84 per the Code Also note.
6. Sequence by the circumstances — I11.0 / I13.- before I50 by the notes; among other conditions, by the reason for the encounter.

1. Chronic systolic heart failure; no hypertension documented.I50.22.
2. Hypertension and acute on chronic diastolic heart failure; nothing states they are unrelated.I11.0 → I50.33. The presumption in I.C.9.a.1 applies; I50’s Code First note orders it.
3. Hypertension, chronic combined heart failure, and CKD stage 3a.I13.0 → I50.42 → N18.31. I13’s Includes note combines I11 and I12; neither is reported.
4. Hypertension and heart failure; the cardiologist documents the failure as due to a prior anterior infarction, unrelated to the hypertension.I50.9 (or the typed code) and I10, sequenced by the circumstances — the unrelated statement removes I11.

• I10 + I50 for a hypertensive patient with heart failure — I11.0 is presumed and required unless the record says unrelated.
• I11.0 or I13.- without the I50 code — both carry a Use Additional Code note for the type of heart failure.
• Two acuity codes (acute plus chronic) — the acute-on-chronic character is the single code.
• I50.2- plus I50.3- for combined failure — I50.4-, which both exclude.
• I11 or I12 beside I13 — I13 includes both.

• Type: systolic/HFrEF, diastolic/HFpEF, combined, right — or none (I50.9).
• Acuity: acute, chronic, acute on chronic.
• Hypertension in the record — which brings I11/I13 in — and any statement that the heart failure is unrelated to it, which takes them out.
• CKD and its stage (I13 + N18).
• End stage heart failure (I50.84).