Heart Failure

Heart failure documentation must include the following key elements:

1. Type of heart failure

  • Diastolic
  • Systolic
  • Combined Diastolic and Systolic

Note: Documentation of Systolic and/or Diastolic Dysfunction does not equate to the type of heart failure. Heart failure and dysfunction are not interchangeable terms; documentation needs to state the type of “heart failure.”

2. Acuity of heart failure

  • Acute
  • Chronic
  • Acute on Chronic

3. Is the heart failure known to be due to an underlying condition?

  • Any causative cardiomyopathy
  • Hypertension
  • Hypertension with chronic kidney disease
  • Acute myocardial infarction this admission or within the last four weeks
  • Relationship with chronic renal failure, volume overload, or non-cardiac pulmonary edema
  • Due to malfunction of cardiac prosthesis
  • Following cardiac surgery
  • Secondary to hypertensive heart disease link supported by physician

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