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Coronary
Artery Disease (CAD) and Congestive Heart Failure (CHF) Codes
Dearth of Data
The
prevalence of clinically documented CHF in one study (ref., below) was
27.1% (1376/5083).
- The
ICD code 428 (CHF), assigned as the primary or a secondary discharge
diagnosis, was associated with 62.8% sensitivity, 95.4% specificity,
83.5% positive predictive value, 87.4% negative predictive value, and
a 24.8% underenumeration of CHF-related hospitalizations.
- An
algorithm based on a series of ICD codes was associated with 67.1% sensitivity,
92.6% specificity, 77.1% positive predictive value, 88.3% negative predictive
value, and a 13.0% underenumeration of CHF-related hospitalizations.
Conclusions:
Reliance on ICD codes results in the exclusion of 1/3 of the patients
with clinical evidence of acute CHF.
"This
underenumeration is compounded by the typical reliance on the first listed
diagnosis. CHF may be a greater public health problem than currently recognized.
The allocation of resources for relevant surveillance, research, medical
care, and preventive efforts should be reevaluated."
Arch Intern Med. 2000;160:197-202.
Other References:
Ho
KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the
Framingham Study. J Am Coll Cardiol. 1993;22:6A-13A.
Krumholz HM, Parent EM, Tu N, et al. Readmission after hospitalization
for congestive heart failure among Medicare beneficiaries. Arch Intern
Med. 1997;157:99-104.
Graves EJ, Gillum BS. National Hospital Discharge Survey: Annual Summary,
1994. Vital Health Stat 1997;128:1-50.
Graves EJ, Gillum BS. Detailed Diagnoses and Procedures, National Hospital
Discharge Survey, 1994. Vital Health Stat 1997;127:1-145.
Rich MW. Epidemiology, pathophysiology, and etiology of congestive heart
failure in older adults. J Am Geriatr Soc. 1997;45:968-974.
ICD Codes:
Source: HealthLeaders.com (in CAPs) and also, from Merck: Level 1 Dx Codes
(file: H:/vol1/Medical/CHF/Codes/CHF_alg and for Rx: CHF_ndc2)
398.91-Rheumatic Heart Failure (congestive)
402.01-Malignant Hypertensive Heart Disease with CHF
402.11-Benign Hypertensive Heart Disease with CHF
402.91-Hypertensive Heart Disease with CHF
404.00-MAL HYPERTEN HEART/REN W/O CHF/RF
404.01-Hypertensive Heart and Renal Disease, Malignant, With CHF
404.03-Hypertensive Heart and Renal Disease, Malignant, With CHF
404.10-BEN HYPERTEN HT/REN W/O CHF/RF
404.11-Hypertensive Heart And Renal Disease, Benign, With CHF
404.13-Hypertensive Heart And Renal Disease, Benign, With CHF
404.90-HYPERTEN HT/REN NOS W/O CHF/RF
404.91-Hypertensive Heart And Renal Disease, Unspecified, With CHF
404.93-Hypertensive Heart + Renal Disease, Unspecified, With CHF
425.* -Cardiomyopathy
425.2-Obscure Cardiomyopathy of Africa
425.4-Other Primary Cardiomyopathies
425.5-Alcoholic Cardiomyopathy
425.7-Nutritional and Metabolic Cardiomyopathy
425.8-Cardiomyopathy In Other Diseases Classified Elsewhere
425.9-Secondary Cardiomyopathy, Unspecified
428.* -Heart Failure
428.0-Congestive Heart Failure
428.1-Left Heart Failure
428.9-Heart Failure, Unspecified
514 - Pulmonary edema
Secondary Diagnoses may be suggested by the following CPT codes 78460,
78461, 78464, 78465, 78472, 78473, 78475, 78478, 78480, 78891, 78990
E&M's (office, hosp., referral) + 92950-93799 93000, 93015, 93307, 93320,
93325, 93350, 93503, 93510, 93526, 93541, 93798
410.0 - 410.9,
the MI code
Use HEDIS
criteria to identify members with a coronary event +
anyone who has had a claim with a CAD or angina diagnosis +
HEDIS criteria for the measures "Cholesterol Management after Acute Cardiovascular
Event" and "Beta Blocker after a Heart Attack" (include the diagnosis
codes 410.x1 for AMI. However, ICD code 410.0 - 410.9, the MI codes, have
been associated with as much as a 20% false positive rate, found when
doing claims analysis, confirmed with laborious chart review. For example,
it appears that sometimes MI is the code used for ruling out MI in patients
who ultimately did not have the diagnosis. This is probably not intentional
upcoding as there are no institutional trends associated with this phenomenon).
411.1
Intermediate Coronary Syndrome
411.81 Coronary Occlusion without Myocardial Infarction
413. Angina Pectoris
413.0 Angina Decubitis 413.1 Prinzmetal Angina
413.9 Angina Pectoris NES/NOS
414.0 Coronary Atherosclerosis
414.00 Cor Ath, Unsp VSL NTV/GFT
785 Cardiovascular Symptoms
Complex: Male & Age > 45 years & 272. Diseases of Lipoid Metabolism &
401. Hypertension & 786.5 Chest Pain 786.50 Chest Pain NOS 786.59 Chest
Pain NEC
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