A Tale as Old as Time: Heart Failure & Fluid Overload

In a daring (yet pedantic) exploration, Dr Felicity Sinclair-Ford wants to dig deep into the coding rules around heart failure and fluid overload.

An episode of The Paper Round on heart failure was recently published here on the CDIA Community. It discussed the presentation, treatment, and clues that CDSs can look for to identify a missing diagnosis of this common condition.

And an astute viewer asked the inevitable question.

“A recurring issue for coding heart failure, is whether or not to code fluid retention [overload] as an additional diagnosis. Would be interested in your and others' opinion on this.”

There’s always one.

But the viewer is right, this topic causes confusion, disagreement, conflict, panic, horror, the tearing apart of otherwise amicable colleagues, the complete collapse of healthcare organisations, the end of the galaxy as we know it.

Okay…maybe it’s not that bad.

But there certainly is nothing close to consensus regarding this slippery subject.

So, is there any guidance from the Australian Coding Standards to help us?

Hold on to your hats, because yes there is…and it’s a lot.

To simplify this discussion, I am going to only discuss clinical situations in which the fluid overload is SECONDARY TO heart failure. And even that is complicated enough.

Coding Wars

Let’s enter hyperspace and chart the saga of coding heart failure.

The First Rule

The retired Coding Matters advice Volume 7 Number 3 stated that “It is not necessary to code volume (fluid) overload in a patient with CHF”. This was a definitive cut-and-dried rule: you can’t code both.

Subsequently, however, this was retired, and further advice superseded this rule.

Attack of the VICC

The VICC coding query 3089 asked whether both fluid overload and congestive cardiac failure can be coded when both are treated during an episode of care. The response?

“VICC advises that if the documentation supports that both the fluid overload and the congestive cardiac failure independently meet criteria for coding, a code for both conditions can be assigned.”

And the response to VICC coding query 3118 said basically the same thing.

“VICC advises that if the documentation supports that both the fluid overload and the left ventricular failure/congestive cardiac failure meet criteria for coding, a code for both conditions can be assigned.”

The Coding Standards Return

Then we have coding rule Coding Rule Q2730. The question posed was specific to end stage renal disease and pulmonary oedema. However, heart failure and fluid overload featured in the answer.

“Fluid overload results from diseases where there is compromised regulation of sodium and water such as renal failure, congestive heart failure (CHF) and liver failure. Fluid overload in a patient with ESKD may cause cardiopulmonary complications such as pulmonary oedema (PO) and CHF. Patients may present with a combination of multiple cardiac and/or liver diseases and/or noncompliance with treatment which may contribute to fluid overload.

The selection of principal diagnosis (PDx) for a patient admitted with fluid overload depends on what other conditions are documented and the circumstances of the admission. Coders should be guided by ACS 0001 Principal diagnosis/Problems and underlying conditions and ACS 0002 Additional diagnoses/Problems and underlying conditions. Each case should be reviewed based on documentation and coders should seek clarification from the clinician where there is uncertainty regarding the principal diagnosis.”

So this rule states that coders should follow the “problems and underlying conditions” in ACS0001 and ACS0002 when considering these conditions.

If we look at the relevant coding rules, the ACS0001 “problems and underlying conditions” instructs that if a patient presents with a problem, and the underlying condition is discovered during the hospital admission, then the underlying condition is coded as the principal diagnosis.

If the patient presents with a problem, and the underlying condition is known at the time of admission, the PROBLEM is coded as the principal diagnosis. But the underlying condition is ALSO coded.

What about ACS0002 “problems and underlying conditions”?

It’s much simpler.

“If a condition (problem) with a known underlying cause is treated in an episode of care, then assign codes for both conditions.”

Western Australia Strikes Back

The Western Australian Coding rule 1017/07 reiterates Coding Rule Q2730. However, this rule instructs coders to assign the principal diagnosis nominated by the doctor, and not resequence based on “ACS 0001 Principal diagnosis/Problems and underlying conditions”.

Phew! It’s understandable that there’s confusion around this topic, given the evolution of the standards over the time, and the fact that some standards seem to contradict each other.

I’ve made this handy table for reference.

Coding Matters (Retired) - December 2000

VICC Coding Query 3089 - June 2016

VICC Coding Query 3118 - September 2016

Coding Rule Q2730 - 2013

Western Australian Coding Rule 1017/07 - 2018

Don’t code fluid overload in patient with CCF

Can code both if they both independently meet ACS0002

Can code both if they both independently meet ACS0002

As per Problems and Underlying Conditions (i.e. sequence problem as PD and underlying cause as AD). If both ADs assign code for problem and underlying condition.

Reiterates Coding Rule Q2730. If doctor’s nominated PD does not align with Problems and Underlying Conditions then code as per Doctor’s nominated PD


So we’ve looked into the forces influencing the (ICD-10-AM) galaxy.

Next time, we’ll dig into the implications, contradictions, and clinical considerations of this plethora of advice. 

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