Problems with pulmonary edema

Acute pulmonary edema is a serious condition, but coding rules don't always give it its due.

From a clinical standpoint, acute pulmonary edema is a serious and potentially life-threatening condition. However, coding rules give short shrift to acute pulmonary edema in many ways.

To assign codes that appropriately reflect the true severity of illness in a patient with acute pulmonary edema, documentation should specifically clarify the underlying cause.

Photo by Thinkstock
Photo by Thinkstock.

If the patient with pulmonary edema has a diagnosis of heart failure documented in the record, coding rules state that no code is assigned for pulmonary edema, only the appropriate code for heart failure. It is assumed that the pulmonary edema is an integral component of the heart failure and so should not be separately coded. This often results in under-representation of the patient's severity of illness because the type (systolic or diastolic) and acute severity of heart failure may not be clearly documented in the record.

Do not assume that acute pulmonary edema will adequately describe severe heart failure; the “acute” severity of heart failure itself must be specifically documented. The terms “exacerbation” and “decompensated” may be used since for coding purposes they translate as “acute.” The type of acute heart failure must also be described as systolic, diastolic or combined systolic/diastolic; otherwise the severity will not be reflected in the assigned code. Describing the type of acute heart failure as systolic or diastolic “dysfunction” will also result in correct coding.

Acute pulmonary edema may occur as the result of conditions other than heart failure, including ARDS (acute respiratory distress syndrome), volume overload with or without pre-existing heart failure, aspiration (as in near-drowning), altitude sickness, or inhaled toxic substances. Acute “flash” pulmonary edema is thought to occur due to acute cardiac decompensation and is sometimes seen with profound ischemia or very rapid cardiac arrhythmia.

In all situations where pulmonary edema is present, the word “acute” must be included for correct coding of severity; without it, the default code will be a nonspecific symptom of “pulmonary congestion.” It's difficult to imagine a clinical situation in which pulmonary edema would not be “acute,” but coding rules are not always consistent with clinical reality.

In summary, whenever acute pulmonary edema is associated with heart failure, always document the type (systolic or diastolic) and the acute severity of the heart failure. When there is another underlying cause, specifically document that the acute pulmonary edema is due to that condition.

Examples of documentation of acute pulmonary edema include the following:

  • acute pulmonary edema due to decompensated systolic heart failure,
  • acute exacerbation of diastolic heart failure causing acute pulmonary edema,
  • acute pulmonary edema due to volume overload,
  • acute pulmonary edema due to ARDS,
  • acute pulmonary edema resulting from caustic chemical inhalation, and
  • acute pulmonary edema caused by near-drowning.

Examples of documentation of type and acuity of heart failure associated with acute pulmonary edema include the following:

  • acute systolic heart failure or dysfunction,
  • acute diastolic heart failure or dysfunction, and
  • acute combined systolic and diastolic heart failure or dysfunction.