AHA Coding Clinic® for ICD-9 - 2007 Issue 3; Clarifications

Fluid Overload Due to Dialysis Noncompliance

The Coding Clinic Second Quarter 2001, page 13, advised to assign code 428.0, Congestive heart failure, as the principal diagnosis for a patient admitted in congestive heart failure (CHF) due to fluid overload and noncompliance with dialysis treatment. More recent advice published in Fourth Quarter 2006, page 136, recommended the assignment of code 276.6, Fluid overload, as principal diagnosis for a patient admitted in fluid overload due to missed dialysis treatments because the patient had no history or evidence of CHF. At our facility, we had a case where a patient with end stage renal disease was admitted for treatment of fluid overload due to dialysis noncompliance. This patient had a history of congestive heart failure. However, the provider documented, “The patient was successfully dialyzed and had no evidence of cardiac or pulmonary decompensation other than that of fluid overload due to dialysis and dietary noncompliance.” How would this case be coded? ...

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