Cardiac Arrest and Cardiogenic Shock

Can cardiac arrest and cardiogenic shock be coded together?

Prior to October 1, 2020 there had been an Excludes1 note at category I46.- Cardiac arrest that excluded R57.0, Cardiogenic shock. Previous direction in response to a question submitted to AHA had stated that only a code from category I46.- Cardiac arrest would be coded if both were documented. Additionally, advice in AHA Coding Clinic, Third Quarter 2020, Page 26 for a similar case instructed that only the code for cardiac arrest, would be assigned if both were documented because the code for cardiogenic shock (R57.30) is a sign/symptom code from Chapter 18 and the category I46.- code is more definitive. However, the advice in Coding Clinic indicated that the CDC would be looking at a possible revision to the Excludes1 note.   As of October 1, 2020, the Excludes1 note has been revised to an Excludes2 note. So, what does this mean? First let’s look at the definitions of these two conditions.

What is Cardiac Arrest?

Cardiac arrest is when the patient’s heart stops. It is the abrupt loss of heart function due to a disruption in the heart’s electrical system.  The heart function or pumping totally stops.  Hence the name “arrested” or stopped. Death can result quickly if CPR and/or defibrillation is not used to restore the heart rhythm.   The most common cause of cardiac arrest is an arrythmia.  Ventricular fibrillation is the most common arrhythmia to cause cardiac arrest.  Other causes include MI, coronary artery disease, cardiomyopathy, valvular heart disease, and congenital heart disease.

What is Cardiogenic Shock?

Cardiogenic shock occurs when the heart can’t pump enough blood to meet the body’s needs. It can be caused by a heart attack, heart failure, myocarditis (inflammation of the heart), endocarditis (inflammation of the heart valves), drug overdoses/poisoning or other causes.  It is not fatal if treated immediately.  Symptoms include rapid breathing, severe shortness of breath, sudden, rapid heartbeat (tachycardia), loss of consciousness, weak pulse, low blood pressure (hypotension), sweating, pale skin, cold extremities and low urine output. It can be fatal if not treated and can cause damage to the liver, kidneys or other organs.  Treatment includes possible mechanical ventilation, vasopresser agents such as Levophed or dopamine, aspirin, use of thrombolysis agents such as Activase or Retavase and blood thinning  and antiplatelet medications. If an MI due to coronary artery blockage is causing cardiogenic shock, then an angioplasty with stents may be performed.   A balloon pump may also be utilized.  Cardiogenic shock can lead to cardiac arrest if not treated immediately.

So, What is the Coder to Do?

As of October, 1, 2020 Excludes1 note under category I46.- was changed to an Excludes2 note as shown below.

I46 Cardiac arrest

Excludes2: cardiogenic shock (R57.0)

I46.2 Cardiac arrest due to underlying cardiac condition

Code first underlying cardiac condition

I46.8 Cardiac arrest due to other underlying condition

Code first underlying condition

I46.9 Cardiac arrest, cause unspecified

Excludes2 notes are defined as “Not included here.” An Excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.  That being said, if cardiogenic shock is due to something other than what caused the cardiac arrest, both can be coded. However, if cardiogenic shock leads to cardiac arrest, what is the coder to do?

Although the instructional note had been changed to Excludes2 note, since cardiogenic shock is a symptom code, it was still unclear whether, based on this it is allowable for both conditions to be reported when they are related to the same cause. To clarify, HIA submitted a case to AHA Coding Clinic to see if both cardiogenic shock and cardiac arrest are both coded when documented. 

In February 2021, HIA received a response from AHA stating that, yes, it is appropriate to report both R57.0, Cardiogenic shock along with a code from category I46.- Cardiac arrest when both conditions are documented by the provider, even if they are related to the same cause.

References:

• mayoclinic.org/diseases-conditions/cardiogenic-shock/symptoms-causes/syc-20366739
• mayoclinic.org/diseases-conditions/sudden-cardiac-arrest/symptoms-causes/syc-20350634

In need of coding support? We offer both inpatient coding support and outpatient coding support services. Partner with us to replace underperforming coding vendors, get coding backlogs caught up, staff for a FMLA/vacation gap, special projects, to assist in Single Path Coding, or for Total Outsource Coding Support.

The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.