Congestive Heart Failure Care Management Guide Content Summary Measures: Compiled from the National Quality Forum, National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, ActiveHealth Management, and more. Pathways and Guidelines: Appearing in the form of stepwise diagrams and charts, these care pathways are currently practiced as management guidelines for diabetes, and recommended by groups such as the University Health System and the Mayo Clinic. Current Tools and Encounter Forms: Refer for examples of tools used in CHF treatment contexts. Sources: 1) http://www.universityhealthsystem.com/files/03-Diuresis%20Algorithm.pdf 2) http://www.universityhealthsystem.com/files/01-Algorithm,%20Page%201.pdf 3) http://www.universityhealthsystem.com/files/02-Algorithm,%20Page%202.pdf 4) http://www.universityhealthsystem.com/files/01- Pharmacologic%20Algorithm%20for%20Acute%20Decompensated%20CHF%20%28May,%202004%29.pdf 5) http://www.lef.org/protocols/heart_circulatory/congestive_heart_failure_03.htm#treatment 6) http://www.mayoclinic.org/congestive-heart-failure/treatment.html 7) http://www.vreehealth.com/vreehealth/products/services?gclid=COGHl4LpprYCFYxaMgodY30ABw 8) http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2007/rwjf27044 9) http://www.iqbalandkhansurgical.com/sitebuildercontent/sitebuilderfiles/preopencounterform.pdf 10) https://providers.amerigroup.com/ProviderDocuments/WAWA_Internal_Medicine_Encounter.pdf
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Congestive Heart Failure Care Management Guide
Content Summary
Measures: Compiled from the National Quality Forum, National Committee for Quality Assurance, Centers for Medicare and Medicaid Services, ActiveHealth Management, and more. Pathways and Guidelines: Appearing in the form of stepwise diagrams and charts, these care pathways are currently practiced as management guidelines for diabetes, and recommended by groups such as the University Health System and the Mayo Clinic. Current Tools and Encounter Forms: Refer for examples of tools used in CHF treatment contexts. Sources: 1) http://www.universityhealthsystem.com/files/03-Diuresis%20Algorithm.pdf 2) http://www.universityhealthsystem.com/files/01-Algorithm,%20Page%201.pdf 3) http://www.universityhealthsystem.com/files/02-Algorithm,%20Page%202.pdf 4) http://www.universityhealthsystem.com/files/01-Pharmacologic%20Algorithm%20for%20Acute%20Decompensated%20CHF%20%28May,%202004%29.pdf 5) http://www.lef.org/protocols/heart_circulatory/congestive_heart_failure_03.htm#treatment 6) http://www.mayoclinic.org/congestive-heart-failure/treatment.html 7) http://www.vreehealth.com/vreehealth/products/services?gclid=COGHl4LpprYCFYxaMgodY30ABw 8) http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2007/rwjf27044 9) http://www.iqbalandkhansurgical.com/sitebuildercontent/sitebuilderfiles/preopencounterform.pdf 10) https://providers.amerigroup.com/ProviderDocuments/WAWA_Internal_Medicine_Encounter.pdf
Measures Used with Congestive Heart Failure
Centers for Medicare and
Medicaid Services
NQF 229: - Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following heart failure (HF) hospitalization for patients 18 and older
NQF 699: - 30-Day Post-Hospital HF Discharge Care Transition Composite Measure - scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of heart failure for three types of events: readmissions, ED visits and evaluation and management (E&M) services.
NQF 698: - 30-Day Post-Hospital AMI Discharge Care Transition Composite Measure - scores a hospital on the incidence among its patients during the month following discharge from an inpatient stay having a primary diagnosis of heart failure for three types of events: readmissions, ED visits and evaluation and management (E&M) services.
NQF 521: - Heart Failure Symptoms Addressed - Percent of patients exhibiting symptoms of heart failure for whom appropriate actions were taken
American Medical
Association - Physician
Consortium for Performance Improvement (AMA-PCPI)
NQF 78: - Heart Failure (HF) : Assessment of Clinical Symptoms of Volume Overload (Excess)
NQF 83: - Heart Failure : Beta-blocker therapy for Left Ventricular Systolic Dysfunction - Percentage of patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting or at hospital discharge
NQF 81: - Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction
NQF 1524: - Assessment of Thromboembolic Risk Factors (CHADS2) - Patients with nonvalvular atrial fibrillation or atrial flutter in whom assessment of thromboembolic risk factors using the CHADS2 risk criteria has been documented
ActiveHealth Management
NQF 610: - Heart Failure - Use of ACE Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) Therapy - The percentage of patients aged 18 and older with Heart Failure who are on an ACEI or ARB
NQF 615: - Heart Failure - Use of Beta Blocker Therapy - The percentage of patients 18 years and older diagnosed with heart failure who are taking a beta blocker
NQF 624: - Atrial Fibrillation - Anticoagulation Therapy - Percentage of adult patients aged 25 and older with atrial fibrillation and major stroke risk factors who are on anticoagulation therapy.
Centers for Disease Control and Prevention
NQF 2020: - Adult Current Smoking Prevalence - Percentage of adult (age 18 and older) U.S. population that currently smoke.
Agency for Healthcare
Research and Quality
NQF 358: - Congestive Heart Failure (CHF) Mortality Rate (IQI 16) - Perecent of discharges with principal diagnosis code of CHF with in-hospital mortality
NQF 277: - Heart Failure Admission Rate (PQI 8) - Percent of county population with an admissions for heart failure.
Accountable Care Organization
ACO 10: - Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure - age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years
Data gathering sources for measures like ACO 10 include claims data, ICD9 codes, and service dates.
Pharmacologic Algorithm for Diuresis in CHF
Yes
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
No
No
No
No
1. Monitoring Parameters: *Weights: initially 1-2lbs weight loss per day until “ideal” weight
achieved *Volume depletion -Hypotension -Dizziness -Decreased urine output -Increased BUN (BUN/Cr > 20) *Electrolytes -Supplement K+ if <3.5 mg/dL in patient not on Digoxin and K+ <
4.0mg/dL if patient on Digoxin 2. If patient symptoms are controlled during day, but worse at night,
may need to administer diuretic regimen in evening or more frequently as needed
3. When Furosemide dose is >80-120 mg/day, use BID dosing 4. May require increase in monitoring and tighter control of K+, Mg2+
At Mayo Clinic, doctors trained in heart care (cardiologists) and cardiologists with advanced training in heart failure (heart failure cardiologists) treat people who have
congestive heart failure. Mayo Clinic cardiac surgeons have extensive experience in all types of surgery to treat heart failure and other heart diseases. Surgeons
Congestive heart failure treatment can significantly improve your symptoms and help your weakened heart work as efficiently as possible. Doctors treat some people by
correcting the underlying cause of the condition, such as controlling a fast heart rhythm, opening blocked arteries or repairing or replacing diseased valves. Heart failure
specialists also treat conditions that may aggravate your underlying heart problems, such as sleep apnea, thyroid problems, anemia and other blood abnormalities.
Congestive heart failure treatment at Mayo Clinic may include surgery, medical devices, medications and lifestyle changes.
Surgery
Heart valve repair or replacement. Cardiologists may recommend heart valve repair or replacement surgery to treat an underlying condition that led tocongestive heart failure. Heart valve surgery may relieve your symptoms and improve your quality of life.
Coronary bypass surgery. Cardiologists may recommend coronary bypass surgery to treat your congestive heart failure if your disease results fromseverely narrowed coronary arteries.
Heart transplant. Some people who have severe congestive heart failure may need a heart transplant.
Myectomy. In a myectomy, the surgeon removes part of the overgrown septal muscle in your heart to decrease the blockage that occurs in hypertrophiccardiomyopathy. Surgeons may perform myectomy when medication no longer relieves your symptoms.
Medical devices
Ventricular assist device (VAD). When your weakened heart needs help pumping blood, surgeons may implant a VAD into yourabdomen and attach it to your heart. These mechanical heart pumps can be used either as a "bridge" to heart transplant or aspermanent therapy for people who aren't candidates for a transplant. Mayo Clinic offers VADs to many people who may have noother options.
Cardiac resynchronization therapy (CRT) device (biventricular cardiac pacemaker). A cardiacresynchronization therapy device (biventricular cardiac heart pacemaker) sends specifically timedelectrical impulses to your heart's lower chambers. CRTs are suitable for people who have moderateto severe congestive heart failure and abnormal electrical conduction in the heart.
Internal cardiac defibrillator (ICD). Doctors implant ICDs under the skin to monitor and treat fast orabnormal heart rhythms (arrhythmias), which occur in some people who have heart failure. The ICDsends electrical signals to your heart if it detects a high or abnormal rhythm to shock your heart intobeating more slowly and pumping more effectively.
Medications. Doctors usually treat people who have congestive heart failure with medications proven torelieve symptoms and increase survival in people who have heart failure. Your doctor may also prescribemedications to lower blood pressure, improve circulation and prevent blocked arteries or blood thinners toprevent blood clots.
Several types of drugs may help treat your heart failure if you have reduced blood flow pumping out of your heart's main pumping chamber (left ventricle).
Angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors lower blood pressure, improve blood flow and decrease your heart's workload.
Angiotensin II (A-II) receptor blockers. These drugs provide several benefits of ACE inhibitors without the potential side effect of a persistent cough.
Beta blockers. Beta blockers slow the heart rate, lower blood pressure and lessen the risk of some abnormal heart rhythms.
Digoxin. Also known as digitalis, digoxin increases the strength of heart contractions and tends to slow your heartbeat.
Diuretics. Diuretics prevent fluid from collecting in your body and decrease fluid in your lungs, making breathing easier.
Nesiritide. Nesiritide, which is given through a vein (intravenously), is a synthetic version of B-type natriuretic peptide (BNP), a hormone that occurs naturallyin your body.
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Aldosterone antagonists. These medications may help your heart work better, reverse scarring of the heart and help prolong your life if you have severecongestive heart failure.
Inotropes. These are intravenous medications used in severe heart failure patients to improve heart pumping function and maintain blood pressure.
Sometimes congestive heart failure becomes severe enough to require hospitalization and monitoring for a few days. While you're in the hospital, you may take
medications that quickly help your heart pump better and relieve your symptoms. You may also receive supplemental oxygen. People who have severe congestive
heart failure that doesn't improve with treatment may need supplemental oxygen on a long-term basis.
Lifestyle changes. Lifestyle changes often can relieve symptoms of congestive heart failure and prevent your disease from worsening. Some changes youcan make include:
Avoiding or limiting alcohol to one drink two or three times a week
Avoiding or limiting caffeine
Eating a low-fat, low-sodium diet
Exercising by yourself or in a structured cardiac rehabilitation program
Maintaining a healthy weight or losing weight if you're overweight
Weight _____________ lbs kgs Height _____________ in cm
COMORBIDITIES (You must select ONLY ONE per category for each system)
First Name _______________________ Chart Number ________________
Hypertension No history Borderline, no medication Diagnosis of hypertension, no medication Treatment with single medication Treatment with multiple medications Poorly controlled by medications, organ damage
Congestive Heart Failure No history or symptoms of congestive heart failure Class I: Symptoms with more than ordinary activity Class II: Symptoms with ordinary activity Class III: Symptoms with minimal activity Class IV: Symptoms at rest
Ischemic Heart Disease No history of ischemic heart disease Abnormal ECG, no active ischemia History of MI or antiischemic medication PCI, CABG Active ischemia
Angina Assessment No chest pain symptoms/angina Anginal chest with extreme exertion (e.g. running, swimming, etc.) Anginal chest pain occurs with moderate activity or exertion Anginal chest pain with minimal exertion (e.g. walking across a room) or 'at rest Unstable angina
Peripheral Vascular Disease No symptoms of peripheral vascular disease Asymptomatic with bruit Claudication, antiischemic medication Transient ischemic attack, rest pain Procedure for peripheral vascular disease Stroke, loss of tissue secondary to ischemia
Lower Extremity Edema No symptoms of lower extremity edema Intermittent lower extremity edema, not requiring treatment Symptoms requiring treatment, diuretics, elevation, or hose Stasis ulcers Disability, decreased function, hospitalization
DVT/PE No history of DVT/PE History of DVT resolved with anticoagulation Recurrent DVT long term anticoagulation meds Previous PE Recurrent PE, decreased function, hospitalization Vena Cava filter
CARDIOVASCULAR DISEASE
METABOLIC Glucose Metabolism No symptoms or evidence of diabetes Elevated fasting glucose Diabetes, controlled with oral medication Diabetes, controlled with insulin Diabetes, controlled with insulin and oral medication Diabetes, with severe complications (retinopathy, neuropathy, renal failure, blindness)
Gout Hyperuricemia No symptoms of gout/hyperuricemia Hyperuricemia, no symptoms Hyperuricemia, medications Arthropathy Destructive joints Disability, unable to walk
Lipids (Dyslipidemia or Hyperlipidemia) Not present Present, no treatment required Controlled with lifestyle change, including Step 1 or Step 2 diet Controlled with single medication Controlled with multiple medications Not controlled
Obstructive Sleep Apnea Syndrome No symptoms or evidence of obstructive sleep apnea syndrome Sleep apnea symptoms (negative sleep study or not done) Sleep apnea diagnosis by sleep study (no oral appliance) Sleep apnea requiring oral appliance such as CPAP Sleep apnea with significant hypoxia or oxygen dependent Sleep apnea with complications (pulmonary HTN, etc.)
Obesity Hypoventilation Syndrome No symptoms of obesity hypoventilation Hypoxemia/hypercarbia on room air Severe hypoxemia or hypercarbia Pulmonary hypertension Right heart failure Right heart failure left ventricular dysfunction
PULMONARY Pulmonary Hypertension No symptoms or indication of pulmonary hypertension Symptoms associated with PH(tiredness, SOB, dizziness, fainting) Confirmed PH diagnosis Well controlled on anticoagulants and/or calcium channel blockers Stronger medications and/or oxygen Patient needs or has had lung transplant
Asthma No symptoms of asthma Intermittent mild symptoms, no medication Symptoms controlled with oral inhaler (such as albuterol) Well controlled with ongoing daily medication Symptoms not well controlled, steroids or anticholinergics Hospitalized within last 2 years, history of intubation
GASTROINTESTINAL GERD No history of GERD Intermittent or variable symptoms, no medication Intermittent medication H2 blockers or low dose PPI High dose PPI Meet criteria for antireflux surgery, or prior surgery for GERD
Cholelithiasis No history of gallstones Gallstones with no symptoms Gallstones with intermittent symptoms Gallstones with severe symptoms or h/o cholecystectomy Gallstones with complications requiring immediate surgery prior to gastric bypass History of cholecystectomy with ongoing complications not resolved
Liver Disease No history of liver disease Hepatomegaly modest, normal LFT's, fatty change Category 1 Modest or greater hepatomegaly, LFT alteration, fatty change Category 2 Moderate to marked hepatomegaly, fatty change Category 3, mild
inflammation, mild fibrosis Definite NASH, cirrhosis, hepatic dysfunction by LFT's Hepatic failure, transplant indicated or done
Multiple Vitamin Calcium Vitamin B12 Iron Vitamin D Vitamin A, D, E Combo Calcium with Vitamin D
COMORBIDITIES (continued) (You must select ONLY ONE per category for each system)
REPRODUCTIVE Polycystic Overian Syndrome No history of polycystic ovarian syndrome Symptoms of PCOS, no treatment OCP's or antiandrogen Rx Medformin or TZD Combination therapy Infertility
Menstrual Irregularities (not PCOS) No history of menstrual irregularities Irregular periods or oligomenorrhea Menorrhagia Amenorrhea Prior total abdominal hysterectomy
MUSCULOSKELETAL
Musculoskeletal Disease No symptoms of musculoskeletal disease Pain with community ambulation Non narcotic analgesia required Pain with household ambulation Surgical intervention required (ex: arthroscopy) Awaiting or past joint replacement or other disability
Back Pain No symptoms of back pain Intermittent symptoms not requiring medical treatment Symptoms requiring nonnarcotic treatment Degenerative changes or positive objective findings, symptoms requiring narcotic treatment Surgical intervention done or recommended pending weight loss Failed previous surgical intervention with existing symptoms
Fibromyalgia No history of fibromyalgia Treatment with exercise Treatment with nonnarcotic medications Treatment with narcotics Treatment with narcotics: Surgical intervention done or recommended Disabling, treatment not effective
MEDICATIONS/VITAMINS & MINERALS
Stress Urinary Incontinence No history of stress urinary incontinence Minimal and intermittent Frequent but not severe Daily occurrence, requires sanitary pad Disabling Operation ineffective
Pseudotumor Cerebri No symptoms of pseudotumor cerebri Headaches with dizziness, nausea, and/or pain behind the eyes, no visual symptoms Headaches with visual symptoms and/or controlled with diuretics Patient has had MRI to confirm PTC, is well controlled with oral diuretics Patient is well controlled with stronger medications Patient requires narcotics or has had (or needs) surgical intervention
Abdominal Hernia No hernia Asymptomatic hernia, no prior operation Symptomatic hernia with or without incarceration Successful repair Recurrent hernia or size > 15 cm Chronic evisceration through large hernia with associated complication or multiple failed hernia repairs
GENERAL Functional Status No impairment of functional status Able to walk 200ft with assistance device (cane or crutch) Cannot walk 200ft with assistance device (cane or crutch) Requires wheelchair Bedridden
Abdominal Skin/Pannus No symptoms Intertriginous irritation Pannus so large it interferes with ambulation Recurrent cellulitis, ulceration Surgical treatment required
SIGNATURE (Name and Signature of person completing Encounter Form)
Name (print) _______________________________ Signature _____________________________________
Psychosocial Impairment No impairment Mild impairment in psychosocial functioning but able to perform all primary tasks Moderate impairment in psychosocial functioning but able to perform most primary tasks Moderate impairment in psychosocial functioning and unable to perform some primary tasks Severe impairment in psychosocial functioning and unable to perform most primary tasks Severe impairment in psychosocial functioning and unable to function
Depression No symptoms of depression Mild and episodic not requiring treatment Moderate, accompanied by some impairment, may require treatment Moderate with significant impairment, treatment indicated Severe, definitely requiring intensive treatment Severe requiring hospitalization
Alcohol Use None Rare Occasional Frequent
Tobacco Use None Rare Occasional Frequent
Substance Abuse (Prescription or Illegal) None Rare Occasional Frequent
PF-ALL-0077-12
Internal Medicine Encounter Form Mail to: Claims Department Amerigroup P.O. Box 61010 Virginia Beach, VA 23466-1010
Member Information Provider Information
Last Name: Provider Name:
First Name: Phone #: Provider ID #:
Member ID #: Date of Birth: Fax #: Date of Visit:
Address:
Level of Care: Please circle at least one CPT (Procedure) Code.
Preventive/Physical Office Visit Counseling
Age New Established New Patient
Established Patient
Code Length of Time
12–17 99384 99394 99201 99211 99401 15 minutes
18–39 99385 99395 99202 99212 99402 30 minutes
40–64 99386 99396 99203 99213 99403 45 minutes
65+ 99387 99397 99204 99214 99404 60 minutes
99205 99215
Diagnosis Codes: Please indicate primary, secondary, and tertiary codes (1, 2, 3). *If elements of well care were performed, please mark a well code as a secondary diagnosis.
Well Child/Preventive ICD-9 Codes ___ 716.90 Arthropathy, NOS ___ 244.9 Hypothyroidism
___ V70.0 Routine Physical (12+) ___ 493.9 Asthma, Unspec ___ 487.1 Influenza w/ Other Resp. Manifestations
___ V70.3 General Medical Exam ___ 724.5 Back Pain, Unspec ___ 724.2 Lower Back Pain
___ V70.5 Health Exam ___ 466.0 Bronchitis, Acute ___ 780.79 Malaise and Fatigue, Other
___ V70.6 Health Exam in Pop Survey ___ 490 Bronchitis ___ 496 Chronic Obstructed Airway (COPD)