Heart Failure
How would you describe Heart Failure in layman's terms?
The heart can’t pump blood well enough to meet your body’s needs. Your heart is still working. But because it can’t handle the amount of blood it should, blood builds up in other parts of your body.
. It means that your heart isn’t pumping enough blood. The heart keeps working, but the body’s need for blood and oxygen isn’t being met.
Source: American Heart Association
How would you describe DM to a patient?
Diabetes is a disease that occurs when your blood sugar is too high. Glucose is your body’s main source of energy. Your body can make glucose, but glucose also comes from the food you eat.
Insulin is a hormone made by the pancreas that helps glucose get into your cells to be used for energy. If you have diabetes, your body doesn’t make enough—or any—insulin, or doesn’t use insulin properly. Glucose then stays in your blood and doesn’t reach your cells.
Source: American Diabetes Association
Common complications caused by DM?
Diabetes raises the risk for damage
What is PAD?
Peripheral artery disease (PAD) is a narrowing of the arteries leading to your limbs and organs, usually your legs.
What are examples of conditions that cause immunodeficiency?
• Asplenia
• Chemotherapeutic agents
• Cirrhosis
• Diabetes mellitus with hyperglycemia*
• Dialysis
• Immunomodulatory agents
• Immunosuppressive agents
• Malignancy: Term applies to many conditions, not all of
which cause SID. Example: history of breast cancer,
completely treated will NOT result in SID, whereas
active leukemia will.
• Radiation exposure
What is Secondary Hyperaldosteronism? What causes Hyperaldosteronism? How is it typically diagnosed?
Hyperaldosteronism happens when one or both of your adrenal glands produce too much aldosterone, a hormone. It causes high blood pressure and has several possible causes. Hyperaldosteronism causes high blood pressure (hypertension) and low potassium levels in your blood.
Causes of reduced kidney blood flow and secondary hyperaldosteronism include:
Blood tests. Your doctor will do blood tests to check your potassium, aldosterone, and renin levels. Low potassium and high aldosterone can mean primary hyperaldosteronism while high renin can mean secondary hyperaldosteronism.
Example of appropriate coding for DM with neuropathic symptoms: HPI: Pt here for follow-up of type 2 DM. Is checking blood glucose at home taking meds as prescribed. Complains of numbness and tingling in feet. Exam: Vitals: WNL; PE: Neuro - feet w/ decreased sensation bilaterally with 128 Hz tuning fork and monofilament. Labs: A1C 7.0, down from 7.5.
(E11.42) Type 2 diabetes mellitus with diabetic polyneuropathy
Signs/Symptoms of PAD?
Leg pain that doesn’t go away after exercising.
Foot or toe wounds that won’t heal or heal slowly.
Poor nail growth on the toes or hair loss on the legs.
Lower temperature in your lower leg or foot compared to the rest of your body
Can we use multiple diagnoses of immunodeficiency?
yes! When multiple causes exist, document all conditions that contribute to the current health status on that date of service. For example, for a patient with multiple myeloma and taking 20 mg of daily prednisone for the last month, it would be appropriate to document both if they are determined by the clinician to be contributing to the immunodeficiency.
Most common medications used to treat HF?
-Diuretics- ie. Furosemide
-ARBS ie. Losartan
-ACE- Lisinopril
-Beta-blockers ie. Metoprolol
-ARNI- ie. Entresto
-SGLT-2 Inhibitors ie. Farxiga/Jardiance
-Aldosterone Antagonists ie. Spirolactone
-Vasodilators ie. Hydralazine and isosorbide dinitrate
-Oxygen therapy delivers concentrated oxygen to the lungs. This helps increase the amount of oxygen that can get into the blood. Oxygen therapy can improve shortness of breath and increase a person’s ability to be physically active.
Example of appropriate coding for DM with CKD:
HPI: Pt here for follow-up of Type 2 DM. Is checking blood glucose at home, taking meds as prescribed, and feels fine. Exam: Vitals: WNL; PE: WNL; Labs: A1C 7.0, GFR 44. Four months ago, A1C 7.2, GFR 43.
Assessment: (E11.22) Type 2 diabetes mellitus with diabetic chronic kidney disease (N18.32) Chronic kidney disease, stage 3b
How would we diagnose DM-Hyperglycemia?
Hyperglycemia is defined as glucose > 180 mg/dL two hours post prandial (or blood sugar above the patient’s goal) An HbA1C ≥ 8% is considered sustained hyperglycemia in most cases.
What tests are done to diagnosis PAD?
-ABI less than .90
-Duplex Ultrasound
-CT angiography
-Magnetic Resonance Angiography
- Peripheral Angiogram
Is an active infection necessary to make an immunodeficiency diagnosis?
No, the patient does not need to present with an acute infection in order to diagnose immunosuppression
What is the Framingham Criteria? What are examples of major/minor criteria?
The Framingham Study breaks down symptoms of heart failure into major and minor criteria. To make a diagnosis of HF, a person must have 2 or more major criteria or 1 major criterion plus 2 minor criteria.
The Framingham major criteria include:4
The Framingham minor criteria include:4
Example of appropriate coding for DM with PAD:
HPI:70-year-old patient with DM. Complains of pain in legs at rest. Active smoker. Exam: Bilateral lower extremities with pale skin, hairless and 1+ pedal pulses. ABI- abnormal, indicating severe PAD (left) and moderate PAD (right). Labs: A1C 7.4%
(E11.51) Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (I70.223) Atherosclerosis of native arteries of extremities with rest pain, bilateral legs “due to diabetes”
What is Diabetic Retinopathy? What are some symptoms of Retinopathy?
damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina)
Toe-Brachial Index-recommended for Diabetics due to calcification of the arteries.Toe arteries are too small caliber to be affected by wall calcification. If ABI results greater than 1.3 in ankle brachial index consider toe brachial index
In a patient with diabetes, at what A1C level would it be reasonable to consider an immunodeficiency?
An A1C ≥ 8% is considered sustained hyperglycemia in most cases. Evidence indicates patients with diabetes
and sustained hyperglycemia are immunosuppressed and are more likely to have recurrent infections.2 This
does not mean that all patients with diabetes and A1C ≥ 8% should be classified as having secondary
immunodeficiency, as this is still a clinical judgment. If in doubt, consider if there is evidence of infection that
would not be expected in the same patient if they did not have that level of hyperglycemia. An active infection is
not required to make the diagnosis, but evidence of recurrent and/or recent infections may be suggestive of an
immunodeficiency.
What physical findings on assessment can we note in someone who is in HF?
• Elevated jugular venous pressure/ distention at 45
degrees elevation
• Crackles (rales), labored breathing
• Bradycardia or tachycardia, lateral displaced point of maximal impulse, third heart sounds (gallop or murmur)
• Extremities dependent/pitting edema
• Skin: cool, pallor, cyanosis
• Ascites (advanced), hepatojugular reflux
• Tachycardia (HR >100)
What are the most common medications used to treat Diabetes?
-Metformin
-Insulin
-Prandin
-Januvia
-Jardiance/Farxiga
-Precose
-Actos
-Glimepiride/Glipizide
-GLP 1- important to note and explain to member that these are not insulin and should not replace insulin ie. Ozempic, Mounjaro, Zepbound
What are some treatment options for those with DM-CKD? How do we chart diabetes with kidney complications?
An ACE inhibitor or ARB is recommended as first-line therapy for people with diabetes, hypertension, and albuminuria and should be titrated to a maximum tolerated dose.
an SGLT2 inhibitor should be started as a first-line antihyperglycemic therapy alongside metformin in people with type 2 diabetes ie. Jardiance, Farxiga, and Invokana
GLP-1 receptor agonists are considered to be an excellent add-on therapy to metformin and an SGLT2 inhibitor to achieve glycemic goals or serve as an alternative for people who are unable to take those medications.
Source: American Diabetes Association
Type 2 diabetes mellitus with chronic kidney disease E11.22 with diabetic chronic kidney disease Use an additional code for the CKD stage: (N18.1-N18.6,N18.9). If known GFR, can apply stage.
GFR categories
G260-89
G3a 45-59
G3b 30-44
G4 15-29
G5<15
What are risk factors for PAD?
Risk factors
Risk factors for peripheral artery disease (PAD) include:
How long and at what dose would a patient need to take a steroid to be considered immunosuppressed?
The Advisory Committee on Immunization Practices (ACIP) considers a dose of 20 mg or more of prednisone (or equivalent) given daily for at least 2 weeks to be immunosuppressive enough to raise concerns about patient safety when receiving live-virus vaccines. Clinicians may consider applying this guidance to determine if a secondary immunodeficiency diagnosis would be appropriate when their patients are on steroid therapy.