PURPOSE: This study explores the initial adoption rate of new ICD-9 diagnosis codes implemented effective 10-1-2002 to expand heart failure identification.

METHODS: The new ICD-9 diagnosis codes expanded the original three four-digit codes for heart failure to an array of fifteen possible five-digit codes. A claims analysis was performed using the CMS Hospital Outpatient Prospective Payment System (OPPS) Identifiable Data Set, Final Rule 2005 File. This data set contained all claims incurred 1-1-03 to 12-31-03 and paid through 6-30-04. Approximately 18,000 OPPS claims utilizing the heart failure ICD-9 codes were analyzed to discover if the new more specific codes were present on the claims submitted for payment by the Medicare program.

RESULTS: The three original existing four-digit codes appeared on 98.14% of all claims analyzed for the calendar year 2003. The general code “congestive heart failure, unspecified” accounted for 96.35% of all claims within this group. The new more specific codes appeared on only 1.86% of claims analyzed. The new codes had become effective as of October 1, 2002, and provider education was circulated by multiple sources prior to that date. Nevertheless, this study reveals a pervasive degree of non-adoption.

CONCLUSIONS: With the new system it is possible to isolate systolic, diastolic, and combined systolic and diastolic heart failure diagnoses and, further, to identify acute, chronic, and acute on chronic conditions for each of these categories. The ability to deconstruct heart failure into fifteen specific conditions is important to policy makers for rate setting purposes. It is equally important to hospital decision makers as they struggle to identify their patient population and the services that population requires. Future research could explore the root causes for non-adoption within hospital facilities. In any case, the importance and power of the new codes must somehow be effectively communicated to stakeholders.