Heart Failure (HF) : Assessment of Clinical Symptoms of Volume Overload (Excess)

Patient visits with assessment of clinical symptoms of volume overload (excess) or documentation of standardized scale or completion of assessment tool*

Medical record must include:
Assessment for the absence or presence of symptoms of volume overload – Dyspnea or orthopnea;
or
Documentation of standardized scale or completion of assessment tool
or
CPT-II code: 1004F Clinical symptoms of volume overload (excess) assessed

*Standardized scale or assessment tools may include the New York Heart Association Functional Classification of Congestive Heart Failure (level of activity only); Kansas City Cardiomyopathy Questionnaire; Minnesota Living with Heart Failure™ Questionnaire; or Chronic Heart Failure Questionnaire (Guyatt)