J02.9 - Acute pharyngitis, unspecified

Clinical Definition

Congestive heart failure (CHF) represents a clinical condition where the heart cannot pump blood efficiently enough to meet the body's needs. This results in fluid backup in the lungs and other tissues, causing congestion.

Documentation Requirements

• Acuity

  • Acute vs. Chronic vs. Acute-on-Chronic

• Type

  • Systolic vs. Diastolic vs. Combined

  • Left vs. Right vs. Biventricular

• Severity

  • NYHA Classification (I, II, III, or IV)

  • EF percentage if available

• Contributing Factors

  • Underlying cardiac conditions

  • Exacerbating circumstances

• Status

  • Compensated vs. Decompensated

Common Synonyms

• "Water on the lungs"

• "Weak heart"

• "Heart pump problem"

• "Fluid overload"

• "Heart failure"

Coding Conflicts

Excludes1:

• Heart failure due to hypertension (I11.0)

• Rheumatic heart failure (I09.81)

• Neonatal cardiac failure (P29.0)

Scribing.io Automation

Our AI scribe automatically identifies:

• Keywords indicating CHF type (systolic/diastolic)

• NYHA classification mentions

• EF percentages from echo reports

• Acuity descriptors

• Associated conditions

• Treatment responses

Keywords are mapped to appropriate ICD-10 codes while maintaining context. The system also flags missing documentation elements needed for optimal coding specificity.