The Same Gap Undercodes and Undertreats the Same Patients

Stage D heart failure patients are simultaneously the most undercoded and the most undertreated population in a typical primary care panel. Both problems trace back to the same root cause: access.

Without frequent, specialist-level contact, advanced HF goes clinically unrecognized as “end-stage,” medication titration stalls well below target dose, and the patient decompensates into the hospitalization the risk contract is trying to prevent.

Heartbeat addresses both halves of this problem with one telehealth model: identify and code Stage D disease correctly, then close the treatment gap that’s driving the utilization.

Part One: Capture the Diagnosis You’re Already Managing

ACC/AHA Stage D is a clinical construct, not a native ICD-10 code, so most practices default to unspecified or chronic heart failure codes regardless of severity. Under CMS-HCC V28, that default leaves the single most valuable diagnosis in the heart failure hierarchy uncaptured.

V28 splits heart failure into a hierarchy of HCCs by severity. Three of them — Acute on Chronic (HCC 224), Acute (HCC 225), and Heart Failure Except End-Stage and Acute (HCC 226) — are constrained, meaning CMS assigns them the identical coefficient regardless of acuity.

One HCC sits above that constrained tier and carries meaningfully more weight: HCC 222, End-Stage Heart Failure, mapped from I50.84. It’s the only unconstrained heart failure code in the model — and the determination behind it is the same clinical judgment that defines Stage D. If a patient meets Stage D criteria and the chart never says “end-stage,” the practice is coding a Stage B or C patient’s HCC onto a Stage D cost profile.

The same gap extends to comorbidities that travel with Stage D and are routinely missed: cardiac cachexia (R64), staged CKD (HCC 326–329) rather than unspecified renal insufficiency, the required I13.0/I13.2 combination codes when hypertension, heart failure, and CKD coexist, and device/transplant status (HCC 221/223) where applicable.

Because V28’s hierarchy logic pays only the highest-severity code in each family, precision here isn’t documentation hygiene — it’s the difference between capturing the RAF value of the sickest patients in the panel or leaving it on the table.

“End-stage” is not a determination a PCP should make in a 15-minute visit — nor should it be. It requires confirming GDMT is genuinely optimized and distinguishing refractory disease from undertreated disease. Made without specialist input, that call is either skipped or asserted without support, which is a RADV liability either way.

Part Two: Close the Gap That’s Driving the Utilization

Correct coding only matters if the underlying disease is also better managed — and the same access barrier that suppresses documentation also suppresses treatment. Fewer than a quarter of eligible HF patients nationally reach target GDMT doses, largely because titration requires a cadence of contact that a quarterly in-person cardiology visit cannot provide.

Heartbeat’s telehealth model closes that gap directly: cardiologist-led televisits paired with structured medication management give patients the frequent, low-friction touchpoints that titration actually requires, without adding visits to the PCP’s own schedule.

The evidence behind this approach is substantial. A systematic review of seven randomized trials comparing nurse- and telehealth-supported titration to usual care found heart failure hospitalizations cut roughly in half (RR 0.51) and all-cause mortality reduced by a third (RR 0.66).

A more recent multicenter randomized trial of telemedicine-based post-discharge management found a similar reduction in HF rehospitalization (RR 0.56) compared with usual care. The mechanism is consistent across studies: faster, more frequent access to a specialist who can safely titrate therapy in response to real-time symptoms and vitals, rather than waiting for the next scheduled visit.

For a risk-bearing practice, that translates directly into economics: every avoided hospitalization is avoided cost of care, and it happens without adding headcount, call volume, or scheduling burden to the practice itself.

What Heartbeat Provides

Specialist-authenticated determination of end-stage/Stage D disease, with MEAT-compliant documentation that holds up under RADV audit

Systematic capture of the comorbid HCCs that travel with advanced HF — cachexia, staged CKD, correct combination coding

Cardiologist-led telehealth titration on a cadence frequent enough to move patients toward target GDMT doses, not just monitor them

Annual recapture so chronic HCCs don’t lapse for patients without a qualifying face-to-face cardiology encounter that year

Co-management, not hand-off — the PCP remains the quarterback; Heartbeat’s specialty bench works inside the existing care pathway

The Bottom Line

Your Stage D patients are already the costliest, most complex cohort in the panel. Under V28, they’re also the group where a single missed diagnosis carries the largest per-patient RAF gap in the entire cardiovascular disease group — and clinically, the group where the largest reduction in avoidable hospitalization is achievable through better access alone.

Heartbeat is built to close both gaps at once, through the same telehealth relationship.

Let’s talk about how this integrates into your existing risk-adjustment and care-management workflow.

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