What is guideline-directed medical therapy (GDMT) for heart failure?

GDMT for HFrEF (EF ≤40%) includes four pillars: ACEi/ARB/ARNI (sacubitril-valsartan preferred), beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), MRA (spironolactone or eplerenone), and SGLT2 inhibitor (dapagliflozin or empagliflozin). Document current doses vs target doses and barriers to optimization for each medication.

How do I document NYHA functional class?

NYHA Class I: No limitation of physical activity. Class II: Slight limitation—comfortable at rest, ordinary activity causes symptoms. Class III: Marked limitation—comfortable at rest, less than ordinary activity causes symptoms. Class IV: Unable to carry on any activity without symptoms, symptoms at rest. Document specific activities the patient can/cannot do.

What documentation supports a 99214 or 99215 for heart failure follow-up?

99214 (moderate MDM) requires: 1+ chronic illness with mild exacerbation OR managing medication with close monitoring. 99215 (high MDM) requires: severe exacerbation OR hospitalization risk. Document: volume status assessment, GDMT optimization rationale, lab review (BMP, BNP trends), lifestyle compliance, and specific medication changes with justification.

When should heart failure patients be referred to advanced HF or transplant?

Consider referral for: NYHA Class III-IV despite optimal GDMT, recurrent hospitalizations (≥2 per year), need for inotropes, consideration for LVAD or transplant, persistent symptoms with EF <25%, cardiac resynchronization therapy candidacy, or end-of-life care planning. Document why advanced therapies are being considered.

How do I document volume status in heart failure?

Document JVP measurement (cm above sternal angle), presence/absence of S3, lung findings (clear vs rales with location), hepatomegaly/ascites, peripheral edema (grade 1-4, location), and weight compared to dry weight. These findings determine whether the patient is euvolemic, volume overloaded, or over-diuresed, guiding diuretic adjustments.

Heart Failure Follow-Up Template - Cardiology Note

Visit Information

Date: [Date]
Last visit: [Date]
Visit type: Routine follow-up / Post-hospitalization / Urgent

Interval History

Days since last visit: [X]
Hospitalizations since last visit: None / [Date, reason, duration]
ED visits: None / [Date, reason]
Overall status: Stable / Improved / Worsening

Heart Failure Classification

Etiology: Ischemic / Non-ischemic / Valvular / Hypertensive / Other
Type: HFrEF / HFmrEF / HFpEF
LVEF: [X]% (date: [X])
NYHA Class: I / II / III / IV
ACC/AHA Stage: A / B / C / D

Symptom Assessment

Dyspnea: None / Exertional / Rest / Orthopnea / PND

Change from last visit: Improved / Stable / Worse

Fatigue: None / Mild / Moderate / Severe
Edema: None / [Location, severity]

Change from last visit: Improved / Stable / Worse

Weight change: [+/- X] lbs since last visit
Exercise tolerance: [Flights of stairs, blocks walked]

Change from last visit: Improved / Stable / Worse

Chest pain/angina: None / [Details]
Palpitations: None / [Details]
Lightheadedness/syncope: None / [Details]

Self-Management

Daily weights: Yes / No — Compliance: [X]%
Fluid restriction: Yes ([X] L/day) / No — Compliance: [Good/Fair/Poor]
Sodium restriction: Yes / No — Compliance: [Good/Fair/Poor]
Medication compliance: Excellent / Good / Fair / Poor

Barriers: [Cost, side effects, complexity, other]

Current Medications

GDMT Status:

ACEi/ARB/ARNI: [Drug, dose] — At target: Yes / No
Beta-blocker: [Drug, dose] — At target: Yes / No
MRA: [Drug, dose] — At target: Yes / No
SGLT2i: [Drug, dose] — On therapy: Yes / No
Diuretic: [Drug, dose] — Adequate: Yes / No
Hydralazine/nitrate: [If applicable]
Digoxin: [If applicable]
Ivabradine: [If applicable]

Other cardiac medications:

[Anticoagulation, antiarrhythmics, etc.]

Physical Examination

Vital signs: BP [X/X], HR [X], RR [X], SpO2 [X]%, Weight [X] lbs
Dry weight target: [X] lbs
Weight status: At dry weight / Above by [X] lbs / Below by [X] lbs
General: [Appearance, distress level]
Cardiovascular:

JVP: [X] cm above sternal angle / Not elevated
Carotid pulses: Normal / Diminished / Bruit
PMI: Normal / Displaced [location]
Heart rhythm: Regular / Irregular
Heart sounds: S1 [normal/diminished], S2 [normal/split]
S3: Absent / Present
S4: Absent / Present
Murmurs: None / [Description]

Lungs: Clear / Rales [location, extent] / Pleural effusion
Abdomen: Soft / Hepatomegaly / Ascites / Hepatojugular reflux
Extremities:

Edema: None / [Grade +1 to +4, location]
Perfusion: Warm / Cool
Pulses: [Femoral, DP, PT assessment]

Device Status (if applicable)

Device type: Pacemaker / ICD / CRT-D / CRT-P / LVAD
Last interrogation: [Date]
Findings: [Battery status, lead function, arrhythmias, pacing %]
Shocks: None / [Number, appropriateness]

Laboratory Review

BMP: Na [X], K [X], Cr [X], BUN [X], GFR [X]
BNP/NT-proBNP: [Value] — Trend: Improving / Stable / Rising
CBC: Hgb [X], Hct [X]
Iron studies: [If applicable]
Thyroid: [If applicable]
Liver function: [If applicable]

Recent/Pending Studies

Echocardiogram: [Date, EF, wall motion, valves, RVSP]
Stress test: [If applicable]
Right heart catheterization: [If applicable]
Cardiopulmonary exercise test: [If applicable]

Assessment

1) Heart failure — [HFrEF/HFmrEF/HFpEF], EF [X]%, NYHA Class [X]
Status: Compensated / Decompensated
Trend: Improving / Stable / Declining
2) [Secondary diagnoses: AFib, CAD, HTN, DM, CKD, etc.]

Plan

1) Volume management:

Current status: Euvolemic / Volume overloaded / Over-diuresed
Diuretic adjustment: [Continue / Increase / Decrease / Add]
Weight goal: [X] lbs

2) GDMT optimization:

[Specific medication changes with rationale]
Target doses: [List targets being worked toward]
Barriers to optimization: [Hypotension, renal function, etc.]

3) Monitoring:

Labs: [BMP, BNP timing]
Weight: Daily, call if [+3 lbs in 1 day or +5 lbs in 1 week]

4) Device management: [If applicable]

[ICD/CRT considerations, interrogation schedule]

5) Referrals:

Cardiac rehabilitation: [If indicated]
Advanced heart failure: [If Stage D considerations]
Palliative care: [If appropriate]

6) Follow-up:

Cardiology: [Timeframe based on stability]
PCP: [Coordination items]
Phone check: [If needed]

Patient Education

Heart failure self-management, daily weight monitoring, sodium and fluid restrictions, medication adherence, warning signs (weight gain, worsening dyspnea, edema), when to call office vs. seek emergency care.

Cardiology — Heart Failure Follow-Up Template

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