By Cindy Basham, MHA, MSCCS, BSN, CCS, CPC
“Oh no, I don’t like coding cases involving cardiovascular diagnoses or procedures,” I’ve heard some coders moan loudly, while others throw their hands in the air.
Coding for cardiovascular diseases and procedures has a tendency to bring out a level of frustration that was present when we used the ICD-9-CM coding system and is now transferred to our use in ICD-10-CM. Coding educators are hearing these responses frequently when the coding training is focused on the cardiovascular system.
This article will explain what to look for when reviewing cardiovascular documentation. Yes, anatomical location and laterality is required by ICD-10-CM for the level of specificity expected with this new coding system. This detail reflects how physicians and coders communicate and to what they pay attention. It is a matter of ensuring the information is captured in the medical record documentation.
ICD-10-CM has three main categories of changes for cardiovascular codes:
- Definition changes
- Terminology differences
- Increased specificity
For cardiology, the goal is increased specificity and documentation of the effects of the patient’s condition. Let’s review some of the more common cardiovascular diseases changes.
Acute myocardial infarction: Definition change
Documentation for hypertension should include the following:
- Timeframe: An acute myocardial infarction (AMI) is now considered “acute” for four weeks or 28 days from the time of the incident, a revised timeframe from the previous ICD-9-CM period of eight weeks
- Episode of care: ICD-10-CM does not capture episode of care (e.g., initial, subsequent, sequelae)
- Subsequent AMI: ICD-10-CM allows coding of a new myocardial infarction that occurs during the four-week or 28-day acute period of the original (initial) AMI
Hypertension: Definition change
In ICD-10-CM, hypertension is defined as essential (primary). The concept of benign or malignant, as it relates to hypertension, no longer exists. Documentation for hypertension should include the following:
- Type: For example, essential, secondary, etc.
- Causal relationship: For example, renal, pulmonary, etc.
Congestive heart failure: Terminology differences, increased specificity
The terminology used in ICD-10 exactly matches the types of congestive heart failure (CHF). If the physician documents “decompensation” or “exacerbation,” the CHF type will be coded as “acute on chronic.” Documentation for CHF should include the following:
- Cause: For example, acute or chronic
- Severity: For example, systolic or diastolic
Atherosclerotic heart disease with angina pectoris: Terminology difference
When documenting atherosclerotic heart disease with angina pectoris, physicians should include the following:
- Cause: Assumed to be atherosclerosis, note whether there is another cause
- Stability: For example, stable angina pectoris, unstable angina pectoris
- Vessel: Note which artery, if known, is involved and whether the artery is native or autologous
- Graft involvement: If appropriate, physicians should report whether a bypass graft was involved in the angina pectoris diagnosis; also note the original location of the graft and whether it is autologous or biologic
Cardiomyopathy: Increased specificity
When documenting cardiomyopathy, physicians should include the following, where appropriate:
- Type: For example, dilated/congestive, obstructive or non-obstructive hypertrophic, etc.
- Location: For example, endocarditis, right ventricle, etc.
- Cause: For example, congenital, alcohol, etc.
Heart valve disease: Increased specificity
ICD-10-CM assumes heart valve diseases are rheumatic. If this is not the case, the physician should note otherwise. When reviewing documentation for heart valve disease, look for the following:
- Cause: For example, rheumatic or non-rheumatic
- Type: For example, prolapse, insufficiency, regurgitation, incompetence, stenosis, etc.
- Location: For example, mitral valve, aortic valve, etc.
Arrhythmias/dysrhythmia: Increased specificity
When documenting arrhythmias, physicians should include the following:
- Location: For example, atrial, ventricular, supraventricular, etc.
- Rhythm name: For example, flutter, fibrillation, type 1 atrial flutter, long QT syndrome, sick sinus syndrome, etc.
- Acuity: For example, acute, chronic, etc.
- Cause: For example, hyperkalemia, hypertension, alcohol consumption, digoxin, amiodarone, verapamil HCI, etc.
Unlike ICD-9-CM, ICD-10-CM is designed to capture specific clinical documentation, which is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10-CM code selection. Coders can limit their apprehension by understanding the changes made to various code groups and sharing this information with physicians and non-physician providers.
HCPro.com – JustCoding News: Outpatient
