ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity

Chapter 9

DISEASES OF THE CIRCULATORY SYSTEM

Introduction

Diseases of the circulatory system are found in Chapter 9. Some of the most frequently diagnosed circulatory system diseases and conditions have undergone significant changes from how they were historically reported including hypertension, coronary atherosclerosis, myocardial infarction, and cardiac arrhythmias. Essential hypertension is no longer designated as benign, malignant, or unspecified and is reported with code I10 Essential hypertension. However, secondary hypertension codes have been expanded and will require specific documentation. Coronary atherosclerosis codes are combination codes that report the presence or absence of angina as well as the atherosclerosis. The definition of the acute phase of treatment for myocardial infarction has been recently changed and is shortened to 4 weeks from 8 weeks There are no fifth digits identifying the myocardial infarction encounter as the initial episode of care or a subsequent episode of care. Instead, there are two code categories. A code from category I21 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction is assigned for the acute phase of care or for myocardial infarctions with a stated duration of 4 weeks (28 days) or less. A code from category I22 Subsequent ST elevation (STEMI) or non-ST elevation (NSTEMI) myocardial infarction is assigned for a subsequent acute (new) myocardial infarction at either the same or a different site in the heart occurring within the 4-week time frame of the initial acute myocardial infarction.

Cardiac arrhythmias are specific as to type. For example, a left bundle branch hemiblock, is designated as a left fascicular block must be documented as left anterior, left posterior, or other specified left fascicular block. Below is a table of sections in ICD-10-CM.

ICD-10-CM Chapter Blocks
I00-I02	Acute Rheumatic Fever
I05-I09	Chronic Rheumatic Heart Diseases
I10-I15	Hypertensive Diseases
I20-I25	Ischemic Heart Diseases
I26-I28	Pulmonary Heart Disease and Diseases of Pulmonary Circulation
I30-I52	Other Forms of Heart Disease
I60-I69	Cerebrovascular Diseases
I70-I79	Diseases of Arteries, Arterioles and Capillaries
I80-I89	Diseases of Veins, Lymphatic Vessels and Lymph Nodes, Not Elsewhere Classified
I95-I99	Other and Unspecified Disorders of the Circulatory System

Coding Note(s)

Some chapters in ICD-10-CM contain chapter level instructions in the form of different types of coding notes, including Includes notes. However, for Chapter 9 Diseases of the Circulatory System, the only chapter level instructions are contained in an Excludes2 note, which is discussed below.

Exclusions

The specific conditions listed in the Excludes2 note appearing for this chapter are listed in the following table:

Excludes1

Excludes2

None

Certain conditions originating in the perinatal period (P04-P96)

Certain infectious and parasitic diseases (A00-B99)

Complications of pregnancy, childbirth and the puerperium (O00-O9A)

Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)

Endocrine, nutritional, and metabolic diseases (E00-E88)

Injury, poisoning and certain other consequences of external causes (S00-T88)

Neoplasms (C00-D49)

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)

Systemic connective tissue disorders (M30-M36)

Transient cerebral ischemic attacks and related syndromes (G45.-)

Chapter Guidelines

Guidelines for coding diseases of the circulatory system cover five conditions which include:

•Hypertension

•Atherosclerotic coronary artery disease and angina

•Intraoperative and postprocedural cerebrovascular accident

•Sequelae of cerebrovascular disease

•Acute myocardial infarction

Hypertension

Hypertension is not classified as benign, malignant, or unspecified. Hypertension without associated heart or kidney disease is reported with the code I10 Essential hypertension.

Hypertension with Heart Disease

Causal relationship between hypertension and heart disease:

•Heart conditions classified to category I50 Heart failure and subcategories I51.4 Myocarditis, unspecified; I51.5 Myocardial degeneration; I51.7 Cardiomegaly; I51.89 Other ill-defined heart diseases, and I51.9 Heart disease, unspecified, are assigned to category I11 Hypertensive heart disease, when a causal relationship is stated, such as “left ventricular heart failure due to hypertension,” or implied, such as “hypertensive left ventricular heart failure.” When a causal relationship between hypertensive heart disease and these conditions is stated or implied, only the code for the hypertensive heart disease is reported. (See includes note under category I11)

•When a causal relationship between hypertensive heart disease and heart failure is stated or implied, the hypertensive heart disease with heart failure (I11.0) is sequenced first followed by a code from category I50 to identify the type of heart failure

No causal relationship between hypertension and heart disease:

•Heart conditions classified to category I50 Heart failure and subcategories I51.4 Myocarditis, unspecified; I51.5 Myocardial degeneration; I51.7 Cardiomegaly; I51.89 Other ill-defined heart diseases, and I51.9 Heart disease, unspecified, without a stated or implied causal relationship to the hypertension are coded separately. The same heart conditions with hypertension are also coded separately when the provider has documented they are unrelated to the hypertension. The hypertension is reported with code I10 Essential hypertension, and the heart disease is reported with a code from category I50 or subcategories I51.4-I51.7, I51.89, I51.9

•The codes are sequenced based on the documentation related to the circumstances of the admission/encounter

Hypertensive Chronic Kidney Disease

A causal relationship between the hypertension and the chronic kidney disease is always presumed and documentation of hypertension with chronic kidney disease is always reported as hypertensive chronic kidney disease.

A code from category I12 Hypertensive chronic kidney disease is assigned first when there is documented hypertension and a condition classifiable to category N18 Chronic kidney disease (CKD). CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.

A code from category N18 is reported secondarily to identify the stage of chronic kidney disease.

If the patient has hypertensive chronic kidney disease and acute renal failure, an additional code for the acute renal failure is also assigned. Codes are sequenced according to the circumstances of the admission or encounter.

Hypertensive Heart and Chronic Kidney Disease

Codes in category I13, Hypertensive heart and chronic kidney disease, are combination codes that include hypertension, heart disease and chronic kidney disease. The includes note at I13 states that the conditions reported in categories I11 and I12 are included in I13. If a patient has hypertension, heart disease, and chronic kidney disease, then a code from I13 should be used, not individual codes for each, or codes from I11 or I12.

If heart failure is also present, assign an additional code from category I50 to identify the type of heart failure.

A code from category N18 Chronic kidney disease should also be assigned to identify the stage of chronic kidney disease. If both acute renal failure and chronic kidney disease are present, the acute renal failure should also be coded and sequenced according to the circumstances of the admission or encounter.

Hypertensive Cerebrovascular Disease

Assign the appropriate code from categories I60-I69 first, followed by the appropriate hypertension code.

Hypertensive Retinopathy

A code from subcategory H35.0 Background retinopathy and retinal vascular changes is reported with a code from categories I10-I15 for the systemic hypertension. Sequencing depends on the reason for the encounter.

Secondary Hypertension

Two codes are required for secondary hypertension, one for the underlying etiology and one from category I15 to identify the hypertension. Sequencing depends on the reason for the encounter.

Transient Hypertension

A code for hypertension is NOT assigned unless the patient has a documented, established diagnosis of hypertension. Assign code R03.0 Elevated blood pressure reading without diagnosis of hypertension.

If the diagnosis is transient hypertension of pregnancy, assign a code from category O13 Gestational [pregnancy-induced] hypertension without significant proteinuria, or one from category O14 Pre-eclampsia, depending on the documentation.

Controlled Hypertension

This diagnosis typically refers to hypertension under control with medication. Assign the appropriate code from categories I10-I15.

Uncontrolled Hypertension

Generally, a diagnosis of uncontrolled hypertension refers to untreated hypertension or to hypertension that is not responding to medication therapy. Uncontrolled hypertension is assigned a code from categories I10-I15 as appropriate to identify the type of hypertension.

Pulmonary Hypertension

Pulmonary hypertension is classified as Other pulmonary heart diseases, category I27. For secondary cases, code also any associated conditions or adverse effects of drugs or toxin. Sequencing depends on the circumstances of the encounter.

Atherosclerotic Coronary Artery Disease and Angina

There are combination codes used reporting atherosclerotic coronary artery disease with angina pectoris. When the two conditions are documented, they are reported with codes from subcategories I25.11 Atherosclerotic heart disease of native coronary artery with angina pectoris, and I25.7 Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris.

•It is not necessary to assign a separate code for angina pectoris when both conditions are documented because the combination code captures both conditions

•A causal relationship between the atherosclerosis and angina is assumed unless documentation specifically indicates that the angina is due to a condition other than atherosclerosis

•If a patient is admitted with an acute myocardial infarction (AMI) and coronary artery disease, the AMI is sequenced first

Intraoperative and Postprocedural Cerebrovascular Accident

A cause and effect relationship between a cerebrovascular accident (CVA) and a procedure cannot be assumed. The physician must document that a cause and effect relationship exists between the procedure and the CVA.

•Documentation must clearly identify the condition as an intraoperative or postoperative event

•The condition must also be clearly documented as an infarction or hemorrhage

•For a cerebrovascular infarction, see the following subcategories:

–I97.81Intraoperative cerebrovascular infarction

–I97.82Postprocedural cerebrovascular infarction

For a cerebrovascular hemorrhage, code assignment depends on the type of procedure performed. See the following subcategories:

–G97.3Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a procedure

–G97.5Postprocedural hemorrhage and hematoma of a nervous system organ or structure complicating a procedure

Sequelae of Cerebrovascular Disease

Category I69 Sequelae of cerebrovascular disease is used to report conditions classifiable to categories I60-I67 as the cause of the late effect, particularly neurological deficits, which are themselves classified elsewhere. Guidelines are as follows:

•Sequelae/late effects are conditions that persist after the initial onset of the conditions classifiable to categories I60-I67

•The neurologic deficits may be present at the onset of the cerebrovascular disease or may arise at any time after the onset

•If the patient currently has cerebrovascular disease and deficits from an old cerebrovascular disease, codes from category I69 and categories I60-I67 may be reported together

•Transient ischemic attack (TIA) is reported instead of a code from category I69 to identify the history of the cerebrovascular disease.

•Some sequelae codes such as those for hemiplegia, hemiparesis and monoplegia which are found in category I69 require specification as to whether the affected side is dominant or nondominant. When the affected side is documented, but not specified as the patient’s dominant or nondominant side, the left side is reported as nondominant and the right side is reported as dominant

Acute Myocardial Infarction

Acute myocardial infarction (AMI) is reported with codes that identify the AMI by type. Type 1 are those related to coronary artery disease and are defined based upon ECG changes as ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). STEMI is further classified based upon the site such as posterior or anterolateral wall. Type 2 AMI is due to ischemia not related to coronary artery disease. Types 3-5 are classified in a single category with instructions to code any related complications.

Initial acute myocardial infarction:

•Assign codes from category I21 for AMIs not documented as subsequent or not occurring within 28 days of a previous myocardial infarction

•Type 1 STEMI is reported with codes in subcategories I21.0-I21.2 and code I21.3

•Type 1 NSTEMI is reported with code I21.4, which is also used for “nontransmural” MIs

•If a Type 1 NSTEMI evolves to STEMI, the code for STEMI is reported

•If a Type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still reported as a STEMI

•Encounters for care of the AMI during the first four weeks (equal to or less than 4 full weeks/28 days), are assigned a code from category I21. Examples of when reporting of a code from category I21 is appropriate include:

–Transfers to another acute care setting for continued care of the AMI

–Any encounter within the 4-week time frame for care related to the myocardial infarction

•Encounters related to the myocardial infarction after 4 full weeks of care are reported with the appropriate aftercare code

•Old or healed myocardial infarctions are assigned code I25.2 Old myocardial infarction

•Acute myocardial infarction, unspecified

–I21.9 is the default code for a myocardial infarction documented only as acute MI, or unspecified type

–If only Type 1 STEMI or transmural MI is documented without the site, query the provider. If the provider cannot be queried, assign code I21.3

•Nontransmural or subendocardial MI with site documented

–Code as a nontransmural/subendocardial (NSTEMI) myocardial infarction I21.4

–Codes for nontransmural/subendocardial myocardial infarction are not specific to site

•Subsequent acute myocardial infarction occurring within 28 days of a previous acute myocardial infarction:

–Assign a code from category I22 for a new STEMI/NSTEMI documented as occurring within 4 weeks (28 days) of a previous type 1 or unspecified myocardial infarction, regardless of site

–Codes in category I22 are never reported alone

»Assign a code from category I21 in conjunction with the code from I22

»Codes from categories I21 and I22 are sequenced based on the circumstances of the encounter

–Assign a code from category I22 only for type 1 or unspecified subsequent myocardial infarctions

–For subsequent type 2 MIs, assign only code I21.A1

–For subsequent type 4 or 5 MIs, assign only code I21.A9

–If a subsequent MI of one type occurs within 4 weeks of a MI of a different type, assign the appropriate codes from category I21 to identify each type. Do not report a code from category I22. Codes in category I22 are only assigned if both the initial and subsequent MIs are type 1 or unspecified

•Other types of myocardial infarction

–ICD-10-CM provides codes for different types of myocardial infarction. Type 1 MIs are reported with I21.0-I21.4 and I21.9

–Type 2 MIs, and MIs due to demand ischemia or secondary to ischemic imbalance, are reported with I21.A1 Myocardial infarction type 2 with the underlying cause coded first

»Do not assign code I24.8 Other forms of acute ischemic heart disease for the demand ischemia

»When a type 2 AMI code is described as NSTEMI or STEMI, assign only code I21.A1. Codes I21.01-I21.4 are only ever assigned for type 1 AMIs

–Acute type 3, 4a, 4b, 4c and 5 MIs are reported with code I21.A9 Other myocardial infarction type.

–Follow “Code also” and “Code first” notes related to complications, and for coding postprocedural MIs during or following cardiac surgery

•See coding guidelines for Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99) for information on reporting tPA (rtPA) in a different facility within the last 24 hours

General Documentation Requirements

In ICD-10-CM, codes for diseases of the circulatory system are becoming much more specific. The increasing specificity requires more complete documentation regarding the condition, site, and often the laterality as well. Assigning the most specific intraoperative and postoperative complication codes requires precise documentation by the physician. In addition, there are combination codes for some conditions that frequently occur together and assignment of these combination codes requires documentation of both conditions when they occur together, such as coronary atherosclerosis with angina pectoris.

Laterality

Laterality is required for many conditions including cerebrovascular diseases (I60-I69), diseases of the arteries, arterioles, and capillaries when pertaining to the extremities (I70-I79), and diseases of the veins of the extremities (I80-I87).

Intraoperative and Postprocedural Complications

Subcategory I97.1 captures other postprocedural cardiac functional disturbances. Functional disturbances are those that affect heart function and include conditions such as cardiac insufficiency, cardiac arrest, and heart failure. Documentation is required as to whether the functional disturbance occurred after a cardiac procedure or after a surgery performed on a site other than the heart and great vessels. Intraoperative cardiac functional disturbances are captured by codes in subcategory I97.7 with specific codes for intraoperative cardiac arrest occurring during cardiac surgery (I97.710) or during other surgery (I97.711). All other intraoperative functional disturbances are captured by codes in subcategory I97.79.

Hemorrhage and hematoma complicating a procedure are specific to whether the complication occurred during the procedure (intraoperative) or following the procedure (postoperative), and whether the hemorrhage or hematoma involving a circulatory system organ or structure was incurred as a result of a circulatory system procedure or a procedure on another organ or body system. For hemorrhage and hematoma resulting from a circulatory system procedure, the complication must be documented as complicating cardiac catheterization, cardiac bypass, or another circulatory system procedure. Accidental puncture or laceration of a circulatory system organ or structure during a procedure is specific to whether the procedure was being performed on a circulatory system organ or structure or on another organ or body system.

Combination Codes

Some conditions that frequently occur together are now reported with combination codes. Combination codes for diseases of the circulatory system include:

•Coronary atherosclerosis and angina (I25.1-). When coronary atherosclerosis and angina occur together, a cause and effect relationship is assumed unless documentation specifically states otherwise and a combination code is reported

–For atherosclerotic heart disease of native coronary artery with angina pectoris, (see subcategory I25.11)

–For atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris (see subcategory I25.7)

•Pulmonary embolism with acute cor pulmonale. (see subcategory I26.0)

There are additional combination codes that are reviewed in the code-specific examples.

Code-Specific Documentation Requirements

In this section, some of the more commonly reported diseases of the circulatory system are reviewed. The corresponding codes are listed with the documentation requirements identified. The focus is on frequently reported conditions with additional and more specific clinical documentation requirements. Though not all of the codes are discussed, this section will provide a representative sample of the type of additional documentation required for coding diseases of the circulatory system.

Angina Pectoris

Angina pectoris is chest pain caused by decreased blood flow to the heart muscle, usually from a spasm or partial occlusion in the coronary arteries. Angina pectoris can be further defined as stable, when pain is triggered by exertion or stress and resolves with rest or sublingual nitroglycerine, or unstable (crescendo), where pain occurs at rest or with minimal exertion and follows a pattern of increasing severity and duration.

In ICD-10-CM, category I20 contains codes for angina with four subcategories, I20.0 Unstable angina, I20.1 Angina pectoris with documented spasm, I20.8 Other forms of angina pectoris, and I20.9 Angina pectoris unspecified. In addition to these changes, there are now combination codes for atherosclerotic heart disease with angina pectoris.

Coding and Documentation Requirements

Identify angina related to atherosclerotic heart disease:

•Complicating atherosclerotic heart disease (see atherosclerotic heart disease)

•Not complicating atherosclerotic heart disease

If no diagnosis of atherosclerotic heart disease with angina, identify the type of angina pectoris:

•Unstable angina, which includes:

–Accelerated angina

–Crescendo angina

–De novo effort angina

–Intermediate coronary syndrome

–Preinfarction syndrome

–Worsening effort angina

•Angina with documented spasm, which includes:

–Angiospastic angina

–Prinzmetal angina

–Spasm-induced angina

–Variant angina

•Other forms of angina pectoris, which includes:

–Angina equivalent

–Angina of effort

–Coronary slow flow syndrome

–Stenocardia

•Unspecified angina pectoris, which includes:

–Angina NOS

–Anginal syndrome

–Cardiac angina

–Ischemic chest pain

–Lipid rich plaque

–Angina Pectoris

ICD-10-CM Code/Documentation
I20.0	Unstable angina
I20.1	Angina pectoris with documented spasm
I20.8	Other forms of angina pectoris
I20.9	Angina pectoris, unspecified

Documentation and Coding Example

Fifty-six-year-old Caucasian female presents to her PMD with C/O new onset burning pain in her left shoulder and jaw lasting 5-10 minutes. She can go days without symptoms or have 3-6 episodes in a day. She often feels lightheaded or dizzy with the pain and sometimes feels like her heart is “skipping beats.” She is divorced, her only child has just gone off to college and she also admits to job stress as the superintendent of an elementary school district faced with severe budget cuts. On examination, this is an extremely thin, immaculately groomed woman who looks her stated age. Her weight is down 12 lbs. since her last visit 7 months ago. She states she has not been interested in cooking with her son gone and often skips meals. Temperature 98.2, HR 70, RR 12, BP 124/82. PERRL, neck supple with no lymphadenopathy. ROM in jaw, shoulders, and arms WNL. HR regular without murmur. Breath sounds clear, equal bilaterally. Abdomen soft, non-tender with bowel sounds present in all quadrants. Peripheral pulses intact with no edema noted. Reflexes are normal in extremities. 12 lead EKG is WNL. Impression: Anxiety vs. Angina. Patient is given a sample of NTG 0.3 mg with instructions on use and a prescription for Xanax 0.5 mg. First available echocardiogram and stress EKG are tomorrow afternoon but patient has to prepare for a School Board meeting and declines this time. She is to schedule them the following day and will return for results immediately after.

Follow up visit PMD: Patient states she had symptoms before the Board meeting last night and took the NTG. She felt better immediately but did have a slight headache for a few hours. She has not filled the Xanax prescription. The echocardiogram and stress EKG were unremarkable per cardiologist. It is his opinion this is stable angina. He agrees with treating symptoms with NTG and Xanax. RTC in 3 months, sooner if symptoms progress or are not responsive to NTG, Xanax.

Diagnosis Code(s)

I20.9

Angina pectoris, unspecified

Coding Note(s)

Stable angina without any additional qualifiers is reported with an unspecified code in ICD-10-CM.

Atherosclerosis of Extremities

Atherosclerosis of the extremities is characterized by inflammation and accumulation of macrophage white blood cells and low-density lipoproteins along the arterial walls. This leads to narrowing of the vessels and decreased blood flow. Lack of blood flow to the extremities can cause a number of complications including pain, ulceration, and gangrene.

Atherosclerosis of the extremities is reported with codes from 6 subcategories: I70.2, I70.3, I70.4, I70.5, I70.6, and I70.7. Atherosclerosis of the extremities is first classified by whether the blood vessel is a native artery or a bypass graft and the fourth character subcategory level identifies the type of graft. The type of bypass graft must be documented as: autologous vein bypass graft, nonautologous biological bypass graft, nonbiological bypass graft, other specified type of bypass graft, or unspecified type of bypass graft. The fifth character identifies any complications. For ulceration of the legs, this level also captures laterality. For other complications, laterality is captured by the sixth character. The sixth character for ulceration identifies the site more specifically as the thigh, calf, ankle, heel and midfoot, other part of foot, other part of leg, or unspecified site of leg.

Coding and Documentation Requirements

Identify atherosclerosis of the extremity as affecting:

•Native artery

•Bypass graft

–Autologous vein

–Nonautologous biological

–Nonbiological

–Other specified type

–Unspecified graft

•Identify complications/manifestations:

–Gangrene

–Intermittent claudication

–Rest pain

–Ulceration

–Other complication/manifestation

–Unspecified or without complication/manifestation

Identify extremity:

•Arm

•Leg

–Right

–Left

–Bilateral

•Unspecified extremity

For atherosclerosis of the arm with ulceration, use additional code (L98.49-) to identify severity:

•Limited to breakdown of skin

•Fat layer exposed

•Necrosis of muscle

•Necrosis of bone

•muscle involvement without evidence of necrosis

•bone involvement without evidence of necrosis

•other specified severity

•Unspecified severity

For atherosclerosis of the leg with ulceration:

•Identify site:

–Thigh

–Calf

–Ankle

–Midfoot

–Heel

–Other part of foot

–Other part of leg

–Unspecified site of leg

•Use additional code (L97.-) to identify severity of ulcer:

–Limited to breakdown of skin

–Fat layer exposed

–Necrosis of muscle

–Necrosis of bone

–muscle involvement without evidence of necrosis

–bone involvement without evidence of necrosis

–other specified severity

–Unspecified severity

•Use additional code to identify any:

–Exposure to environmental tobacco smoke (Z77.22)

–History of tobacco use (Z87.891)

–Occupational exposure to environmental tobacco smoke (Z57.31)

–Tobacco dependence (F17.-)

–Tobacco use (Z72.0)

Atherosclerosis of Native Artery of Left Leg with Ulceration

ICD-10-CM Code/Documentation
I70.241	Atherosclerosis of native arteries of left leg with ulceration of thigh
I70.242	Atherosclerosis of native arteries of left leg with ulceration of calf
I70.243	Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244	Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245	Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I70.248	Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg
I70.249	Atherosclerosis of native arteries of left leg with ulceration of unspecified site

Documentation and Coding Example

Patient presents to Wound Care Clinic for continuing treatment of left calf ulceration due to atherosclerosis of native vessels. This sixty-one-year-old gentleman is well known to us. He has been disabled from a back injury since age forty-eight and was diagnosed with Peripheral Vascular Disease (PVD) 10 years ago. He is a long-time smoker, has elevated cholesterol, and Type II diabetes. Medications include Cilostazol for leg pain and claudication, Crestor for cholesterol, and Glucophage for diabetes. On examination, of both lower legs, he has muscle wasting, hair loss, thickened toenails, and bluish red discoloration from toes to knee. Pulses are weak but palpable on the right, present only by Doppler on the left. Unna Boot dressing carefully removed from left lower leg to expose a crater like wound measuring 2 cm by 3 cm with a depth of 1.5 cm in the center. Skin is gone, fat pad exposed. The bottom of the wound has a small slough of yellow tissue. Wound is gently debrided and cleaned with betadine and water. Unna Boot reapplied. Patient will return to clinic in 10 days for re-evaluation and continued treatment.

Diagnosis Code(s)

I70.242	Atherosclerosis of native arteries of left leg with ulceration of calf
L97.222	Non-pressure chronic ulcer of left calf with fat layer exposed
E11.622	Type II diabetes mellitus with other skin ulcer
Z72.0	Tobacco use

Coding Note(s)

The only condition treated at this visit is the leg ulcer; however, both the Type II diabetes and the smoking affect healing of chronic ulcers so these conditions should be reported secondarily. The elevated cholesterol is not coded because it is not evaluated or treated at this visit.

Subcategory I70.24 includes any condition classifiable to I70.212 and I70.222 so the leg pain and claudication are not reported additionally. Atherosclerosis requires documentation of the blood vessel as a native artery or bypass graft and also requires the type of bypass graft. Atherosclerosis codes with ulceration are specific to the right leg, left leg, or other extremities (arms). For ulceration of the legs, the site of the ulcer must also be documented to capture the most specific code. An additional code is required to identify the severity of the ulcer (category L97). The type II diabetes code also reflects a skin ulcer complication. Tobacco use and tobacco dependence are clearly differentiated in ICD-10-CM. The code for tobacco use is reported because the documentation does not specify tobacco dependence.

Bundle Branch Blocks: Left Hemiblock/Right Branch Block

Left bundle branch hemiblock and right bundle branch block are types of conduction disorders of the heart. Conduction refers to electrical impulses that move through heart tissue and cause the heart to beat. Conduction disorders affect heart rhythm and rate. In some instances, rhythm and rate disturbances produce physiological symptoms, but sometimes they can only be identified when an electrocardiogram (ECG) is obtained. The following are some of the more common types of conduction disorders:

Left anterior fascicular block: Left anterior fascicular block (LAFB), also referred to as left anterior hemiblock, is the most common partial block of the left bundle branch and involves electrical conduction of impulses from the atrioventricular node. In a left anterior fascicular block, the anterior half of the left bundle branch is defective causing the impulse to pass first to the posterior area of the ventricle which delays activation of the anterior and upper ventricle. It can be observed on an ECG tracing as left axis deviation.

Left posterior fascicular block: Left posterior fascicular block, also referred to as left posterior hemiblock, is a less common partial block of the left bundle branch and involves electrical conduction of impulses from the atrioventricular node. In left posterior fascicular block, the posterior half of the left bundle branch is defective causing the impulse to pass first to the anterior and upper ventricle which delays activation of the posterior ventricle. It can be observed on an ECG tracing as right axis deviation.

Right fascicular block: This is a defect in the heart’s electrical conduction system in which the right ventricle is not activated by an impulse from the right bundle branch but does depolarize when impulses from the left bundle branch travel through the myocardium. It can be observed on an ECG tracing as a wide QRS complex.

In ICD-10-CM, conduction disorders are found in two categories, I44 Atrioventricular and left bundle branch block, and I45 Other conduction disorders. Conditions in these two categories that have specific documentation requirements include left bundle branch hemiblock and right bundle branch block. Left bundle branch hemiblock must be specified as left anterior fascicular block, left posterior fascicular block, or other specified fascicular block to avoid assigning the code for an unspecified fascicular block. Right bundle branch block must be specified as right fascicular block or other specified right bundle branch block to avoid assigning the code for unspecified right bundle branch block.

Coding and Documentation Requirements

For left bundle branch hemiblock, identify fascicular block:

•Left anterior fascicular block

•Left posterior fascicular block

•Other fascicular block

•Unspecified fascicular block

For right bundle branch block, identify fascicular block:

•Right fascicular block

•Other right bundle branch block

•Unspecified right bundle branch block

Bundle Branch (Hemi) Block

ICD-10-CM Code/Documentation
I44.4	Left anterior fascicular block
I44.5	Left posterior fascicular block
I44.69	Other fascicular block
I44.60	Unspecified fascicular block
I45.0	Right fascicular block
I45.19	Other right bundle branch block
I45.10	Unspecified right bundle-branch block

Documentation and Coding Example

Patient is a 45 year-old Caucasian male referred to cardiology after a routine preoperative EKG showed an abnormal rhythm. He is scheduled for an elective left shoulder arthroscopy in 5 days and anesthesia requests cardiology clearance prior to the procedure. Temperature 97.2, HR 62, RR 12, BP 128/70, Ht. 71 inches, Wt. 172 lbs. On examination, this is an athletic appearing, well-groomed gentleman who looks younger than his stated age. He states he is left handed, an avid tennis player and runner and began having left shoulder pain and stiffness a few months ago. MRI showed a small rotator cuff tear and he hopes surgery will help improve his ROM and allow him to resume tennis. He denies chest pain, SOB, dizziness, or palpitations. PERRL, neck supple. Carotid arteries without bruit. Extremities are without clubbing, pulses are full. HR regular without gallop, rub, bruit, or murmur. Breath sounds clear and equal. Abdomen soft, non-tender without bruit. EKG shows a left deviation in the QRS axis of -45 degrees and slight widening of the QRS complex. Also noted on EKG is a mild deviation of qR complex in the lateral limb leads of I, aVL. An abnormal rS pattern in inferior leads II, III, aVF and a 0.055 sec. delay of the intrinsicoid deflection in aVL. Results are consistent with a benign left anterior hemiblock. He is cleared for surgery. Cardiology note electronically transmitted to his orthopedist and to the anesthesia group.

Diagnosis Code(s)

I44.4

Left anterior fascicular block

Coding Note(s)

A hemiblock refers to an arrest of the electrical impulses in one of the two main divisions of the left branch of the atrioventricular bundle, either the anterior or posterior. The term hemiblock is synonymous with a fascicular or divisional block. In this case, the block is in the anterior portion, so code I44.4 is reported.

Cardiac Arrest

Cardiac arrest is the failure of the heart muscle to contract effectively which impedes the normal circulation of blood and prevents oxygen delivery to the body.

Cardiac arrest is not synonymous with a myocardial infarction. A myocardial infarction refers to a loss of blood supply to an area of the heart usually due to blockage of a coronary artery which causes the heart tissue to die (necrosis).

There are three codes for reporting a cardiac arrest. These codes identify the cardiac arrest as due to an underlying cardiac condition (I46.2); due to an underlying other (noncardiac) condition (I46.8); or due to an unspecified cause (I46.9). Codes in category I46 are not used to report a myocardial infarction, which is reported with codes from categories I21 and I22. There is also an Excludes2 note for cardiogenic shock which is reported with code R57.0.

Coding and Documentation Requirements

Identify cardiac arrest as due to:

•Underlying cardiac condition

•Other underlying condition

•Unspecified cause

Cardiac Arrest

ICD-10-CM Code/Documentation
I46.2	Cardiac arrest due to underlying cardiac condition
I46.8	Cardiac arrest due to other underlying condition
I46.9	Cardiac arrest, cause unspecified

Documentation and Coding Example

Thirty-six-year-old Caucasian female brought in by EMS after suffering a witnessed cardiac arrest. Patient was training for a recreational 5K run with a group of friends when she suddenly collapsed on the high school track where they were training. Bystanders rushed to her side and an off-duty nurse assessed her to be pulseless and breathless and started CPR. EMS was called and an AED on the premises was activated. She was defibrillated x 2 and had a pulse by the time paramedics arrived on scene. She is conscious on arrival in ED, oriented only to self and has no recall of the incident. Sinus tach on monitor, 12 lead EKG shows prolonged QT interval. Blood drawn for CBC, electrolytes, and cardiac enzymes. Patient admitted to CCU for observation.

CCU Note: Patient had an uneventful night. She is alert and oriented x 3. She c/o chest discomfort during the night and was medicated twice with intravenous morphine sulfate with good relief. Patient was able to provide cardiologist with a history significant for syncopal episodes in adolescence which were attributed to low blood sugars, a family history of SIDS in a sibling, and a niece with congenital hearing loss. She is scheduled for echocardiogram to r/o cardiomyopathy or congenital heart defect. She was started on Propranolol 40 mg BID last evening. Transfer to telemetry floor following echo.

Telemetry Floor Note: Stable overnight with no evidence of tachycardia, improving QT interval although it is still prolonged. Echocardiogram was negative for cardiomyopathy or congenital defect. Genetic work up initiated given the family history of SIDS and congenital HL. Patient is discharged home on Propranolol. Appointment with cardiologist in 1 week. She is advised not to return to her job until cleared by cardiology and is forbidden to engage in any strenuous exercise.

Impression: Sudden cardiac arrest brought on by exercise with underlying long QT syndrome.

Diagnosis Code(s)

I45.81	Long QT syndrome
I46.2	Cardiac arrest due to underlying cardiac condition
Y93.02	Activity, running
Y92.39	Other specified sports and athletic area as the place of occurrence of the external cause
Y99.8	Other external cause status

Coding Note(s)

Long QT syndrome is a hereditary defect of the heart’s electrical conduction system characterized by an abnormally long gap in the time it takes for the ventricles to contract.

The long QT syndrome is the principal/first-listed diagnosis followed by code I46.2 which identifies the cardiac arrest as due to an underlying cardiac condition. An external cause code should also be reported because the cardiac arrest has been documented as due to strenuous exercise (running) and the underlying cardiac condition. Code Y93.02 is reported to identify the activity as running; Y99.8 identifies the external cause status as a leisure activity; and Y92.39 identifies the place of occurrence.

Coronary Atherosclerosis

Coronary atherosclerosis is a condition affecting arterial blood vessels in the heart, characterized by inflammation and accumulation of macrophage white blood cells and low-density lipoproteins along the arterial walls. This leads to narrowing of the vessels and decreased blood flow to the heart muscle and may cause angina (chest pain).

In ICD-10-CM, there are combination codes for when coronary atherosclerosis and angina occur together. Codes for atherosclerotic heart disease are listed in category I25 Chronic ischemic heart disease, in subcategories I25.1, I25.7, and I25.8. Other conditions listed in this category include: old myocardial infarction (I25.2), aneurysm of heart (I25.3), coronary artery aneurysm and dissection (I25.4), ischemic cardiomyopathy (I25.5), and silent myocardial ischemia (I25.6).

Coding and Documentation Requirements

Identify site of coronary atherosclerosis:

•Native coronary artery

•Graft

–Autologous

»Artery bypass graft

»Vein bypass graft

–Nonautologous biological bypass graft

–Other specified type of bypass graft

–Unspecified type of bypass graft

•Transplanted heart

–Native coronary artery of transplanted heart

–Bypass graft (artery/vein) of transplanted heart

Identify presence or absence and type of angina pectoris:

•With angina pectoris

–Unstable

–With documented spasm

–With other documented form of angina pectoris

–Unspecified type of angina pectoris

•Without angina pectoris

Identify also any of the following conditions (assign additional code):

•Chronic total occlusion of coronary artery

•Coronary atherosclerosis due to

–Calcified coronary lesion

–Lipid rich plaque

Use additional code to identify any:

•Exposure to environmental tobacco smoke (Z77.22)

•History of tobacco use (Z87.891)

•Occupational exposure to environmental tobacco smoke (Z57.31)

•Tobacco dependence (F17.-)

•Tobacco use (Z72.0)

Atherosclerosis Native Coronary Artery

ICD-10-CM Code/Documentation
I25.10	Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.110	Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.118	Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.111	Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118	Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119	Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris

Documentation and Coding Example

Patient is a seventy-five-year-old Black male well known to us in Cardiac Clinic. He has a history of AMI 3 years ago with 4 vessel aortocoronary bypass grafts using saphenous vein left leg. He is a retired train engineer, recently widowed, and is accompanied today by his daughter. He complains of increasing SOB and chest tightness with exertion. EKG shows abnormal ST segments unchanged from previous tracings. Oxygen saturation is 97% on RA. There is a well healed midline chest scar. HR regular without bruit, murmur, or rubs. Breath sounds decreased in bases with fine wheezes scattered over bronchus. He has a history of asthma well controlled with Symbicort daily, Xopenex when symptoms flare. Current medications also include Crestor and Atenolol. Pulses full in all extremities. Well healed scar from groin to ankle left leg. Patient and daughter agree to noninvasive cardiac testing to evaluate cardiac function and possible angiogram or nuclear medicine thallium study to assess the coronary graft sites. He is scheduled for OP echocardiogram, stress test. Further tests to be determined by those results.

Cardiac Testing Lab Note: Patient tolerated echocardiogram well but developed CP during bicycle stress test and the test had to be aborted. He was admitted to Telemetry floor and scheduled for an angiogram in the AM. Labs drawn for CBC, cardiac enzymes, PT and PTT, blood type and hold.

Cardiac Catheterization Lab: Under monitored anesthesia care patient is prepped and draped and procedure is carried out through a cut down in right groin. The angiogram shows clean vascular grafts with good coronary blood flow in the anterior wall. There is a new atherosclerotic lesion along the left circumflex coronary artery with almost total occlusion of this artery. Patient tolerated procedure well and was transferred back to Telemetry floor for overnight observation.

Impression: Chronic occlusion of native left circumflex artery with angina on exertion.

Discharge Note: Test results were discussed with patient and daughter. They decline surgery for the blocked artery and prefer to treat symptoms if possible. He will return to cardiac clinic in 1 week for post angio checkup. We will review his medications at that time and make changes as appropriate. He is discharged home in the care of his daughter.

Diagnosis Code(s)

I25.118	Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.2	Old myocardial infarction
Z95.1	Presence of aortocoronary bypass graft

Coding Note(s)

Angina on exertion or angina of effort is classified as an “other form of angina.” Code I25.82 is not reported because this code requires a diagnosis of “chronic total occlusion” and the documentation states that there is “almost total occlusion” but not “total occlusion.”

Hemorrhage, Nontraumatic: Intracerebral, Intracranial, Subarachnoid

Intracerebral

An intracerebral hemorrhage is defined as bleeding inside the brain. In ICD-10-CM, nontraumatic intracranial hemorrhage (I61) is specific to the region where the hemorrhage occurred. To assign the most specific code, documentation must identify the site as subcortical or cortical hemisphere, brain stem, cerebellum, or intraventricular. Alternatively, the documentation may state that there are multiple localized intracerebral hemorrhages as this condition also has a specific code.

Coding and Documentation Requirements

Identify the region of the nontraumatic cerebral hemorrhage:

•Brain stem

•Cerebellum

•Hemispheric

–Cortical

–Subcortical

–Unspecified

•Intraventricular

•Multiple localized sites

•Other specified site

•Unspecified site

Nontraumatic Intracerebral Hemorrhage

ICD-10-CM Code/Documentation
I61.0	Nontraumatic intracerebral hemorrhage in hemisphere, subcortical
I61.1	Nontraumatic intracerebral hemorrhage in hemisphere, cortical
I61.2	Nontraumatic intracerebral hemorrhage in hemisphere, unspecified
I61.3	Nontraumatic intracerebral hemorrhage in brain stem
I61.4	Nontraumatic intracerebral hemorrhage in cerebellum
I61.5	Nontraumatic intracerebral hemorrhage, intraventricular
I61.6	Nontraumatic intracerebral hemorrhage, multiple localized
I61.8	Other nontraumatic intracerebral hemorrhage
I61.9	Nontraumatic intracerebral hemorrhage, unspecified

Documentation and Coding Example

Seventy-four-year-old Caucasian male presents to neurologist with new onset confusion and speech difficulties. The patient is widowed and is accompanied today by his housekeeper/caregiver. Patient was diagnosed with cerebral amyloid angiopathy several years ago after suffering seizures. The seizures have been well controlled with Tegretol. His caregiver reports he was well until yesterday when he had a headache and vomiting. They thought he had the flu and symptoms seemed to resolve with fluids and rest. She went in to his bedroom this morning when he did not come down to breakfast and found him sitting in a chair, dressed but unable to figure out where he was and what he should be doing. He is oriented to person and recognizes his caregiver and this physician. VSS. There is no history of a fall or injury to the head. He is transferred to ED with orders for blood draw to include CBC, electrolyte panel, coagulation studies, Type and Cross, IV of NS and head CT to r/o intracranial bleed or tumor. Admit to floor after CT scan.

Radiology Note: Patient underwent a CT scan of the brain which showed a small cerebellar hemorrhage. He developed bradycardia and hypotension during the scan, which resolved after administration of IV atropine. He was transferred to neurosurgical floor for observation and is scheduled for MRI in the morning.

Floor Note: Patient is oriented x 3 after an uneventful night. He has a wry sense of humor and likes joking with the staff. He ate breakfast but complained that the hospital food is atrocious and he will surely wither away to nothing if his housekeeper cannot bring him in home cooked meals. Neurosurgical Team will evaluate him after the MRI.

Neurosurgical Note: Patient tolerated MRI well and scan reveals a small hemorrhage in the lateral cerebellum with no obstructive hydrocephalus present. Labs are WNL. Plan is to monitor one more day and discharge if symptoms continue to improve.

Discharge Note: Patient is discharged home in the care of his housekeeper. His only medication is Tegretol and he has an appointment with his neurologist in 1 week. Recommend he have a repeat MRI in 2-4 weeks.

Diagnosis Code(s)

I61.4	Nontraumatic intracerebral hemorrhage in cerebellum
E85.4	Organ-limited amyloidosis
I68.0	Cerebral amyloid angiopathy

Coding Note(s)

Cerebral amyloid angiopathy is a neurological condition that is characterized by the build-up of proteins, specifically amyloid, on the artery walls in the brain. Typically, the protein is deposited only in the cerebral arteries and not elsewhere in the body. The condition increases the risk of hemorrhagic stroke and dementia. The cause is unknown. The cerebral amyloid angiopathy is reported additionally because it is related to the intracerebral hemorrhage and affects the management of the patient.

The code for the nontraumatic intracerebral hemorrhage is specific to the cerebellum.

Intracranial

The brain is covered by three membranes. The dura mater is the outer membrane, the arachnoid is the middle membrane, and the pia mater is the inner membrane. Nontraumatic extradural hemorrhage, also called epidural hemorrhage, refers to spontaneous bleeding between the dura mater and the skull. Extradural bleeding is usually arterial. Nontraumatic subdural hemorrhage refers to spontaneous bleeding between the dura mater and the arachnoid. A subdural hemorrhage most often arises from bridging veins that cross the subdural space. Both extradural and subdural hemorrhage increase intracranial pressure and compress brain tissue.

In ICD-10-CM, other and unspecified nontraumatic intracranial hemorrhage, category I62, contains codes for subdural hemorrhage which must be documented as acute, subacute, or chronic; a code for extradural (epidural) nontraumatic hemorrhage; and one for unspecified intracranial hemorrhage.

Coding and Documentation Requirements

Identify site of other and unspecified intracranial hemorrhage:

•Extradural

•Subdural

–Acute

–Chronic

–Subacute

–Unspecified

•Unspecified intracranial hemorrhage

Nontraumatic Intracranial Hemorrhage

ICD-10-CM Code/Documentation
I62.1	Nontraumatic extradural hemorrhage
I62.00	Nontraumatic subdural hemorrhage, unspecified
I62.01	Nontraumatic acute subdural hemorrhage
I62.02	Nontraumatic subacute subdural hemorrhage
I62.03	Nontraumatic chronic subdural hemorrhage
I62.9	Nontraumatic intracranial hemorrhage, unspecified

Documentation and Coding Example

Fifty-five-year-old Caucasian female presents to PMD with c/o difficulty with balance and lower extremity weakness x 1 week. She has a history of bioprosthetic aortic valve replacement 2 years ago and is on Coumadin therapy. INR has been within target range except for one elevated level about a month ago thought to be due to dietary changes when she was visiting her daughter. She is a self-employed interior designer and also works part time in an antiques store. She denies recent illness or exposure to chemicals/paints and can recall no injury that might account for her symptoms. She lives with her husband. Their daughter is married, with a new baby and lives quite a distance away.

Temperature 99, HR 80, RR 12, BP 136/80. On examination, this is a well-groomed, tired appearing woman who looks a little older than her stated age. PERRL, neck supple, cranial nerves grossly intact. No weakness appreciated in upper extremities. Apical pulse is regular with ejection click audible, PMI at apex. No rubs or gallop appreciated. Breath sounds clear, equal bilaterally. Abdomen soft, mildly obese. Liver at RCM, spleen not palpated. Negative for bruit over abdominal vessels. Lower extremity pulses are weak bilaterally. DTR of medial hamstring, patellar and Achilles are 1+ with a very slight positive Babinski. Muscle tone is decreased and balance is poor both on 2 feet and single footed, gait is slow and unsteady. There is no appreciated foot drop. Her symptoms are perplexing. She is sent to lab for blood draw, CBC, electrolytes, INR. Scheduled for noncontrast CT of head tomorrow to r/o tumor.

Admit Note: Patient is admitted to Neurosurgical service for evacuation of subdural hematoma caused by her Coumadin therapy. Her head CT revealed a large crescent shaped bleed in the frontal lobe consistent with an evolving liquefaction of a chronic subdural hemorrhage. She is clinically stable and can safely be an add on case today or tomorrow.

Post-Operative Note: Patient was taken to OR and under monitored anesthesia care, 2 Burr holes were placed through the frontal bone and the hematoma evacuated. Patient tolerated the procedure well and will be observed overnight in Neurosurgical ICU. INR 2.5 prior to procedure. She will be monitored closely for bleeding.

Post Op Day 1: Uneventful night. Patient is awake, oriented X3, tolerating liquid diet. Has required no pain medication. She will be transferred to rehabilitation unit for 3 days of intensive PT to ensure she regains strength in lower extremities. She will have a repeat head CT prior to discharge.

Rehab Discharge Note: Patient did well with inpatient rehab. She feels she is almost back to her baseline level of strength and functioning. Repeat cranial CT shows no re-accumulation of blood in the frontal lobe subdural space. She is discharged home and will continue PT in OP clinic. INR this morning is 3.1. PMD will assume care to monitor INR, Coumadin dose. Follow up appointment in Neurosurgical Clinic in 10 days.

Diagnosis Code(s)

I62.03	Nontraumatic chronic subdural hemorrhage
T45.515A	Adverse effect of anticoagulants, initial encounter
Z95.2	Presence of prosthetic heart valve
Z79.01	Long term use of anti-coagulants

Coding Note(s)

A mechanical heart valve is one made from synthetic materials. This type of heart valve requires continuous use of blood thinners, such as Coumadin. The subdural hemorrhage has been documented as an adverse effect of the Coumadin therapy. An adverse effect code is assigned as a secondary diagnosis for a drug that is correctly prescribed and properly administered. The adverse effect, in this case the chronic subdural hemorrhage, is the principal diagnosis. Additional codes are assigned for the presence of the prosthetic heart valve and the long-term use of anti-coagulants.

In ICD-10-CM, there are specific codes for subdural hematoma which must be documented as acute, subacute, or chronic. The supplementary code identifying the presence of a heart valve is more specific and requires documentation of the type of heart valve as prosthetic (mechanical), xenogeneic (bovine, porcine), or other type of heart valve.

Subarachnoid

A subarachnoid hemorrhage is defined as bleeding between the middle (arachnoid) and inner (pia mater) membranes covering the brain. In ICD-10-CM, nontraumatic subarachnoid hemorrhage, category I60, is specific to site and must be documented as involving the carotid siphon or bifurcation, middle cerebral artery, anterior communicating artery, posterior communicating artery, basilar artery, vertebral artery, or other specified intracranial artery. For all sites except the basilar artery, laterality (right, left) is also required.

Coding and Documentation Requirements

Identify the site of the nontraumatic subarachnoid hemorrhage:

•Anterior communicating artery

•Basilar artery

•Carotid siphon and bifurcation

•Middle cerebral artery

•Posterior communicating artery

•Vertebral artery

•Other specified intracranial artery

•Unspecified intracranial artery

•Other specified site, which includes:

–Meningeal hemorrhage

–Rupture of arteriovenous malformation

•Unspecified subarachnoid hemorrhage

Identify laterality (except for basilar artery, other specified intracranial artery, and unspecified intracranial artery):

•Right

•Left

•Unspecified

Nontraumatic Subarachnoid Hemorrhage

ICD-10-CM Code/Documentation
Carotid Siphon & Bifurcation
I60.00	Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation
I60.01	Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation
I60.02	Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation
Posterior Communicating Artery
I60.30	Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating artery
I60.31	Nontraumatic subarachnoid hemorrhage from right posterior communicating artery
I60.32	Nontraumatic subarachnoid hemorrhage from left posterior communicating artery
Middle Cerebral Artery
I60.10	Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery
I60.11	Nontraumatic subarachnoid hemorrhage from right middle cerebral artery
I60.12	Nontraumatic subarachnoid hemorrhage from left middle cerebral artery
Vertebral Artery
I60.50	Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery
I60.51	Nontraumatic subarachnoid hemorrhage from right vertebral artery
I60.52	Nontraumatic subarachnoid hemorrhage from left vertebral artery
Basilar Artery
I60.4	Nontraumatic subarachnoid hemorrhage from basilar artery
Anterior Communicating Artery
I60.2	Nontraumatic subarachnoid hemorrhage from anterior communicating artery
Other/Unspecified Intracranial Arteries
I60.6	Nontraumatic subarachnoid hemorrhage from other intracranial arteries
I60.7	Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery
Other/Unspecified Subarachnoid Hemorrhage
I60.8	Other nontraumatic subarachnoid hemorrhage
I60.9	Nontraumatic subarachnoid hemorrhage, unspecified

Documentation and Coding Example

Fifty-year-old Black female presents to ER with a two-hour history of worsening headache and weakness in her left leg. PMH is significant for poorly controlled hypertension largely due to financial constraints to obtaining her medication. She states she has taken her BP meds consistently for the past month. Temperature 97.8, HR 96, RR 14, BP 182/104. On examination, this is a thin, quiet woman who apologizes for bothering us today. She is accompanied by her son and his wife. She squints and attempts to shade her eyes with her hand stating the light bothers them. Fundoscopic exam is difficult because of light sensitivity but pupils appear to be equal and reactive to light. Neck supple without lymphadenopathy, no nuchal rigidity. Cranial nerves grossly intact. Upper extremities with normal CSM. Apical pulse regular with a soft S3 gallop. Breath sounds clear, equal bilaterally. Abdomen soft, flat with active BS. Lower extremity pulses intact with a marked decrease in reflexes and muscle strength in the left leg. IV started and blood drawn for CBC, coagulation studies, comprehensive metabolic panel. She is sent emergently to CT to r/o cerebral vascular accident.

Neurology Note: Called to examine patient in radiology. A noncontrast CT shows bleeding in the subarachnoid space. CT angiography was then performed and confirms a non-traumatic subarachnoid bleed from the right middle cerebral artery into the interhemispheric fissure and extending to the surface of the right frontal lobe. She is transferred to Neuro ICU in good condition for observation and conservative care.

Neuro ICU Note: Patient had an uneventful night with BP stable on Lotrel. No progression of weakness in her left lower extremity. Headache and light sensitivity have decreased in intensity but are still present. She was offered pain medication but has refused. Transfer to floor. PT evaluation requested to determine safety for ambulation and possible adaptive equipment.

Floor Note: PT evaluated patient and she is using a cane for assisted ambulation. Headache is described as very mild and light sensitivity has resolved. Plan discharge tomorrow after repeat CT scan.

Discharge Note: Subarachnoid hemorrhage from right middle cerebral artery. Hypertension. Resolving left leg weakness caused by subarachnoid hemorrhage. Repeat CT scan without contrast shows no extension of subarachnoid bleed. Patient is discharged home on Lotrel for BP regulation and a cane for ambulation. She will continue PT as an outpatient and follow up in Neurology Clinic in 1 week.

Diagnosis Code(s)

I60.11	Nontraumatic subarachnoid hemorrhage from right middle cerebral artery
I10	Essential hypertension

Coding Note(s)

In ICD-10-CM, there is a code also note indicating that hypertension is reported additionally when documented. The left leg weakness is a symptom of the current subarachnoid hemorrhage and is documented as resolving, so no additional codes are reported. In the PMH, it is noted that the patient’s hypertension has been poorly controlled in the past due to economic hardship, but the patient has been taking her medication for the past month. The physician did not document that the subarachnoid hemorrhage was due to underdosing of hypertension medication, so a code for underdosing would not be reported.

Hypertensive Diseases

Hypertensive disease is classified into two broad types, essential hypertension and secondary hypertension. Essential hypertension, also called primary or idiopathic hypertension, refers to abnormally elevated blood pressure levels that have no underlying cause. Essential hypertension is often associated with an increase in age and there may be familial, genetic, and environmental factors to developing the disorder. The following conditions are associated with increased risk of developing essential hypertension: obesity, sodium sensitivity, elevated renin levels, insulin resistance, and vitamin D deficiency. Hypertension increases an individual’s risk for cerebral, cardiac, and renal problems. Secondary hypertension refers to abnormally elevated blood pressure levels due to an underlying condition or cause. These can include: renal disease, adrenal gland tumors, congenital malformations of blood vessels, sleep apnea, medications (hormone contraceptives, decongestants, steroids), recreational drug use (cocaine), and thyroid and parathyroid gland disorders.

Hypertension is reported with codes from categories I10-I15. Categories I10-I14 classify essential hypertension as follows: I10 Essential hypertension; I11 Hypertensive heart disease; I12 Hypertensive chronic kidney disease; and I13 Hypertensive heart and chronic kidney disease. Secondary hypertension is reported with codes in category I15. ICD-10-CM no longer differentiates hypertension as benign, malignant, or unspecified. An additional instructional guideline has been added to ICD-10-CM to use an additional code to identify exposure to environmental and occupational tobacco smoke, any history of tobacco use, or current use of or dependence on tobacco.

Hypertension, Essential

Even though coding for essential hypertension has been made simpler with the elimination of historical subcategories for malignant, benign, and unspecified severity. Coding and documentation requirements related to hypertension are covered here because essential hypertension is one of the most common cardiovascular diseases.

Coding and Documentation Requirements

For essential hypertension, identify presence/absence of hypertensive heart and/or chronic kidney disease:

•Essential hypertension only

•Hypertensive heart disease

–With heart failure

–Without heart failure

•Hypertensive chronic kidney disease

–With Stage 1-4 (I-IV) or unspecified chronic kidney disease

–With Stage 5 (V) or end stage chronic kidney disease

•Hypertensive heart and chronic kidney disease

–With heart failure

»With Stage 1-4 (I-IV) or unspecified chronic kidney disease

»With Stage 5 (V) or end stage chronic kidney disease

–Without heart failure

»With Stage 1-4 (I-IV) or unspecified chronic kidney disease

»With Stage 5 (V) or end stage chronic kidney disease

For essential hypertensive heart disease with heart failure, use an additional code to specify the type of heart failure (I50.-).

For essential hypertensive chronic kidney disease, use an additional code to specify the stage of chronic kidney disease (N18.1-N18.9).

Use additional code to identify any:

•Exposure to environmental tobacco smoke (Z77.22)

•History of tobacco use (Z87.891)

•Occupational exposure to environmental tobacco smoke (Z57.31)

•Tobacco dependence (F17.-)

•Tobacco use (Z72.0)

ICD-10-CM Code/Documentation
I10	Essential hypertension
I11.9	Hypertensive heart disease without heart failure
I11.0	Hypertensive heart disease with heart failure
I12.9	Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I12.0	Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I13.10	Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.0	Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.11	Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2	Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

Documentation and Coding Example

Thirty-one-year-old Asian female is seen for follow up of hypertension. Patient initially presented for annual physical exam six months ago and was found to have a BP of 158/94. She was asked to monitor her BP daily at home for 1 month and readings were consistently above 140/90. She was resistant to go on medication and agreed to some dietary changes while continuing her usual exercise routine. Patient teaches jazz dance 2-4 hours a day, 4 days week. Of interest her Vitamin D, 25 OH level was low (8 ng/ml) and she was started on supplemental Vit D 5000 units/day. She also cut down on her sodium intake, which was quite high as she eats a lot of take-out food. BP readings improved for a few months with SBP ranging from 130-144 and DBP in the range of 82-92. However, in the last month her SBP is in the 140-150 range and DBP in the 90-100 range despite a much healthier diet. Her most recent Vit D level was 18 ng/ml. Patient is counseled on the long-term effects of hypertension and risks of not treating. She agrees to start medication and is given samples of Cozaar 25 mg. She will begin with 1 tablet in the evening and if she has no side effects she will increase the dose to 1 tablet in the evening and 1 in the AM. Patient will continue to monitor her BP daily. RTC in 1 month to report BP readings and any side effects of the medication.

Diagnosis Code(s)

I10	Essential hypertension

Coding Note(s)

There is a single code for reporting essential hypertension that is not complicated by hypertensive heart and/or chronic kidney disease. There is no documentation of exposure to tobacco smoke or any history of or current use or dependence on tobacco, so no additional codes are assigned.

Hypertension, Secondary

Secondary hypertension (I15) has five subcategories which include: renovascular hypertension, hypertension secondary to other renal disorders, hypertension secondary to endocrine disorders, other secondary hypertension, and unspecified secondary hypertension.

An additional code is required for secondary hypertension to identify the underlying condition, and an additional code should be reported for any documented exposure to tobacco smoke or any history of or current use or dependence on tobacco.

Coding and Documentation Requirements

Identify cause/type of secondary hypertension:

•Renovascular

•Due to other renal disorders

•Due to endocrine disorders

•Other secondary type

•Unspecified

Code also underlying condition

Use additional code to identify any:

•Exposure to environmental tobacco smoke (Z77.22)

•History of tobacco use (Z87.891)

•Occupational exposure to environmental tobacco smoke (Z57.31)

–Tobacco dependence (F17.-)

–Tobacco use (Z72.0)

Secondary Hypertension

ICD-10-CM Code/Documentation
I15.0	Renovascular hypertension
I15.1	Hypertension secondary to other renal disorders
I15.2	Hypertension secondary to endocrine disorders
I15.8	Other secondary hypertension
I15.9	Secondary hypertension, unspecified

Documentation and Coding Example

Forty-eight-year-old Hispanic female presents to ED with c/o dizziness and “tightness” around her head for the past 2 hours. Patient is a kindergarten teacher with a strong family history of early onset hypertension in females. Her BP was moderately elevated at her last PE and she has been going to the school nurse twice a week for BP checks and reporting them to her doctor. She states that today was a fairly typical day but her symptoms began just before lunch. She waited until her students were dismissed to visit the school nurse who checked her BP and found it be 190/120. Triage nurse at PMD office directed her to ED where she was driven by a school staff member. Temperature 97.8, HR 88, RR 16, BP 202/122. On examination, this is an anxious appearing, slim, well-groomed woman who looks significantly younger than her stated age. PERRL, with no evidence of papilledema. Neck supple, without masses. Carotid arteries without bruit. HR regular without murmur, gallop, rub, or bruit. Breath sounds clear and equal bilaterally. Abdomen soft and flat with active bowel sounds, soft bruit present in the midline. Reflexes are brisk and pulses bounding in all four extremities. EKG obtained and shows NSR without ectopy. IV started in left forearm, blood drawn for CBC, comprehensive metabolic panel, renin, and aldosterone levels. Labetalol 10 mg administered IVP with BP down to 150/100 and resolution of her headache and dizziness. Labetalol 100 mg given PO with orders to repeat PO dose q 12 hours and to repeat IV Labetalol for SPB>180 or DBP>110. Patient transferred to telemetry for observation. Doppler US of renal arteries scheduled for AM to evaluate for renal artery stenosis.

Telemetry Note Day 1: BP has been stable on PO Labetalol. Doppler US shows renal artery stenosis with mild ischemic renal atrophy.

Diagnosis: Renovascular hypertension due to fibromuscular dysplasia.

Plan: Continue Labetalol. Check renal function in 3 months, repeat renal US in 6 months. Discharge home today. Patient to check BP daily and f/u with PMD in 1 week.

Diagnosis Code(s)

I15.0	Renovascular hypertension
I77.3	Arterial fibromuscular dysplasia

Coding Note(s)

Fibromuscular dysplasia is a disease of the arteries that affects medium sized arteries, most often the renal arteries causing renal artery stenosis and renal atrophy from the reduced blood supply to the kidney. The renovascular disease may then cause secondary hypertension.

Because the secondary hypertension is due to the renovascular disease it is reported with code I15.0. The renal artery stenosis and resulting renal ischemia and atrophy are due to fibromuscular dysplasia, which is also referred to as fibromuscular hyperplasia. Fibromuscular hyperplasia of the renal artery is reported with code I77.3.

Myocardial Infarction

Myocardial infarction (MI) is an interruption of blood flow to an area of the heart muscle leading to cell damage or death. Type 1 myocardial infarctions are those related to coronary artery disease such as atherosclerotic plaque erosion or rupture and are defined based upon ECG changes as ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI). STEMI stands for ST segment elevation myocardial infarction and is the more severe type.

STEMI occurs when a coronary artery is totally occluded and virtually all the heart muscle dependent on blood supplied by the affected artery begins to die. STEMI is further classified based upon the site such as posterior or anterolateral wall. NSTEMI is the milder form of myocardial infarction and stands for non-ST segment elevation myocardial infarction. In NSTEMI, the coronary artery is only partially occluded, and only the inner portion of the heart muscle supplied by the affected artery dies. NSTEMI is also referred to as a subendocardial infarction.

Historically the type of MI, (STEMI, NSTEMI), site, and the episode of care were required.

Codes for initial and subsequent type 1 acute ST elevation myocardial infarction (STEMI) are specific to site requiring identification of the affected coronary artery. Codes for the initial type 1 AMI should be used only for an AMI that is equal to or less than 4 weeks old (category I21). Codes for subsequent type 1 AMI are used only when the patient suffers a new AMI within 4 weeks (28 days) of a previous AMI. The codes for NSTEMI are used for initial or subsequent type 1 AMI documented as nontransmural or subendocardial. There is additional instruction to code also any documented exposure to tobacco smoke or any history of or current use or dependence on tobacco.

Coding and Documentation Requirements

Identify initial or subsequent AMI:

•Initial

•Subsequent (new AMI occurring within the 4-week time frame of the initial AMI)

Identify type of myocardial infarction:

•Type 1 ST elevation myocardial infarction (STEMI)

•Type 1 Non-ST elevation myocardial infarction (NSTEMI)

•Other type

–Type 2

–Other type (type 3, 4a, 4b, 4c, 5)

–Unspecified acute MI

For type 1 STEMI identify site:

•Initial

–Anterior wall

»Left main coronary artery

»Left anterior descending artery

»Other coronary artery of anterior wall

–Inferior wall

»Right coronary artery

»Other coronary artery of inferior wall

–Other specified sites

»Left circumflex coronary artery

»Other specified site

–Unspecified site

•Subsequent

–Anterior wall

–Inferior wall

–Other sites

For type 1 NSTEMI:

•No site-specific information required

•Identify as initial or subsequent

Identify any current complications of STEMI or NSTEMI (within initial 28-day period) and report additionally:

•Hemopericardium

•Atrial septal defect

•Ventricular septal defect

•Rupture of cardiac wall

•Rupture of chordae tendineae

•Rupture of papillary muscle

•Thrombosis of

–Atrium

–Auricular appendage

–Ventricle

•Postinfarction angina

•Other specified type of current complication of AMI

Use additional code to identify any:

•Exposure to environmental tobacco smoke (Z77.22)

•History of tobacco use (Z87.891)

•Occupational exposure to environmental tobacco smoke (Z57.31)

•Tobacco dependence (F17.-)

•Tobacco use (Z72.0)

•Status post administration of tPA in a different facility within the last 24 hours prior to admission to current facility (Z92.82)

For Type 2, code first the underlying cause, if known and appropriate, such as:

•Anemia (D50.0-D64.9)

•Chronic obstructive pulmonary disease (J44.-)

•Paroxysmal tachycardia (I47.0-I47.9)

•Shock (R57.0-R57.9)

For other types of AMI:

•Code first, if applicable, causation:

–Following cardiac surgery (I97.190)

–During cardiac surgery (I97.790)

•Code also any known and applicable complication:

–(Acute) stent occlusion (T82.897-)

–(Acute) stent stenosis (T82.857-)

–(Acute) stent thrombosis (T82.867-)

–Cardiac arrest due to underlying cardiac condition (I46.2)

–Complication of PCI (I97.89)

–Occlusion of coronary artery bypass graft (T82.218-)

Acute Myocardial Infarction

ICD-10-CM Code/Documentation
I21.01	ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02	ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09	ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11	ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19	ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21	ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29	ST elevation (STEMI) myocardial infarction involving other sites
I21.3	ST elevation (STEMI) myocardial infarction of unspecified site
I21.4	Non-ST elevation (NSTEMI) myocardial infarction
I21.9	Acute myocardial infarction, unspecified
I21.A1	Myocardial infarction type 2
I21.A9	Other myocardial infarction type
I22.0	Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1	Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2	Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8	Subsequent ST elevation (STEMI) myocardial infarction of other sites
I22.9	Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

Documentation and Coding Example 1

Sixty-eight-year-old Caucasian male presents to Urgent Care with a 24-hour history of nausea, vomiting, dizziness. Temperature 97.8, HR 52, RR 16, BP 132/90. On examination, this is a pale appearing, mildly diaphoretic gentleman who looks his stated age. On cardiac monitor he is in sinus bradycardia. 12-lead EKG obtained and shows ST elevation. O2 saturation is 96 % on RA. He denies chest pain but says he did have some pressure when he first started to feel ill. He describes waves of nausea but no vomiting. Oxygen started at 2 L NC, IV placed in right hand and blood drawn for cardiac enzymes, CBC, coagulation studies, comprehensive metabolic panel. Nitroglycerin 0.3 mg sublingual causes a drop in BP but patient feels no change in his symptoms. Impression: Acute myocardial infarction. Transport to ER with direct admit to CCU. Cardiologist is expecting him.

CCU Note 1: Patient admitted from Urgent Care. Initial cardiac enzymes show elevated Troponin I and T, myoglobin, CK and CK-MB. EKG with ST elevation. Bedside echocardiogram shows decreased blood flow to inferior wall. Bradycardia is resolving. HR 68. Denies chest, jaw, or arm pain. Skin color is pink, warm and dry to touch. Breaths sounds clear and equal bilaterally. Patient has an unremarkable medical history. He is a retired financial analyst, has regular medical checkups, has never had elevated BP, cholesterol, or triglycerides. He takes low dose ASA, Enzyme CoQ10, and Saw Palmetto for mild BPH. Patient is scheduled for Thallium study tomorrow to assess cardiac damage.

CCU Note 2: Uneventful night. Tolerating a liquid diet.

Pain has subsided. Serial cardiac enzymes show stable CK and CK-MB, Troponins still rising. Thallium nuclear scan of heart is positive for ischemic changes to the inferior wall and narrowing in multiple areas of the right coronary artery.

Diagnosis: STEMI, inferior wall, right coronary artery.

Diagnosis Code(s)

I21.11

ST elevation (STEMI) myocardial infarction involving right coronary artery

Coding Note(s)

Code I21.11 is the correct code because this AMI has not been preceded by a previous admission for an AMI. Subsequent AMI codes are assigned only when the patient has had a documented admission for an AMI during the previous 28 days.

Documentation and Coding Example 2

Fifty-five-year-old Caucasian male presents to ED with C/O midsternal chest discomfort and nausea. He states the pain occurred during sexual intercourse and was not relieved by NTG. He walked 2 blocks from his apartment to the hospital and appears pale and slightly diaphoretic. PMH is significant for acute MI three weeks ago with angioplasty and stent placement. Patient admits to being non-compliant with cardiac rehabilitation, including making changes to his diet or starting an exercise program. Medications include Lopressor for HTN, Lipitor for hyperlipidemia and NTG for postinfarction angina. His previous records are available. The EKG shows changes consistent with old STEMI involving left anterior descending coronary artery and new changes possibly indicating an inferolateral transmural infarction.

Plan: Cardiac enzymes, CBC w/diff, comprehensive electrolyte panel. IV has been started in his left forearm with #18 angio and D5W is infusing at TKO rate. MS 2 mg IVP has alleviated most of his chest pain. O2 started at 2 L/min per NC, O2 saturation is 97%. Patient has been seen by Cardiology fellow and is on call to cardiac cath lab.

Procedure Note: Successful coronary angiography with balloon angioplasty and stent placement of left circumflex artery. He was admitted to CCU following the procedure.

Discharge Summary: Patient had an uneventful hospital course and was discharged home. He has a follow up visit scheduled in 2 days with his cardiologist and will meet with the cardiac rehabilitation nurse at that time.

Diagnosis Code(s)

I22.1	Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I21.02	ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I23.7	Postinfarction angina
I10	Essential (primary) hypertension
E78.5	Hyperlipidemia, unspecified
Z91.11	Patient’s noncompliance with dietary regimen
Z91.19	Patient’s noncompliance with other medical treatment and regimen
Z95.5	Presence of coronary angioplasty implant and graft

Coding Note(s)

The patient was admitted for treatment of a second ST elevation acute MI at a different site from an ST elevation acute MI 3 weeks prior.

When a patient who suffered an acute myocardial infarction (AMI) has a new AMI within 4 weeks of the initial AMI, a code from category I22 Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction must be used in conjunction with a code from category I21 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. In this case, the subsequent AMI is the reason for the admission so the code from category I22 is sequenced first. Codes in category I21 (initial AMI) and category I22 (second AMI) describe the specific site. There is a code block level instructional note for ischemic heart diseases (I20-I25) directing the coder to assign an additional code to identify presence of hypertension (I10-I15). Postinfarction angina is also reported additionally.

Occlusion of Cerebral Arteries

The cerebral arteries are those located within the cranium or brain. Occlusion of the cerebral arteries due to embolism or thrombosis and/or narrowing of the cerebral arteries affects blood flow to the region of the brain fed by the affected artery. Any interruption in blood flow can cause either transient ischemia or infarction.

Codes for occlusion and stenosis of the cerebral arteries are found in two categories. Category I63 identifies cerebral infarction of the precerebral and cerebral arteries. Subcategories I63.3, I63.4, and I63.5 are specific to the cerebral arteries. Documentation must identify the specific cerebral artery as anterior, middle, or posterior cerebral; cerebellar; other specified cerebral artery; or unspecified cerebral artery. The etiology of the cerebral infarction must be specified as due to thrombosis, embolism, or unspecified occlusion and stenosis. Laterality is also required. Category I66 reports occlusion and stenosis of the cerebral arteries not resulting in stroke. Documentation requirements for this category are the same as for category I63 except that etiology of the obstruction and stenosis is not required.

Coding and Documentation Requirements

Identify infarction status of occlusion and stenosis of cerebral arteries:

•With cerebral infarction

•Without cerebral infarction

With infarction

Identify etiology:

•Embolism

•Thrombosis

•Unspecified occlusion or stenosis

Identify site:

•Cerebral

–Anterior

–Middle

–Posterior

•Cerebellar

•Other specified cerebral artery

•Unspecified cerebral artery

Identify laterality:

•Right

•Left

•Unspecified

Without infarction

Identify site:

•Cerebral artery

–Anterior

–Middle

–Posterior

•Cerebellar artery

•Other specified cerebral artery

•Unspecified cerebral artery

Identify laterality:

•Right

•Left

•Bilateral

•Unspecified

Occlusion and Stenosis of Cerebral Arteries without Infarction

ICD-10-CM Code/Documentation
Middle Cerebral Artery
I66.01	Occlusion and stenosis of right middle cerebral artery
I66.02	Occlusion and stenosis of left middle cerebral artery
I66.03	Occlusion and stenosis of bilateral middle cerebral arteries
I66.09	Occlusion and stenosis of unspecified middle cerebral artery
Anterior Cerebral Artery
I66.11	Occlusion and stenosis of right anterior cerebral artery
I66.12	Occlusion and stenosis of left anterior cerebral artery
I66.13	Occlusion and stenosis of bilateral anterior cerebral arteries
I66.19	Occlusion and stenosis of unspecified anterior cerebral artery
Posterior Cerebral Artery
I66.21	Occlusion and stenosis of right posterior cerebral artery
I66.22	Occlusion and stenosis of left posterior cerebral artery
I66.23	Occlusion and stenosis of bilateral posterior cerebral arteries
I66.29	Occlusion and stenosis of unspecified posterior cerebral artery
Cerebellar Arteries
I66.3	Occlusion and stenosis of cerebellar arteries
Other/Unspecified Arteries
I66.8	Occlusion and stenosis of other cerebral arteries
I66.9	Occlusion and stenosis of unspecified cerebral artery

Documentation and Coding Example

Fifty-eight-year-old Caucasian female brought in by EMS after her speech became nonsensical while working. She is an Assistant DA and was in court arguing a case when she suddenly could not word find. She had no other symptoms but became extremely anxious and combative with people who tried to come to her aid. The judge had to have a bailiff subdue her and then ordered her to the hospital before she stopped resisting EMS. On arrival she is almost 15 minutes post onset of symptoms and she is regaining her speech although it is slow and measured. Temperature 98, HR 100, RR 14, BP 150/88. PERRL, neck supple. Cranial nerves grossly intact. Upper and lower extremities without weakness, reflexes normal. She denies headache, dizziness, visual changes. Blood drawn for CBC, coagulation study, electrolytes, toxicology screen. EKG normal. IV started in left forearm. Impression: Possible TIA, r/o vascular accident. On call for CT scan.

Radiology Note: CT was non-conclusive. Cranial angiography performed under MAC and reveals a 40% occlusion of the right middle cerebral artery, no infarction or bleeding present. Neurology consult ordered and she is admitted to floor overnight.

Neurology Note: This is thin, intensely energetic woman who is alert and oriented on examination. PMH is significant for elevated cholesterol identified 3 years ago for which she takes Lipitor 20 mg. She drinks 2-3 glasses of red wine daily. She works very long hours, eats irregular meals. She is started on clopidogrel 300 mg x 1 and ASA 325 mg. Consult with PMD to increase Lipitor dose.

Discharge Note: Uneventful night. She has no residual speech difficulties. Discharge home on clopidogrel 75 mg and ASA 325 mg daily, increase Lipitor to 40 mg/day. She is anxious to return to work and is advised to discuss that with her PMD at the appointment scheduled in 1 week. She has orders for a blood draw prior to that appointment to check CBC, platelets, coagulation, cholesterol, triglycerides, and LFT.

Diagnosis: Single TIA due to 40% MCA occlusion.

Plan: Conservative medical management.

Diagnosis Code(s)

I66.01	Occlusion and stenosis of right middle cerebral artery
G45.9	Transient cerebral ischemic attack, unspecified
E78.0	Pure hypercholesterolemia

Coding Note(s)

In ICD-10-CM, the same code is assigned regardless of whether the documentation indicates an occlusion or stenosis of the cerebral artery. Under Stenosis, artery, cerebral in the Alphabetic Index, the coder is directed to Occlusion, artery, cerebral. The code for cerebral atherosclerosis is not assigned without a specific diagnosis of atherosclerosis of the cerebral arteries. While the patient does have elevated cholesterol, the physician has documented only that the patient has occlusion/stenosis. In this case, the ischemia was temporary and did not lead to infarction so code I66.01 Occlusion and stenosis of right middle cerebral artery is reported.

Occlusion and Stenosis

Precerebral Arteries

The precerebral arteries, such as the common carotid, vertebral, and basilar arteries, are arteries that lead to the brain but are not contained within the cranium or skull. These arteries can become blocked by a thrombus or embolus or they can become narrowed, affecting blood flow to the brain.

In ICD-10-CM, codes for occlusion and stenosis of the precerebral arteries are found in two categories. Category I63 identifies cerebral infarction of the precerebral and cerebral arteries. Subcategories I63.0, I63.1, and I63.2 are specific to the precerebral arteries. Documentation must identify the specific precerebral artery as vertebral, basilar, carotid, or other specified artery, along with the etiology of the cerebral infarction as due to thrombosis, embolism, or unspecified occlusion and stenosis. Laterality is required for the vertebral and carotid arteries. Category I65 reports occlusion and stenosis of the precerebral arteries not resulting in stroke. Documentation requirements for this category are the same as for category I63 except that etiology of the obstruction and stenosis is not required.

Coding and Documentation Requirements

Identify infarction status of occlusion and stenosis of precerebral arteries:

•With cerebral infarction

•Without cerebral infarction

With cerebral infarction

Identify etiology:

•Embolism

•Thrombosis

•Unspecified occlusion or stenosis

Identify site:

•Basilar

•Carotid

•Vertebral

•Other specified precerebral artery

•Unspecified precerebral artery

Identify laterality for carotid and vertebral arteries:

•Right

•Left

•Bilateral

•Unspecified

Without cerebral infarction

Identify site:

•Basilar

•Carotid

•Vertebral

•Other specified precerebral artery

•Unspecified precerebral artery

Identify laterality for carotid and vertebral arteries:

•Right

•Left

•Bilateral

•Unspecified

Occlusion and Stenosis of Precerebral Arteries with Infarction

ICD-10-CM Code/Documentation
Thrombosis
I63.011	Cerebral infarction due to thrombosis of right vertebral artery
I63.012	Cerebral infarction due to thrombosis of left vertebral artery
I63.013	Cerebral infarction due to thrombosis of bilateral vertebral arteries
I63.019	Cerebral infarction due to thrombosis of unspecified vertebral artery
Embolism
I63.111	Cerebral infarction due to embolism of right vertebral artery
I63.112	Cerebral infarction due to embolism of left vertebral artery
I63.113	Cerebral infarction due to embolism of bilateral vertebral arteries
I63.119	Cerebral infarction due to embolism of unspecified vertebral artery
Unspecified Occlusion/Stenosis
I63.211	Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery
I63.212	Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery
I63.213	Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.219	Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral artery

Documentation and Coding Example

Discharge summary: Patient is a thirty-six-year-old Caucasian female who was admitted for left vertebral artery thrombotic event with cerebral infarction. She presented initially to her PMD with a 3-day history of occipital headache and posterior nuchal stiffness and pain. Her symptoms were attributed to an unusually intense yoga workout and she was prescribed a muscle relaxant. When her symptoms escalated to include numbness in the left side of her face, loss of taste, vocal hoarseness, and distorted vision she presented to the ER where she was evaluated and sent for imaging studies. CT scan and duplex studies confirmed a clot located in Segment I of the left vertebral artery. She was admitted for anticoagulation therapy and observation. Initially treated with heparin and then switched to Coumadin. She is being discharged today after 5 days of observation and treatment with some improvement in her symptoms. Today her VS are normal, Temperature 97.4, HR 66, RR 12, BP 102/70 and INR stable at 3.0 on 7 mg Coumadin daily. She continues to have mild tingling/numbness on the left side of her face and oscillopsia. Vocal hoarseness and loss of taste has resolved. Plan: Repeat duplex study in 3 months. Monitor INR monthly with Coumadin adjustments as needed.

Impression: Stable left vertebral artery thrombosis with cerebral infarction.

Diagnosis Code(s)

I63.012

Cerebral infarction due to thrombosis of left vertebral artery

Coding Note(s)

In ICD-10-CM, codes in category I63 are specific to cerebral infarction. The infarction must be identified as due to thrombosis, embolism, or unspecified occlusion or stenosis. In this case, the documentation indicates that this was a thrombotic event so the code for thrombosis is assigned. The code is specific to the vertebral artery and laterality is documented as left, so code I63.012 is assigned.

Paroxysmal Tachycardia

Tachycardia refers to rapid beating of the heart, usually applied to rates over 90 beats per minute. Paroxysmal tachycardia refers to recurrent attacks of rapid heart rate, usually with abrupt onset and often with abrupt return to a normal heart rate. The condition originates from an abnormal electrical focus in the atrium, atrioventricular node, or ventricle.

There is a single code for supraventricular tachycardia (I47.1), but ventricular tachycardia must now be identified as re-entry ventricular arrhythmia (I47.0) or ventricular tachycardia (I47.2). There is also a code for unspecified paroxysmal tachycardia (I47.9).

Coding and Documentation Requirements

Identify type of paroxysmal tachycardia:

•Re-entry ventricular arrhythmia

•Supraventricular

•Ventricular

•Unspecified

Paroxysmal Tachycardia

ICD-10-CM Code/Documentation
I47.1	Supraventricular tachycardia
I47.0	Re-entry ventricular arrhythmia
I47.2	Ventricular tachycardia
I47.9	Paroxysmal tachycardia, unspecified

Documentation and Coding Example

Patient is a 75-year-old Asian male S/P anterior wall MI 1 year ago. He is seen in Cardiology Clinic for routine follow up. He states he is feeling well, swimming daily in the local pool or the ocean when the weather is warm. He denies chest pain or SOB but does state in recent weeks he occasionally has short episodes of a “fast” heartbeat that makes him feel dizzy and he has to sit down. Episodes rarely last more than 5 minutes and then he feels fine. Current medications include ASA, Zocor, and Captopril. On examination, HR 86, RR 14, BP 138/80. Color pink, skin warm, dry with good turgor. Upper extremities without clubbing, pulses intact. Left carotid artery has a very soft bruit. Apical pulse regular without bruit, rub, gallop, or murmur. Breath sounds clear, equal bilaterally. Abdomen soft, non-distended, liver palpated at 2 cm below RCM, spleen is not palpated. No bruit appreciated over abdominal vessels. Femoral pulses full. Lower extremities without clubbing or edema, pulses intact. EKG shows occasional unifocal PVCs and broad Q waves in precordial leads and poor R wave progression from V1-3 to V4-6. QR waves consistent with his history of old anterior wall MI and previous EKGs. Stress echocardiogram is initiated, patient goes into a run of V-tach and becomes dizzy. Test aborted and he is observed and recovers in 6 minutes without intervention. Blood drawn for CBC, electrolytes, cardiac enzymes. RTC in 3 days for test results and possible medication adjustment. Patient is cautioned to call clinic or go to ED if episodes last longer than 10 minutes and to call 911 if he has syncope, nausea, chest pain, shortness of breath.

Impression: New onset ventricular tachycardia, possibly due to scar tissue formation at old MI site or electrolyte imbalance.

Diagnosis Code(s)

I47.2	Ventricular tachycardia
I25.2	Old myocardial infarction

The code for ventricular tachycardia is reported along with the code for the old myocardial infarction. Historically the term paroxysmal was used in the description for the ventricular tachycardia and is no longer the common terminology, therefor does not appear in the ICD-10-CM description. The physician is ruling out electrolyte imbalance, but since this is an outpatient visit the r/o condition is not reported.

Phlebitis and Thrombophlebitis of Lower Extremities

Phlebitis is the inflammation of a vein. Thrombophlebitis is vein inflammation with formation of a blood clot within the vessel. Causes of phlebitis and thrombophlebitis include: bacteria, chemicals, mechanical injury, prolonged immobilization, certain medications, genetic disorders, and alcohol and drug abuse. Phlebitis and thrombophlebitis of superficial veins are usually characterized by tenderness, redness, warmth and swelling over the inflamed vessel. Deep vein phlebitis and thrombophlebitis usually manifest with widespread pain and swelling in the affected limb. Thrombophlebitis poses a risk of the blood clot breaking free of the vessel wall and circulating to other areas of the body including the lungs and brain.

In ICD-10-CM, category I80 Phlebitis and thrombophlebitis lists codes for all sites, but only lower extremities codes are specific to superficial or deep vessels and only the lower extremities have some codes that are also specific to certain veins. There is a subcategory for superficial vessels, which includes the greater and lesser saphenous veins and the femoropopliteal vein. Codes for the iliac vein are listed in the subcategory for phlebitis and thrombophlebitis of the deep vessels of the extremities and there are also specific codes for the femoral, iliac, popliteal, and tibial veins. Laterality must be documented as right, left, or bilateral.

Coding and Documentation Requirements

Identify phlebitis or thrombophlebitis of lower extremity as affecting:

•Deep vessels

–Calf muscle vein (gastrocnemius/soleal)

–Iliac vein (common/external/internal)

–Peroneal vein

–Popliteal vein

–Tibial vein (anterior/posterior)

–Other specified deep vessel

–Unspecified deep vessel

•Femoral vein (common/deep)

•Superficial vessels

•Unspecified lower extremity blood vessel

Specify laterality:

•Right

•Left

•Bilateral

•Unspecified

Phlebitis and Thrombophlebitis of Deep Vessels of Lower Extremities

ICD-10-CM Code/Documentation
Femoral Vein
I80.10	Phlebitis and thrombophlebitis of unspecified femoral vein
I80.11	Phlebitis and thrombophlebitis of right femoral vein
I80.12	Phlebitis and thrombophlebitis of left femoral vein
I80.13	Phlebitis and thrombophlebitis of femoral vein, bilateral
Unspecified Deep Vessels
I80.201	Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity
I80.202	Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity
I80.203	Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral
I80.209	Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity
Iliac Vein
I80.211	Phlebitis and thrombophlebitis of right iliac vein
I80.212	Phlebitis and thrombophlebitis of left iliac vein
I80.213	Phlebitis and thrombophlebitis of iliac vein, bilateral
I80.219	Phlebitis and thrombophlebitis of unspecified iliac vein
Popliteal Vein
I80.221	Phlebitis and thrombophlebitis of right popliteal vein
I80.222	Phlebitis and thrombophlebitis of left popliteal vein
I80.223	Phlebitis and thrombophlebitis of popliteal vein, bilateral
I80.229	Phlebitis and thrombophlebitis of unspecified popliteal vein
Tibial Vein
I80.231	Phlebitis and thrombophlebitis of right tibial vein
I80.232	Phlebitis and thrombophlebitis of left tibial vein
I80.233	Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.239	Phlebitis and thrombophlebitis of unspecified tibial vein
Peroneal Vein
I80.241	Phlebitis and thrombophlebitis of right peroneal vein
I80.242	Phlebitis and thrombophlebitis of left peroneal vein
I80.243	Phlebitis and thrombophlebitis of peroneal vein, bilateral
I80.249	Phlebitis and thrombophlebitis of unspecified peroneal vein
Calf Muscular Vein
I80.251	Phlebitis and thrombophlebitis of right calf muscular vein
I80.252	Phlebitis and thrombophlebitis of left calf muscular vein
I80.253	Phlebitis and thrombophlebitis of calf muscular vein, bilateral
I80.259	Phlebitis and thrombophlebitis of unspecified calf muscular vein
Other Deep Vessels of Lower Extremities
I80.291	Phlebitis and thrombophlebitis of other deep vessels of right lower extremity
I80.292	Phlebitis and thrombophlebitis of other deep vessels of left lower extremity
I80.293	Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral
I80.299	Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity

Documentation and Coding Example

Sixty-five-year-old female presents to PMD with pain and swelling in her right leg. The patient is recently retired and she and a friend just returned from a dream vacation to the South Pacific. The trip included almost 24 hours of airplane travel in each direction. She states she took ASA as a prophylactic, stayed hydrated, did seat exercises and walked around on the plane because she was aware of the dangers of blood clots. On examination, her right leg is edematous from toes to knee, posterior leg is exquisitely tender to palpation with positive Homans sign. Pulses are intact from groin to toes bilaterally, weaker on the right. Arrangements made for emergent Doppler US of bilateral lower extremities to be done outpatient at the hospital. She will be admitted if it is positive for blood clots.

Admit Note: Doppler US shows an extensive thrombophlebitis of the right lower leg involving the popliteal vein, anterior and posterior tibial veins, and the soleus muscle sinus. She is placed on BR. Blood drawn for CBC, PT, PTT, INR, D-dimer, comprehensive metabolic panel. IV Heparin therapy initiated. Fitted with compression stockings bilaterally.

Diagnosis Code(s)

I80.221	Phlebitis and thrombophlebitis of right popliteal vein
I80.231	Phlebitis and thrombophlebitis of right tibial vein
I80.251	Phlebitis and thrombophlebitis of right calf muscular vein

Coding Note(s)

There are no codes that capture phlebitis and thrombophlebitis for multiple vessels, so each site is coded separately. The codes are, however, specific to site and laterality. The thrombophlebitis of the tibial veins is reported with a single code because there are no separate codes for anterior and posterior, which are both included in category I80.23-. The soleus muscle sinus is captured by the code for right calf muscular vein, which includes both the soleus and gastrocnemius vein.

Premature Beats (Depolarization)

Premature heart beats, also referred to as ectopic beats, extrasystoles, or premature contractions, is a type of a heart rate irregularity caused by extra or skipped heart beats. This results in an irregular pulse. The condition often has no known cause and is usually harmless (benign).

The historical term premature beats has been replaced with premature depolarization and a code has been added to report ventricular premature depolarization (I49.3) which was previously reported using a nonspecific code for other premature beats/depolarization. There is also a specific code for atrial premature depolarization (I49.1) and codes for other premature depolarization (I49.49) and unspecified premature depolarization (I49.40).

Coding and Documentation Requirements

Identify type of premature depolarization:

•Atrial (supraventricular)

•Ventricular

•Other specified premature beats

•Unspecified type

Premature Beats (Depolarization)

ICD-10-CM Code/Documentation
I49.40	Unspecified premature depolarization
I49.1	Atrial premature depolarization
I49.3	Ventricular premature depolarization
I49.49	Other premature depolarization

Documentation and Coding Example

Twenty-four-year-old female presents to ER with c/o “heart beating crazy.” Patient states this has been going on for a few days but in the past hour it has gotten much worse. HR 92, RR 14, BP 144/90. On examination, this is an anxious appearing young woman, clean, well groomed, and articulate. She states she is getting married in 2 days and has been overwhelmed with last minute details and entertaining out of town guests. She admits to only four hours sleep in the past 30 hours and has been consuming coffee and energy drinks non-stop. Hands are tremulous, cool to touch. PERRL, neck supple, mucus membranes moist and pink. Apical pulse is regularly irregular and cardiac monitor shows a steady run of bigeminy. 12 lead EKG obtained and confirms multifocal ventricular premature beats. Blood drawn for CBC, electrolytes, and cardiac enzymes. Patient is medicated with 1.0 mg Lorazepam PO and transferred to ER holding area for monitoring.

Holding Area Note: Patient slept for 3 hours in HA and awakes feeling less anxious. Only occasional multifocal PVCs are observed on monitor. She denies dizziness or chest pain. Blood tests all WNL. Patient is counseled regarding her caffeine intake and lack of sleep. She is given a prescription for Lorazepam to be used for anxiety and sleep. She admits to not having a PMD other than her gynecologist and is encouraged to establish with an internist when she returns from her honeymoon. She is discharged home accompanied by her fiancé.

Diagnosis: Benign premature ventricular contractions.

Diagnosis Code(s)

I49.3

Ventricular premature depolarization

Coding Note(s)

In ICD-10-CM, the term premature contraction is synonymous with depolarization and premature beats. The correct code can be found by referencing Contraction, premature, ventricular in the Alphabetic Index. It should be noted that the ICD-10-CM Alphabetic Index does not list ventricular under the main term Beats, premature, so if the diagnosis was stated as ventricular premature beats it would be necessary to reference synonymous terms such as contraction, depolarization, ectopic, or extrasystole to identify the correct code I49.3.

Pulmonary Embolism

Pulmonary embolism occurs when a blood clot or other intravascular material migrates and forms a blockage in the main artery to the lungs or arterial branches in the lungs. The most common cause of blockage is a blood clot from the legs due to deep vein thrombosis, but air, fat, amniotic fluid, and talc seen in intravenous drug users can also cause a pulmonary embolism. Symptoms include difficulty breathing, low oxygen saturation levels, chest pain (especially with inspiration), cough, and elevated heart and respiratory rates.

In ICD-10-CM, pulmonary embolism (I26.-) includes a diagnosis of pulmonary infarction, pulmonary thromboembolism, and pulmonary thrombosis. Documentation should include whether or not the condition is complicated by acute cor pulmonale. Pulmonary embolism should also be documented as septic embolism, saddle embolus, or other type of pulmonary embolism. For pulmonary embolism without acute cor pulmonale, subsegmental should also be identified and reported as either single or multiple emboli, with single subsegmental pulmonary embolism as the unspecified default. Pulmonary embolism due to complications of surgical and medical care (iatrogenic pulmonary embolism) is reported with codes from Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes, categories T80-T88. Complications of surgical and medical care not classified elsewhere. Iatrogenic pulmonary embolism must be documented as pulmonary air embolism following infusion, transfusion, and therapeutic injection (T80.0-); pulmonary artery embolism following a procedure (T81.718); pulmonary embolism of vein following a procedure (T81.72-); pulmonary embolism as a complication of a cardiac prosthetic device, implant, or graft (T82.817-); pulmonary embolism as a complication of a vascular prosthetic device, implant, or graft (T82.818-).

Coding and Documentation Requirements

Identify type of pulmonary embolism and infarction

Identify if pulmonary embolism is care-related:

•Iatrogenic/post-operative/post-procedural

•Other pulmonary embolism (excludes pulmonary embolism complicating abortion, ectopic pregnancy, molar pregnancy, other pregnancy, childbirth, the puerperium, and trauma)

For iatrogenic/post-operative/post-procedural pulmonary embolism, specify as a complication due to:

•Infusion, transfusion, therapeutic injection

•Other medical or surgical procedure with pulmonary embolism of

–Artery

–Vein

•Prosthetic device, implant, or graft

–Cardiac

–Vascular

For other pulmonary embolism, specify type and presence/absence of acute cor pulmonale:

•Identify type

–Septic pulmonary embolism

–Single subsegmental pulmonary embolism

–Multiple subsegmental pulmonary emboli

–Saddle pulmonary embolism

–Other pulmonary embolism

Identify presence/absence of acute cor pulmonale

–With acute cor pulmonale

–Without acute cor pulmonale

Pulmonary Embolisms

ICD-10-CM Code/Documentation
T80.0-	Air embolism following infusion, transfusion and therapeutic injection
T81.718-	Complication of other artery following a procedure, not elsewhere classified
T81.72-	Complication of vein following a procedure, not elsewhere classified
T82.817-	Embolism of cardiac prosthetic devices, implants and grafts
T82.818-	Embolism of vascular prosthetic devices, implants and grafts
I26.01	Septic pulmonary embolism with acute cor pulmonale
I26.90	Septic pulmonary embolism without acute cor pulmonale
I26.02	Saddle embolus of pulmonary artery with acute cor pulmonale
I26.92	Saddle embolus of pulmonary artery without acute cor pulmonale
I26.09	Other pulmonary embolism with acute cor pulmonale
I26.99	Other pulmonary embolism without acute cor pulmonale
I26.93	Single subsegmental pulmonary embolism without acute cor pulmonale
I26.94	Multiple subsegmental pulmonary emboli without acute cor pulmonale

Documentation and Coding Example

A 36-year-old male presented with 1 week of fever, cough, chest pain, and difficulty walking. Computed tomography (CT) of the chest demonstrated bilateral pulmonary nodules and cavitation, consistent with septic pulmonary emboli. Blood cultures grew MRSA on admission. CT of the abdomen/pelvis, as well as magnetic resonance imaging (MRI) of the spine did not reveal thrombophlebitis or abscess. Pt started on IV vancomycin. Patient remained febrile with complaint of pain in left leg so on day 6 of the admission, a gallium scan was obtained which demonstrated increased uptake in the left thigh. CT of the lower extremities revealed an enhancing fluid collection extending the full length of the left quadriceps muscle, consistent with pyomyositis, without evidence of deep-vein thrombosis. Surgical drainage revealed gram-positive cocci in clusters on Gram stain; the culture (obtained during vancomycin therapy) was negative. The patient defervesced after drainage and recovered with 4 weeks of vancomycin therapy.

Diagnosis: Sepsis due to MRSA complicated by septic pulmonary embolism. Pyomyositis, left quadriceps muscle, due to MRSA.

Diagnosis Code(s)

A41.02	Sepsis due to Methicillin resistant Staphylococcus aureus
I26.90	Septic pulmonary embolism without acute cor pulmonale
M60.052	Infective myositis, left thigh
B95.62	Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere

Coding Note(s)

The reason for the admission is the sepsis which is complicated by septic pulmonary embolism.

The underlying infection, which is the sepsis, is coded first per the coding instructions under septic pulmonary embolism. Pulmonary embolism has a combination code to identify concurrent acute cor pulmonale. In this case, there is no documentation indicating the patient has acute cor pulmonale, so code I26.90 Septic pulmonary embolism without acute cor pulmonale is reported. The patient also has pyomyositis which is likely the cause of the sepsis, but the sepsis complicated by the septic pulmonary embolism is the reason for the admission, so the infective myositis is reported secondarily. An additional code, B95.62 is reported to identify the infectious organism causing the pyomyositis which is also documented as due to MRSA. Even though the cultures from the drainage did not show MRSA, this is due to the patient being on Vancomycin prior to obtaining the culture and the physician has documented the pyomyositis as due to MRSA so it is appropriate to code it as such.

Sequelae (late effect) of Cerebrovascular Disease

A late effect is the residual effect or condition that is present after the acute phase of an illness or injury has terminated. There is no time limit as to when a late effect code can be assigned. In some cases, the residual condition may be apparent early or it may occur months or years later. The term late effect has been replaced with the term sequela in ICD-10-CM.

Category I69 Sequelae of cerebrovascular disease, captures both the condition that caused the sequela and the specific sequela being treated. Codes are first classified by the cause of the sequela. These conditions include: nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage, other nontraumatic intracranial hemorrhage, cerebral infarction, other cerebrovascular diseases, and unspecified cerebrovascular diseases. Sequelae of nontraumatic cerebrovascular disease are then classified as cognitive deficits, speech and language deficits, hemiplegia/hemiparesis, monoplegia of upper and lower limbs, other paralytic syndromes, other late effects, and unspecified late effects.

The types of sequelae that require more specific documentation are monoplegia and hemiplegia/hemiparesis. These conditions require documentation related to the side affected by the sequela (right, left) and whether that side is dominant or non-dominant, (right side dominant, left side dominant, right side non-dominant, left side non-dominant). Note that alterations of sensation and visual disturbances do not have specific codes. Sequelae of traumatic intracranial injuries are not reported with codes from category I69.

Coding and Documentation Requirements

Identify the cause of the sequela(e) as nontraumatic:

•Cerebral infarction

•Intracerebral hemorrhage

•Intracranial hemorrhage

•Subarachnoid hemorrhage

•Other cerebrovascular disease

•Unspecified cerebrovascular disease

Identify the late effect of the cerebrovascular disease:

•Apraxia

•Ataxia

•Cognitive deficits

–Attention and concentration deficit

–Cognitive social or emotional deficit

–Frontal lobe and executive function deficit

–Memory deficit

–Psychomotor deficit

–Visuospatial deficit and spatial neglect

–Other cognitive signs and symptoms

–Unspecified cognitive symptoms and signs

•Dysphagia

•Facial weakness

•Hemiplegia/hemiparesis affecting

–Right side dominant

–Right side non-dominant

–Left side dominant

–Left side non-dominant

–Unspecified side

•Monoplegia

–Upper limb affecting

»Right side dominant

»Right side non-dominant

»Left side dominant

»Left side non-dominant

»Unspecified side

–Lower limb affecting

»Right side dominant

»Right side non-dominant

»Left side dominant

»Left side non-dominant

»Unspecified side

•Other paralytic syndrome affecting

–Bilateral (both sides)

–Right side dominant

–Right side non-dominant

–Left side dominant

–Left side non-dominant

–Unspecified side

•Speech and language deficits

–Aphasia

–Dysphasia

–Dysarthria

–Fluency disorder

–Other specified speech and language deficit

•Other sequelae

•Unspecified sequelae

Hemiplegia/Hemiparesis Dominant Side as Late Effect (Sequela) of Cerebrovascular Disease

ICD-10-CM Code/Documentation
I69.051	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side
I69.151	Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side
I69.251	Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side
I69.351	Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.851	Hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side
I69.951	Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side
I69.052	Hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side
I69.152	Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side
I69.252	Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting left dominant side
I69.352	Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.852	Hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side
I69.952	Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side

Documentation and Coding Example

Intake Note: Patient is a seventy-year-old gentleman who is admitted to Rehabilitation Center following stabilization and treatment of a cerebral infarction due to small spontaneous intracerebral vertebro-basilar bleed. On examination, this is a right hand dominant, thin Asian male who looks younger than his stated age. He has right hemiparesis involving arm, leg, and trunk. He also displays significant Pusher Syndrome with loss of postural balance and ataxia. There is some difficulty with processing verbal directions such as moving the correct side of his body when asked to lift his right and then left hand. There are no vestibular symptoms or visual field deficits. He has no aphasia or cognitive impairments. Patient will be evaluated by OT, PT, and ST and a plan of care will be instituted. Estimated length of stay is three weeks, possibly longer with Pusher Syndrome. He does not appear to be at risk for aspiration and may have a soft diet and thin liquids unless ST finds this to be contraindicated.

Diagnosis Code(s)

I69.151

Hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side

Coding Note(s)

Pusher syndrome is a symptom of stroke that is seen in approximately 10% of patients. Patients with Pusher syndrome push forcefully away from the stronger side while sitting or standing. The pushing is caused by an altered perception of the body’s midline in relation to gravity. The patient believes his/her body is oriented upright when his/her body is actually leaning toward the hemiparetic side. When the patient is upright this causes the patient to push away from the stronger, nonhemiparetic side. There is not a code for Pusher syndrome in ICD-10-CM, so only the hemiparesis is reported.

The code identifies the hemiplegia as affecting the right side and identifies this as the dominant side. It also identifies the cause of the sequela as a nontraumatic intracerebral hemorrhage. The code for hemiparesis/hemiplegia as a sequela of cerebral infarction not otherwise specified (I69.351) is not used because code I69.151 identifying the intracerebral hemorrhage is a more specific code.

Transient Cerebral Ischemia/Other and Ill-Defined Cerebrovascular Disease

Transient cerebral ischemia is defined as a temporary loss of blood to an area in the brain. In ICD-10-CM, Diseases of the Circulatory System are found in Chapter 9 within subcategory 167.8 Other specified cerebrovascular diseases. Conditions in this subcategory include acute cerebrovascular insufficiency, cerebral ischemia, posterior reversible encephalopathy syndrome, cerebral vasospasm and constriction, and other cerebrovascular disease. However, additional codes for transient cerebral ischemic attacks and related syndromes are listed in Chapter 6 Diseases of the Nervous System. Category G45 lists codes for vertebro-basilar artery syndrome, carotid artery syndrome, multiple and bilateral precerebral artery syndromes, amaurosis fugax, transient global amnesia, and other and unspecified transient cerebral ischemic attacks.

Coding and Documentation Requirements

Identify the transient cerebral ischemia or related syndrome:

•Amaurosis fugax

•Carotid artery syndrome

•Multiple or bilateral precerebral artery syndrome

•Transient global amnesia

•Vertebro-basilar artery syndrome, which includes:

–Basilar artery syndrome

–Vertebral artery syndrome

•Other specified transient cerebral ischemic attacks and related syndromes, which includes:

–Subclavian steal syndrome

•Unspecified transient cerebral ischemia, which includes:

–Cerebral artery spasm

–Intermittent cerebral ischemia

–Transient ischemic attack (TIA)

Transient Cerebral Ischemia

ICD-10-CM Code/Documentation
G45.3	Amaurosis fugax
G45.0	Vertebro-basilar artery syndrome
G45.8	Other transient cerebral ischemic attacks and related syndromes
G45.1	Carotid artery syndrome (hemispheric)
G45.2	Multiple and bilateral precerebral artery syndromes
G45.8	Other transient cerebral ischemic attacks and related syndromes
G45.9	Transient cerebral ischemic attack, unspecified
G45.4	Transient global amnesia

Documentation and Coding Example

Fifty-year-old Caucasian female presents to ED accompanied by her family who states that she woke this morning and appeared to have memory loss. On examination, this is a tall, slim, athletic appearing woman who is cooperative but anxious. She is oriented to person and place and recognizes her husband and daughter. Her last clear memory is being in her hot tub last evening. Her husband fills in that she worked yesterday as usual, went to a martial arts class (she is a black belt) in the late afternoon, returned home to cook dinner, clean kitchen. She swam laps in the pool for 30 minutes and then used the hot tub before going to bed. Her husband left for work before she awoke and it was her daughter who noticed she kept repeating questions and actions. She called her father who came home and they brought her to the ED. PERRL, neck supple, cranial nerves grossly intact. There is no weakness in her extremities, no involuntary movement noted. Semantic and syntax language is preserved. Attention is normal, visual/spatial skills intact. She is able to identify common objects and follow simple directions. Her husband doubts she could have received a head injury at her martial arts class yesterday. She has a PMH of migraine headaches and takes Lipitor for elevated cholesterol. Heplock placed and blood drawn for CBC, comprehensive metabolic panel, PT, PTT, INR. Brain MRI with diffusion weighted imaging is negative for bleeding, infarctions, or tumor. Phone consult obtained with neurologist on call who is able to view the MRI and discuss with radiologist. Their impression is Transient Global Amnesia. Neurologist can see patient in his office at 3 pm today. Patient and family are given information regarding TGA. They agree to follow up with neurologist this afternoon. She is discharged in good condition.

Diagnosis Code(s)

G45.4

Transient global amnesia

Coding Note(s)

In ICD-10-CM, transient global amnesia is classified as a transient cerebral ischemic attack and related syndrome in the nervous system chapter.

Valve Disorders – Nonrheumatic

Disorders of the heart valves relate to the inability of the valves to open and close properly, either not allowing blood to flow properly to other heart chambers or not allowing blood to flow properly to the pulmonary and aortic arteries. Valve disorders are classified as rheumatic, nonrheumatic, or congenital. Only nonrheumatic types are classified in categories I34-I37. Rheumatic heart disease, including valve disorders, is classified in categories I00-I09. Congenital anomalies of the heart valves are classified in categories Q22-Q23. Below is a discussion of the most common disorders of each heart valve and the most common causes of each disorder.

Aortic valve: The aortic valve is located between the left ventricle of the heart and the aorta and is formed by 3 leaflets. The most common disorder of the aortic valve is stenosis, which is a narrowing and stiffening of the valve that restricts the outflow of blood from the left ventricle into the aorta and systemic circulation. Stenosis can be due to degenerative calcification of the valve, damage from disease, or a congenital defect. Another disorder is valve insufficiency and regurgitation characterized by leakage of blood backward into the ventricle during diastole, the resting phase of the heartbeat.

Mitral valve: The mitral valve is located between the left atrium and the left ventricle of the heart and is formed by 2 leaflets. The most common disorder of the mitral valve is insufficiency and regurgitation of blood backward toward the atrium after systole, the atrial contraction phase of the heartbeat. Mitral valve insufficiency may be due to degenerative diseases that weaken the valve and supporting structures, infection, and congenital anomalies. Another disorder is mitral stenosis which restricts the forward flow of blood through the left atrium to the left ventricle. Mitral valve stenosis is most often caused by rheumatic fever which is an inflammatory disease following Group A Streptococcus infection that can affect the heart as well as other body organs.

Pulmonary valve: The pulmonary valve is located between the right ventricle of the heart and the pulmonary artery and is formed by 3 leaflets. Pulmonary valve disorders include atresia, a congenital anomaly in which the valve fails to develop, stenosis which restricts the forward flow of blood from the ventricle to the lungs, and insufficiency and regurgitation which is characterized by leakage of blood backward into the ventricle during diastole. Pulmonary valve disorders are rare and are almost always congenital.

Tricuspid valve: The tricuspid valve is located between the right atrium and the right ventricle of the heart and is formed by 3 leaflets. Tricuspid valve disorders include stenosis which restricts the forward flow of blood through the atrium to the ventricle, and insufficiency and regurgitation which is characterized by leakage of blood backward into the ventricle during diastole. Tricuspid valve disorders may be congenital or caused by infection, or rheumatic fever.

In ICD-10-CM, codes are classified first by site, which includes I34 Nonrheumatic mitral valve disorders; I35 Nonrheumatic aortic valve disorders; I36 Nonrheumatic tricuspid valve disorders; and I37 Nonrheumatic pulmonary valve disorders. Nonrheumatic valve disorders are then further classified by the specific type of disorder, which must be documented as insufficiency alone, stenosis alone, stenosis with insufficiency, or a specific other type of nonrheumatic valve disorder.

Coding and Documentation Requirements

Identify site of nonrheumatic valve disorder:

•Aortic

•Mitral

•Pulmonary

•Tricuspid

For mitral valve, specify condition:

•Insufficiency

•Prolapse

•Stenosis

•Other specified disorder

•Unspecified

For aortic, pulmonary, and tricuspid valve, specify condition:

•Insufficiency (without stenosis), which includes:

–Incompetence

–Regurgitation

•Stenosis

–With insufficiency

–Without insufficiency

•Other specified disorder

•Unspecified

Nonrheumatic Heart Valve Disorders

ICD-10-CM Code/Documentation
I34.0	Nonrheumatic mitral (valve) insufficiency
I34.1	Nonrheumatic mitral (valve) prolapse
I34.2	Nonrheumatic mitral (valve) stenosis
I34.8	Other nonrheumatic mitral (valve) disorders
I34.9	Nonrheumatic mitral (valve) disorder, unspecified
I35.0	Nonrheumatic aortic (valve) stenosis
I35.1	Nonrheumatic aortic (valve) insufficiency
I35.2	Nonrheumatic aortic (valve) stenosis with insufficiency
I35.8	Other nonrheumatic aortic (valve) disorders
I35.9	Nonrheumatic aortic (valve) disorder, unspecified
I36.0	Nonrheumatic tricuspid (valve) stenosis
I36.1	Nonrheumatic tricuspid (valve) insufficiency
I36.2	Nonrheumatic tricuspid (valve) stenosis with insufficiency
I36.8	Other nonrheumatic tricuspid (valve) disorders
I36.9	Nonrheumatic tricuspid (valve)
I37.0	Nonrheumatic pulmonary (valve) stenosis
I37.1	Nonrheumatic pulmonary (valve) insufficiency
I37.2	Nonrheumatic pulmonary (valve) stenosis with insufficiency
I37.8	Other nonrheumatic pulmonary (valve) disorders
I37.9	Nonrheumatic pulmonary (valve) disorder, unspecified

Documentation and Coding Example

Eighteen-year-old Black female presents to Cardiology Clinic having been referred by Student Health. Patient is a freshman at the University on a full athletic scholarship, she plays basketball and sprints short distance for Track and Field. Temperature 97.4, HR 60, RR 12, BP 90/58, Pulse oximeter 99%. Ht. 70 inches, Wt. 123 lbs. According to patient she presented to SH a number of times with c/o heart palpitations and chest pain. She was told she had “anxiety” and prescribed Xanax. Those symptoms have continued and in the past month she has also experienced trouble catching her breath especially after exercise, mild fatigue, and a chronic cough. For the past two nights she wakes up suddenly feeling like she cannot breathe, sitting up seems to make the feeling go away. Her coach accompanied her to Student Health this morning and insisted she be referred to a specialist. On examination, this is a tall, thin, athletic appearing young woman who looks her stated age. PERRL, neck supple without lymphadenopathy, mucous membranes moist and pink. Carotid arteries without bruit. Extremities are without edema, clubbing, pulses are full. HR is regular with a mid-systolic click murmur that fades when upright, intensifies when supine. Breath sounds clear, equal bilaterally. She has a very mild scoliosis that she states has not progressed since it was diagnosed at age 11. She sees an orthopedist yearly for monitoring. Abdomen soft, non-distended with active bowel sounds. No bruit or rub appreciated over abdominal vessels. EKG is unremarkable at this time. Patient is fitted with a 24-hour Holter monitor and given directions for use. RTC tomorrow for echocardiogram and Holter monitor results.

Cardiology Follow Up: Holter monitor was significant for occasional runs of atrial fibrillation but overall shows a sinus bradycardia which would be expected in a young athlete. Echocardiogram at rest and during exercise was performed with results significant for mildly enlarged left ventricle and moderate decrease in ejection fraction.

Impression: Mitral valve prolapse with significant regurgitation, no stenosis. Results were discussed and shared with her father via phone call at the patient’s request. She is prescribed Propranolol 20 mg BID. RTC in 1 week for recheck and medication dosage adjustment.

Diagnosis Code(s)

I34.1

Nonrheumatic mitral (valve) prolapse

Coding Note(s)

The condition is specified as mitral valve prolapse. The regurgitation is a symptom of the prolapse and is not reported additionally.

Varicose Veins of Lower Extremities

Varicose veins occur most often in the lower extremities but can occur anywhere in the body. Varicose veins result from valve incompetence. Leaflet valves in the vein which normally open and close to move blood forward do not function properly allowing retrograde (backward) flow and pooling of blood in the vessels. The vein then becomes enlarged, tortuous (twisted), and painful. The condition is more common in women, with pregnancy often a precipitating factor. Varicose veins may form following injury, as a sequela to deep vein thrombosis, or be present at birth.

In ICD-10-CM, varicose veins of lower extremities, category I83, are also classified based on whether the condition is asymptomatic or associated with complications such as ulcer, inflammation, both ulcer and inflammation, pain, or other complications. In addition, documentation of laterality is required for varicose veins complicated by ulcers either with or without inflammation. Documentation of the site of the ulcer is also required. Severity of the ulcer is captured by an additional code from category L97.

Coding and Documentation Requirements

Identify status of varicose veins of lower extremity:

•Asymptomatic

•Complicated by:

–Inflammation

–Pain

–Ulcer

–Ulcer and inflammation

–Other complication (edema, swelling)

•Identify laterality:

–Right

–Left

–Unspecified

With ulcer or ulcer and inflammation

•Identify site of ulcer:

–Ankle

–Calf

–Foot

»Heel

»Midfoot

»Other part of foot

–Thigh

–Other part of leg

–Unspecified site of leg

•Use additional code (L97.-) to identify severity of ulcer:

–Limited to breakdown of skin

–Fat layer exposed

–Necrosis of muscle

–Necrosis of bone

–Unspecified severity

Varicose Veins of Lower Extremities with Other Complications

ICD-10-CM Code/Documentation
Varicose Veins with Pain
I83.811	Varicose veins of right lower extremity with pain
I83.812	Varicose veins of left lower extremity with pain
I83.813	Varicose veins of bilateral lower extremity with pain
I83.819	Varicose veins of unspecified lower extremity with pain
Varicose Veins with Other Complications
I83.891	Varicose veins of right lower extremity with other complications
I83.892	Varicose veins of left lower extremity with other complications
I83.893	Varicose veins of bilateral lower extremity with other complications
I83.899	Varicose veins of unspecified lower extremity with other complications

Documentation and Coding Example

Patient is a twenty-seven-year-old Caucasian female who presents with complaint of painful and swollen superficial veins in both legs. She is one year post delivery of twins and states she developed the enlarged veins during her pregnancy. She is interested in having laser treatments. On examination, this is a healthy, athletic appearing woman, tan and well dressed. Patient states she swims and plays tennis and is very self-conscious of how her legs look. There are numerous dark red to purple superficial spider like varicosities on anterior and posterior thighs bilaterally, posterior knee, and anterior calf. They are also prominent over the dorsum of her left foot and just inside the left ankle. Additionally, there are areas of bulging red varicosities along the left long and short saphenous veins, dorsal venous arch, calf perforator veins, and posterior arch vein. The right leg is less affected with only a few bulging red areas along the calf perforator veins. The swelling abates in all areas when patient is supine, increases when standing. Patient is advised that a surface laser could be used effectively on the superficial spider type veins but she would need sclerotherapy injections to treat the larger veins. She is further advised that her insurance company may consider this a cosmetic procedure and refuse to cover the costs. She is interested in pursuing treatment. An appointment will be arranged for venous Doppler study of bilateral lower extremities to rule out any deep vein involvement and map the affected area. Patient will return once that has been completed and a detailed treatment plan will be discussed.

Diagnosis Code(s)

I83.813	Varicose veins of bilateral lower extremities with pain
I83.893	Varicose veins of bilateral lower extremities with other complications

Coding Note(s)

In ICD-10-CM, there is a specific code for varicose veins with pain, but swelling is captured by the code for varicose veins with other complications. The documentation must specify laterality, and there is a code for bilateral varicose veins.

Summary

Physicians and coders for all specialties will be affected by the new documentation requirements in the circulatory system chapter because these conditions are commonly evaluated and treated by primary care providers, cardiologists, neurologists, surgeons, emergency department physicians, and geriatricians as well as other specialties. Some of the areas to focus on include the guidelines that identify new definitions for the acute phase of a myocardial infarction and subsequent myocardial infarctions. Most code categories related to the blood vessels are more specific to site, often the specific blood vessel must be identified. Laterality is an important component of many codes including conditions affecting the cerebrovascular system such as cerebrovascular hemorrhage, infarction, and occlusion and stenosis. Laterality must also be documented for conditions affecting the arteries and veins of the legs such as atherosclerosis, phlebitis and thrombophlebitis, and varicosities.

Resources

Documentation checklists are available in Appendix A for the following condition(s):

•Angina

•Coronary atherosclerosis

•Myocardial infarction

•Varicose veins of lower extremities

Chapter 9 Quiz

1.The physician documentation indicates that the patient is status post recent acute myocardial infarction (AMI) and is now being seen for a new STEMI of left anterior descending artery. What information is needed to assign the correct code for the new AMI?

a.Documentation of the amount of time that has elapsed since the first acute myocardial infarction

b.Documentation of whether or not the first AMI has healed

c.Documentation of whether the new AMI is transmural or nontransmural

d.Documentation of whether this patient is being transferred from another facility

2.How is atherosclerosis of a native coronary artery with angina pectoris reported?

a.Two codes are needed, one for the coronary artery disease and one for the angina pectoris

b.Since angina pectoris is a symptom of atherosclerosis only the code for atherosclerosis is reported

c.A combination code is used that captures both the coronary artery disease and the angina pectoris

d.None of the above

3.What information is NOT needed to assign the most specific code for hypertension?

a.Documentation of the hypertension as primary or secondary

b.Documentation of any related heart disease

c.Documentation of any chronic kidney disease

d.Documentation of the hypertension as benign or malignant

4.There is not a specific code for varicose veins of the lower extremities with which of the following complications?

a.Pain

b.Swelling

c.Inflammation and ulcer

d.Ulcer alone

5.Atherosclerosis of the native arteries of the lower extremities documented as complicated by ulcer, claudication, and rest pain is assigned codes as follows:

a.A separate code is assigned for each complication

b.A combined code is assigned for the claudication and rest pain and an additional code is assigned for the ulcer

c.A code is assigned for the atherosclerosis with the ulcer and an additional code is assigned to identify the severity of the ulcer

d.Three separate codes are assigned for atherosclerosis with claudication, atherosclerosis with rest pain, and atherosclerosis with ulcer, and a fourth code is assigned to identify the severity of the ulcer.

6.A patient who has undergone a cardiovascular surgical procedure has a postoperative cerebrovascular accident (CVA). Identify the correct guideline related to coding of the postoperative CVA.

a.A cause and effect relationship between a CVA and a procedure cannot be assumed. The physician must specify that a cause and effect relationship exists between the procedure and the CVA

b.A cause and effect relationship between a CVA and a cardiovascular procedure is always assumed and code G97.52 Postprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure is assigned

c.A cause and effect relationship between a CVA and a cardiovascular procedure is always assumed and code I97.820 Postprocedural cerebrovascular infarction during cardiac surgery is assigned

d.There are no guidelines related to CVAs occurring after a procedure. Use the correct code from category I63 to identify the cerebral infarction.

7.The physician has documented that the patient has a left posterior bundle branch block. How is this reported?

a.I44.5 Left posterior fascicular block

b.I44.60 Unspecified fascicular block

c.I44.69 Other fascicular block

d.I44.7 Left bundle branch block, unspecified

8.The physician has documented the reason for the encounter as prinzmetal angina. How is this reported?

a.I20.0 Unstable angina

b.I20.1 Angina pectoris with documented spasm

c.Since there is not a specific code for prinzmetal angina, code I20.8 Other forms of angina pectoris is reported

d.The physician must be queried for a more specific diagnosis

9.Subcategory I97.1 captures postprocedural cardiac functional disturbances. Which of the following is not classified as a postprocedural cardiac functional disturbance?

a.Cardiac insufficiency

b.Cardiac arrest

c.Hemorrhage of a circulatory system organ

d.Heart failure

10.Which condition would not be reported with a code from category I69 sequelae of cerebrovascular disease?

a.Hemiparesis due to nontraumatic subarachnoid hemorrhage

b.Monoplegia following traumatic brain injury

c.Cognitive deficit due to nontraumatic intracerebral hemorrhage

d.Aphasia due to cerebral infarction

Chapter 9 Answers and Rationales

1.The physician documentation indicates that the patient is status post recent acute myocardial infarction (AMI) and is now being seen for a new STEMI of left anterior descending artery. What additional information is needed to assign the correct code for the new AMI?

a.Documentation of the amount of time that has elapsed since the first acute myocardial infarction

Rationale: Information on the amount of time that has elapsed since the first AMI is needed. If less than 4 weeks (28 days) has elapsed, a code from category I22 Subsequent STEMI and NSTEMI myocardial infarction is assigned. If more than 4 weeks (28 days) has elapsed, a code from category I21 STEMI and NSTEMI myocardial infarction is assigned. Whether the first AMI is documented as healed or not has no bearing on code assignment for the current MI. The AMI has been documented as a STEMI, which is the same thing as a transmural MI. Transfer of the patient from another facility does not affect code assignment for the new MI.

2.How is atherosclerosis of a native coronary artery with angina pectoris reported?

c.A combination code is used that captures both the coronary artery disease and the angina pectoris

Rationale: In ICD-10-CM a combination code is reported that captures both the atherosclerosis of the native coronary artery and the angina pectoris.

3.What information is NOT needed to assign the most specific code for hypertension?

d.Documentation of the hypertension as benign or malignant

Rationale: Hypertension codes are no longer classified as benign or malignant in ICD-10-CM, so these qualifiers are no longer required. There are specific codes for secondary hypertension, hypertension with related heart disease, and hypertension with chronic kidney disease, so these conditions must be documented to allow for assignment of the most specific code.

4.There is not a specific code for varicose veins of the lower extremities with which of the following complications?

b.Swelling

Rationale: There are specific codes for varicose veins with inflammation and ulcer, ulcer alone, and pain. There is also a specific code for varicose veins with inflammation alone. However, varicose veins documented as complicated by swelling are reported with a code from subcategory I83.89 Varicose veins of lower extremities with other complications, which includes edema and swelling but is not specific to either of these conditions.

5.Atherosclerosis of the native arteries of the lower extremities documented as complicated by ulcer, claudication, and rest pain is assigned codes as follows:

c.A code is assigned for the atherosclerosis with the ulcer and an additional code is assigned to identify the severity of the ulcer

Rationale: There is an Includes note to indicate that the atherosclerosis of the native arteries with ulceration includes any condition in subcategory I70.21 (intermittent claudication) and I70.22 (rest pain), so only the code for the atherosclerosis with ulceration is reported. There is a note indicating that an additional code is needed to identify the severity of the ulcer.

6.A patient who has undergone a cardiovascular surgical procedure has a postoperative cerebrovascular accident (CVA). Identify the correct guideline related to coding of the postoperative CVA.

a.A cause and effect relationship between a CVA and a procedure cannot be assumed. The physician must specify that a cause and effect relationship exists between the procedure and the CVA

Rationale: The guidelines for Chapter 9 Circulatory System Diseases specifically address CVA following a procedure and state that a cause and effect relationship cannot be assumed. The physician must document that a cause and effect relationship exists.

7.The physician has documented that the patient has a left posterior bundle branch block. How is this reported in?

a.I44.5 Left posterior fascicular block

Rationale: Code I44.5 Left posterior fascicular block is used. The terms left posterior bundle branch block and left posterior fascicular block are synonymous.

8.The physician has documented the reason for the encounter as prinzmetal angina. How is this reported?

b.I20.1 Angina pectoris with documented spasm

Rationale: Angina with documented spasm includes angina documented as angiospastic angina, prinzmetal angina, spasm-induced angina, and variant angina.

9.Subcategory I97.1 captures postprocedural cardiac functional disturbances. Which of the following is not classified as a postprocedural cardiac functional disturbance?

c.Hemorrhage of a circulatory system organ

Rationale: Functional disturbances are those that affect heart function and include conditions such as cardiac insufficiency, cardiac arrest, and heart failure. Documentation is required as to whether the functional disturbance occurred after a cardiac procedure or after a surgery performed on a site other than the heart and great vessels.

10.Which condition would not be reported with a code from category I69 sequelae of cerebrovascular disease?

b.Monoplegia following traumatic brain injury

Rationale: Category I69 Sequelae of cerebrovascular disease, reports sequelae of nontraumatic conditions, such as nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage, other nontraumatic intracranial hemorrhage, cerebral infarction, other cerebrovascular diseases, and unspecified cerebrovascular diseases. Sequelae of traumatic intracranial injuries are not reported with codes from category I69. In these cases, the specific type of sequela is reported first, such as monoplegia, followed by the code for the traumatic injury with 7th character ‘S’ to identify the condition as a sequela of the injury.