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ICD-10 Clinical Concepts Series
ICD-10 Clinical Concepts for Cardiology is a feature of Road to 10, a CMS online tool built with physician input.
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l (^) Build an ICD-10 action plan customized for your practice l (^) Use interactive case studies to see how your coding selections compare with your peers’ coding l (^) Access quick references from CMS and medical and trade associations l (^) View in-depth webcasts for and by medical professionals To get on the Road to 10 and find out more about ICD-10, visit: cms.gov/ICD roadto10.org Official CMS Industry Resources for the ICD-10 Transition ICD-10 Compliance Date: October 1, 2015 www.cms.gov/ICD
Clinical Concepts
for Cardiology
Common Codes
Clinical Documentation Tips
Clinical Scenarios
- Scenario 1: Hypertension/
Cardiac Clearance
- Scenario 2: Syncope
- Scenario 3: Chest Pain
- Scenario 4: Subsequent AMI
- Scenario: CHF and
Pulmonary Embolism
Example
Clinical Scenarios
Table Of Contents
Common Codes
Clinical Documentation Tips
Heart Rhythm
- Atrial Fibrillation and Flutter
- Cardiac Arrhythmias (Other)
- Chest Pain
- Heart Failure
- Hypertension
- Nonrheumatic
Valve Disorders
- Selected Atherosclerosis,
Ischemia, and Infarction
- Syncope and Collapse
- Acute Myocardial
Infraction (AMI)
- Hypertension
- Congestive Heart Failure
- Underdosing
- Atheroclerotic Heart Disease
with Angina Pectoris
- Cardiomyopathy
- Heart Valve Disease
- Arrythmias/Dysrhythmia
I49.01 Ventricular fibrillation I49.02 Ventricular flutter I49.1 Atrial premature depolarization I49.2 Junctional premature depolarization I49.3 Ventricular premature depolarization I49.40 Unspecified premature depolarization I49.49 Other premature depolarization I49.5 Sick sinus syndrome I49.8 Other specified cardiac arrhythmias I49.9* Cardiac arrhythmia, unspecified
Cardiac Arrhythmias (Other) (ICD-9-CM 427.41, 427.42, 427.60,
Codes with a greater degree of specificity should be considered first. I20.0 Unstable angina I20.1 Angina pectoris with documented spasm I20.8 Other forms of angina pectoris I20.9 Angina pectoris, unspecified R07.1 Chest pain on breathing R07.2 Precordial pain R07.81 Pleurodynia R07.82 Intercostal pain R07.89 Other chest pain R07.9 Chest pain, unspecified
Chest Pain (ICD-9-CM 411.1, 413.1, 413.9, 786.50 to 786.59 Range)
*Codes with a greater degree of specificity should be considered first.
I50.1 Left ventricular failure I50.20* Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure I50.30* Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40* Unspecified combined systolic (congestive) and diastolic (congestive) heart failure I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure I50.9* Heart failure, unspecified
Heart Failure (ICD-9-CM 428.0, 428.1, 428.20 to 428.23 Range,
428.30 TO 428.33 Range, 428.40 TO 428.43 Range, 428.9)
*Codes with a greater degree of specificity should be considered first. I10 Essential (primary) hypertension
Hypertension (ICD-9-CM 401.9)
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 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 I23.0 Hemopericardium as current complication following acute myocardial infarction I23.1 Atrial septal defect as current complication following acute myocardial infarction I23.2 Ventricular septal defect as current complication following acute myocardial infarction I23.3 Rupture of cardiac wall without hemopericardium as current complication following acute myocardial infarction I23.4 Rupture of chordae tendineae as current complication following acute myocardial infarction I23.5 Rupture of papillary muscle as current complication following acute myocardial infarction I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
Selected Atherosclerosis, Ischemia, and Infarction (ICD-9-CM 410.
to 410.92 Range, 411.1, 412, 413.0, 413.1, 413.9, 414.00 to 414.
Range, 414.10, 414.11, 414.12, 414.19, 414.2, 414.3, 414.4, 414.8, 414.9,
*Codes with a greater degree of specificity should be considered first.
I23.7 Postinfarction angina I23.8 Other current complications following acute myocardial infarction 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 I25.111 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 I25.2 Old myocardial infarction I25.3 Aneurysm of heart I25.41 Coronary artery aneurysm I25.42 Coronary artery dissection I25.5 Ischemic cardiomyopathy I25.6 Silent myocardial ischemia I25.700* Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris I25.701* Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm I25.708* Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris I25.709* Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
Selected Atherosclerosis, Ischemia, and Infarction (ICD-9-CM 410.
to 410.92 Range, 411.1, 412, 413.0, 413.1, 413.9, 414.00 to 414.
Range, 414.10, 414.11, 414.12, 414.19, 414.2, 414.3, 414.4, 414.8, 414.9,
429.2, 429.5, 429.6, 429.71, 429.79) (continued)
*Codes with a greater degree of specificity should be considered first.
I25.769* Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris I25.799* Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris I25.82 Chronic total occlusion of coronary artery I25.83 Coronary atherosclerosis due to lipid rich plaque I25.84 Coronary atherosclerosis due to calcified coronary lesion I25.89 Other forms of chronic ischemic heart disease I25.9* Chronic ischemic heart disease, unspecified
Selected Atherosclerosis, Ischemia, and Infarction (ICD-9-CM 410.
to 410.92 Range, 411.1, 412, 413.0, 413.1, 413.9, 414.00 To 414.
Range, 414.10, 414.11, 414.12, 414.19, 414.2, 414.3, 414.4, 414.8, 414.9,
429.2, 429.5, 429.6, 429.71, 429.79) (continued)
*Codes with a greater degree of specificity should be considered first. R55 Syncope and collapse
Syncope and Collapse (ICD-9-CM 780.2)
Specifying anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects how physicians and clinicians communicate and to what they pay attention - it is a matter of ensuring the information is captured in your documentation. In ICD-10-CM, there are three main categories of changes:
Definition Changes
Terminology Differences
Increased Specificity
For cardiology, the focus is increased specificity and documenting the downstream effects of the patient’s condition. ACUTE MYOCARDIAL INFARCTION (AMI) Definition Change When documenting hypertension, include the following:
1. Timeframe An AMI is now considered “acute” for 4 weeks from the time of the incident, a revised timeframe from the current ICD-9 period of 8 weeks. 2. Episode of care ICD-10 does not capture episode of care (e.g. initial, subsequent, sequelae). 3. Subsequent AMI ICD-10 allows coding of a new MI that occurs during the 4 week “acute period” of the original AMI. Clinical Documentation Tips
ICD-10 Compliance Date: October 1, 2015
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
ICD-10 Code Examples
UNDERDOSING
Terminology Difference Underdosing is an important new concept and term in ICD-10. It allows you to identify when a patient is taking less of a medication than is prescribed. When documenting underdosing, include the following:
1. Intentional, Unintentional, Non-compliance Is the underdosing deliberate? (e.g., patient refusal) 2. Reason Why is the patient not taking the medication? (e.g.financial hardship, age-related debility) Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship T36.4x6A Underdosing of tetracyclines, initial encounter T45.526D Underdosing of antithrombotic drugs, subsequent encounter
ICD-10 Code Examples
ATHEROSCLEROTIC HEART DISEASE WITH ANGINA PECTORIS
Terminology Difference When documenting atherosclerotic heart disease with angina pectoris, include the following:
1. Cause Assumed to be atherosclerosis; notate if there is another cause 2. Stability e.g. Stable angina pectoris, unstable angina pectoris 3. Vessel Note which artery (if known) is involved and whether the artery is native or autologous 4. Graft involvement If appropriate, whether a bypass graft was involved in the angina pectoris diagnosis; also note the original location of the graft and whether it is autologous or biologic I25.110 Atherosclerotic heart disease of a native coronary artery with unstable angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
ICD-10 Code Examples
ARRYTHMIAS/DYSRHYTHMIA
Increased Specificity When documenting arrhythmias, include the following:
1. Location e.g. Atrial, ventricular, supraventricular, etc. 2. Rhythm name e.g. Flutter, fibrillation, type 1 atrial flutter, long QT syndrome, sick sinus syndrome, etc. 3. Acuity e.g. Acute, chronic, etc. 4. Cause e.g., Hyperkalemia, hypertension, alcohol consumption, digoxin, amiodarone, verapamil HCl I48.2 Chronic atrial fibrillation I49.01 Ventricular fibrillation
ICD-10 Code Examples
Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty. The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented. Clinical Scenarios
ICD-10 Compliance Date: October 1, 2015
Scenario Details Chief Complaint
- “Dr. Smith asked that you check my hypertension prior to my surgery.” History
- 81 year old male scheduled for a TURP in 5 days. Dr. Smith requested evaluation for hypertension and cardiac clearance assessment for surgery^1.
- Inferior wall MI one year ago, received thrombolytic therapy and experienced complete resolution of his symptoms. Last EF (last month) was 50%.
- Regular physical activity includes walking, swimming, and golfing. He denies SOB with exertion.
- No history of cerebrovascular disease. No DM, CHF, renal failure, or angina.
- Has history of essential hypertension and was prescribed metoprolol succinate once daily by PCP, but patient is not taking as he cannot afford it^2. Exam
- Patient is an 81 year old male in no acute distress. Height and weight are appropriate for age.
- Vitals taken; BP is elevated at 157/92.
- Chest is clear. Physical exam is normal. No pedal edema.
- EKG shows nonspecific T-wave changes.
- Labs show creatinine at 1.5, a slight increase from his baseline and possibly indicating early renal insufficiency^3.
Scenario 1: Hypertension/Cardiac Clearance
Coding Other Impacts For hierarchical condition categories (HCC) used in Medicare Advantage Risk Adjustment plans, certain diagnosis codes are used as to determine severity of illness, risk, and resource utilization. HCC impacts are often overlooked in the ICD-9-CM to ICD-10-CM conversion. The physician should examine the patient each year and compliantly document the status of all chronic and acute conditions. HCC codes are payment multipliers.
Scenario 1: Hypertension/Cardiac Clearance (continued)
ICD-9-CM Diagnosis Codes 401.9 Unspecified essential hypertension 794.31 Nonspecific abnormal electrocardiogram [ECG] [EKG] 794.4 Nonspecific abnormal results of function study of kidney 412 Old myocardial infarctions N/A N/A V72.81 Pre-operative cardiovascular examination ICD-10-CM Diagnosis Codes I10 Essential (primary) hypertension R94.31 Abnormal electrocardiogram [ECG] [EKG] R94.4 Abnormal results of kidney function studies I25.2 Old myocardial infarction T46.5X6A Underdosing of other antihypertensive drugs, [initial encounter] Z91.120 Patient’s intentional underdosing of medication regimen due to financial hardship Z01.810 Encounter for pre-procedural cardiovascular examination
Scenario Details Chief Complaint
- Dizziness, weakness, and feeling tired last few days. He reports passing out at school. History
- 20 year old male college athlete with no prior medical history. On wrestling and cross country running team. Feeling dizzy, lightheaded, weak, and tired for the past two days. Had three several second witnessed syncopal episodes at school yesterday. Went to university clinic and was referred by nurse. Patient states no palpitations, no tachycardia, and no blurred vision noticed prior to each episode^1.
- Upon questioning, patient admitted he had to lose 11 lbs. to meet wrestling weight requirement. He accomplished this by ingesting carbohydrates, minimal fluids, heavy exercise, and purging^2.
- No medication or allergies. Denies alcohol, drugs, supplements, or diuretics use. Exam
- Looks exhausted. No apparent distress. Afebrile.
- Orthostatic VS:
- Lying BP 116/78 with HR 56,
- Sitting BP 107/60 with HR 74,
- Standing BP 92/49 with HR 112^3
- Mucus membranes pale, skin is dry, with turgor and tenting. Capillary refill is 2-3 seconds.
- Chest is clear. Heart sounds normal.
- Labs significant for creatinine (2.13), BUN (43), glucose (60).
- EKG shows sinus tachycardia^4. Assessment and Plan
- Orthostatic intolerance. Dizziness, fatigue, and syncope likely secondary to hypotension, dehydration and hypovolemia.
- Provided fluid challenge of 2L IV NS in office today with improved condition post infusion including resolution of orthostasis and tachycardia.
- Ordered nutritional consult for dietary intake requirements, physical activity, and potential bulimia^2.
- Recommended patient have a psychological consult for potential bulimia; stated he would think about it.
- Scheduled a follow-up in 2 weeks to ensure no further symptoms. Return earlier if symptoms persist. No driving until follow up appointment.
Scenario 2: Syncope
