Hello, and welcome to the MedAxiom Academy. The session I'll be covering with you today is on the ICD-10-CM Cardiovascular Diagnosis Coding. My name is Jamie Quimby, and I'm a Revenue Cycle Senior Coding Consultant with MedAxiom. So we're gonna start with just an introduction into the diagnosis reporting if you're fairly new to the coding world. So start with a little bit of background. The National Center for Health Statistics developed the ICD-10-CM in consultation with the Technical Advisory Panel, physician groups, and clinical coders to assure clinical accuracy and utility. There are no codes for procedures in the ICD-10-CM version. There is a separate one that's called ICD-10-PCS, and that is the Inpatient Procedural Coding System. So today we're just gonna focus on the ICD-10-CM version, which is our diagnosis reporting. So ICD-10 was endorsed by the 43rd World Health Assembly in May of 1990, and it came into use in WHO member states in 1994. It's used to classify diseases and other health and vital records, including death certificates, health records, health problems. All that information is recorded via this version. You'll see, once we kind of dive into some of the diagnosis codes itself, we're gonna have specific codes for specific diseases. We'll also have some for signs and symptoms, any abnormal findings, a complaint. There's social circumstances. There's also external causes of injuries, as well as a table for neoplasms. ICD-10 is updated on a fiscal yearly basis. So this means that every October 1st, the updated version for the next fiscal year will become effective. So when we come up to this October 1st, that October 1st will be the next year's version will be in effect. They do also publish official guidelines for coding and reporting. Those are also updated yearly on the fiscal year. And the nice thing about this ICD-10-CM version here is you can get all the updated material online for free. So right before they publish it and it becomes effective, you can find the information on Medicare's website or the CDC's website, and they will have everything in files. You can go by the categories. You can look up specifically what's changed from the prior year, instead of having to go through every single code. So it's very nice. And again, all that information is free. So we're gonna start with the alphabetic index. So ICD-10-CM is divided into an alphabetic index, which is an alphabetic list of terms and their corresponding codes. And then there's a tabular list, which is a numerical list of the codes divided by chapter according to the condition or body system. The alphabetic index is organized by these main terms, index of diseases and injuries, index of external causes or injuries, table of neoplasms, and then there's a table of drugs and chemicals. So looking at the format and structure, the tabular list contains categories, subcategories, and codes. Each character for all categories, subcategories, and codes may either be a letter or a number. All categories are at least three characters. The first character of a category is always a letter. The second and third characters may either be numbers or alpha characters. A three-character category that has no further subdivision is equivalent to a code. So for example, our essential hypertension that we see a lot in our cardiovascular world, that is coded to I10. So that's the three characters and there is no further subcategory behind that. So the I10 is the three characters and that is the complete code for that condition. Subcategories are either four or five characters. A subcategory character may either be letters or numbers. Codes are three, four, five, or six characters, and the final character in a code may either be a letter or a number. There are certain categories that do have a seventh character extension. So a code that has that applicable seventh character is considered invalid without that seventh character. And we'll cover that in an upcoming slide, kind of how that looks. Not a lot of the codes we deal with in the cardiology world go up to seven characters, but if you have an injury or a complication, some of those would go up to the seventh character code. So just kind of looking at how all this looks. So this is an example of a three-character category that's in our circulatory system, which is chapter nine. So you can see how it's all kind of broken out. So like our hypertension that we were talking about, the I10, there's a whole category of hypertensive diseases. So our essential hypertension, of course, is that I10 code. And then there's further codes available depending on the specificity in that condition. Same thing with like our ischemic heart diseases, that's where our coronary artery disease, those types of codes will lie. You can see the code range in that three-character category. So breaking it into further, so looking at an example of a four-character category. So these, of course, are further defined by the site, the etiology, or the manifestation of the state of the disease or condition. The fourth character subcategory includes the three-character category, plus that decimal, and then that additional character to identify the condition. Again, that's giving you further specificity to that condition. So more of a higher level of specificity. So here in our example, we have the I25, which is our chronic ischemic heart diseases, but further specifying with that additional character, you could see the I25.2 would be an old MI, so that's an old heart attack, or the I25.3 as another example, which is an aneurysm of the heart. All right, so now let's look at some fifth and sixth character subclassifications. So again, this has given us further specificity. So in this example, we're gonna look at heart failure. So you can see the three-character category, the I50 is for heart failure. Adding that additional fourth character would give us systolic congestive heart failure. So again, further specificity. And then behind that too, so adding that additional character here, you can see we have unspecified systolic heart failure, acute, chronic, and then we have acute on chronic. So looking at all the heart failure codes that are available, there are a lot. So of course, having that specific detail documented from the physician will definitely help you make sure you're selecting the right code. All right, so now let's look at an example of that seventh character extension. So again, these are typically where you will see complications. So the T82 is a complications of cardiac and vascular devices, implants, or grafts. So what we do see in cardiology periodically is this T82855A. So this is an example of a code where a patient had a cardiac stent placed in a coronary artery. Maybe the patient came back in and they had to have a repeat catheterization done due to symptoms. And so the provider shot dye through all the coronary arteries. If they have history of having stents or bypass grafts or anything like that, that dye will still go through those areas. So if they see a stenosis that has now formed within a stent that was already placed to make that previous stenosis open up, then you would code it to this. And so normally the reports are very clear. It'll say that the patient has in-stent stenosis and maybe the right coronary artery. And so you would code it to this. So that T82855A, so that would be the initial encounter, that is telling the insurance carrier that the patient now has stenosis within that stent that was placed. And again, that would be an example of your seventh character. All right, so now we're gonna look at some of the ICD-10 conventions. So we're gonna kind of go through what some of all the notes would mean, some of the symbols that you might see in the coding book. So first we'll start with the code first, use additional code notes. So guidelines state codes that have both an underlying etiology and multiple body system manifestations due to the underlying etiology require sequencing of the underlying condition first, followed by the manifestation codes. So wherever such a combination exists, there is a use additional code note in at that etiology code and a code first note at the manifestation code. So both codes will kind of guide you to report those services together if they're connected. So these instructional notes indicate the proper sequencing order of the codes, etiology followed then by that manifestation. So to give you an example of what that might look like, so say we have a patient with heart failure. So you go to that I50, which is that three character category. You'll see a code first note in red under that I50 category. So let's say for example, the patient also has hypertension. And we'll cover these in great detail in an upcoming slide, but guidelines for coding hypertension and heart failure state that there is a presumed relationship between these conditions and they should be coded as related unless the provider specifically documents that they are not related. And I've been in cardiology many, many years. I can tell you, I've never seen a provider document that. So that's an important thing to point out here because we see a lot of patients that have hypertension and heart failure. So unless that physician clearly states they are not related, you have to code them as related. So looking at that, you would then have to go to code I11.0. So if you have your book in front of you, open it up and you can kind of follow along and as I'll explain this. So the I11.0 is your category here, that's hypertensive heart disease with heart failure. You'll also notice a note that says, use additional code to identify the type of heart failure. This is letting us know that the correct sequencing for reporting these two conditions together. So what we'll have here is the I11.0, which is for our hypertension with the CHF involvement. Then we don't know for this example, we don't know the specificity of the CHF. So what we would code here is the I50.9, which is an unspecified congestive heart failure. So that would be the sequencing of those codes. And again, looking at the two codes in the book, you know, there are notes under both of them. So you would know that you would have to code those. All right, so not elsewhere classifiable. This abbreviation in the alphabetic index represents other specified. So when a specified code is not available for condition, the alphabetic index directs the coder to the other specified code in the tabular list. So this abbreviation in the tabular list represents other specified. So when a specific code is not available for a condition, the tabular list includes that NEC entry under a code to identify that the code has an other specified, but there's just not one available in the actual coding book. So a good example here, acute coronary syndrome. So let's go to the alphabetic index and then search under that syndrome. Then from there, you'll go to coronary. Then you'll see the word acute. Now in the index, it brings us to a NEC indication, code I24.9. So now let's go to that code in itself in that tabular list. You can see when we go to the code, it further specifies, this is assigned to an acute ischemic heart disease unspecified. So that was the highest specificity that we could go for that particular condition. Not otherwise specified, so the NOS, this abbreviation is equivalent to an unspecified service. So that would be like the congestive heart failure we just had. We did not have any further specificity, so that's why we selected the I50.9. Another example would be chest pain. There's a few options when selecting chest pain, depending on that level of specificity. So if you just have chest pain, chest pain, that would correlate to the code R07.9, which again is an unspecified chest pain. Code also, a code also note instructs that two codes may be required to fully describe a condition, but the sequencing of the two codes depends on the severity of the conditions and the reason for the encounter. So for this example, let's go to code I16 in the tabular list. So opening up that area to your book, you'll see a note that says code also identified hypertensive disease I10 through I15. So let's say we have a patient that comes to the emergency room and the provider documents hypertensive emergency in a patient with non-malignant hypertension. So for this example, we would assign code I16.1, which is that hypertensive emergency. Then we would also code I10 for that hypertension. So again, that's just letting us know that code also. All right, so let's now go through some of the punctuation. So you'll see a lot of these within the book. They all have a specific meaning to that particular code. So it does help to know what these all mean and kind of understand that way, when you're looking at a code with these, kind of how to apply all that. So the brackets are used in the tabular lists to enclose synonyms, alternate wording, or any type of explanatory phrases. Brackets are used in the alphabetic index to identify manifestation codes. So they kind of have two separate meanings, depending on if you're in that tabular list or the alphabetic index. The parentheses are used both in that alphabetic index and the tabular list to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as non-essential modifiers. The non-essential modifiers in the alphabetic index to diseases apply to subterms following a main term, except when a non-essential modifier and a sub-entry are mutually exclusive, then that sub-entry would then take precedence. The colons are used in the tabular list after an incomplete term, which needs one or more of the modifiers following the colon to make it assignable to a given category. The brace encloses a series of terms, each of which is modified by the statement appearing at the right of the brace. And then finally, words following a comma are essential modifiers. The term in the inclusion note must be present in the diagnostic statement to qualify the code. Okay, so this is another really important area with the, you're gonna see under some of the codes, you'll see an excludes one, and then you'll also see an excludes two sometimes. So they're not always both present. Some codes don't have the excludes notes at all. Some have both. So each have their own unique meaning. So we're gonna kind of break these down. So again, a type one excludes note is a pure excludes note. It means not coded here. An excludes one note indicates that the code excluded should never be used at the same time as the code above the excludes one note. An excludes one is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. So that's what that means. If you see excludes one note under a certain code that you're looking at in the book, then it would reference that that particular code you're looking at in the book and whatever codes are listed under the excludes one, you can never code those together. Now an excludes two note represents not included here. So completely different. It indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. So when you see that excludes two note appears under a code, it is acceptable to use both the code and the excluded code together when it's appropriate. So now let's kind of look at an example of what that would look like. Excuse me. So under exclude one example, if you go to the code I-20 in your tabular list, you'll see an excludes one note that shows if the patient has known coronary artery disease, which starts with your code range of I-25.1, you would not also code the I-20 for the angina. There are combination codes if the patient has that known coronary artery disease and they also have angina documented. So you would have to report that combination code instead of coding those individually. So now if you go back into your code book and look at the I-25.11 series, you can see that's where those combination codes are located. So you would never code the I-25.10, for example, that's coronary artery disease, and then an I-20.0, which would be our unstable angina. You would never code those like that. It would be the I-25.110, which is that combination code that describes both of those conditions. Now for an excludes two example, if you go to the I-50 again in your tabular list for the heart failure, you'll see that there's an exclude one and an exclude two notes. So for this one, let's look at that excludes two note. So here you can see it specifies that the patient also has cardiac arrest. It would be appropriate to report that with the heart failure. So again, just keep in mind, exclude ones means you can never report them together. Exclude to means you can if it's appropriate. All right, so now we're gonna go through some of the general coding guidelines. So let's, again, start with some of the basics on how to locate a code in the book itself. As you can see, if you have your ICD-10 book in front of you, it's quite thick. There's a lot of information in it. So to select a code in the classification that corresponds to a diagnosis or a reason for visit documented within that patient's medical record, first, you wanna locate the term in the index, and then you wanna verify the code in that tabular list. So you never wanna just look it up in the index, write the code down, and then go from there. You always wanna verify it within that tabular list, going to the actual book, or to the actual code in the book, and reading whatever notes may be correlated with that specific condition. There sometimes might be more specificity to it that you would need that you could only get from going to the actual code. So again, you wanna read and be guided by the instructional notes that appear in both that index and tabular list. Again, it is essential to use both systems, the index and that tabular list. I would not, again, recommend coding just strictly from looking it up in the index without going again to that code specifically within the book. So diagnosis codes are used to report, again, to their highest number of characters available. As we stated, ICD-10 diagnosis codes at least have three characters. Some can go all the way up to seven. So a code with three characters that are included in ICD-10 as the heading of a character could have further subdivided subsections, again, with those additional characters. A code is invalid if it has not been coded to the full number of characters required for that code. So that would also include that seventh character category if it's applicable. Acute and chronic conditions. So if the same condition is described as both acute and chronic and a separate sub-entry exists in the alphabetic index, you would code both the acute and then also code that chronic code. You would sequence the acute code first in most examples. So an example here would be if a patient is found to be in acute renal failure, but they also have known chronic kidney disease stage four. So that's acute and chronic conditions. So for the acute condition, you would code the N17.9, which is that acute heart or acute kidney failure or renal failure. And then you would code that N18.4, which is that chronic kidney disease stage four. All right, so furthering on with the combination codes. So like we talked about with the coronary artery disease, those do have combination. There are other services within the book that also have combinations like your peripheral vascular disease. So again, just depending on the level of specificity would depend, of course, of where the ultimate code being selected falls. So again, in this selection here, we have a coronary artery disease with that unstable angina. So we would not code separately as the I2510 with the I20.0. You instead would select that combination code, which is that I25.110, which again describes both of those conditions. So laterality. This is important with our peripheral vascular patients. We do fall under here a lot. So some ICD-10 codes indicate laterality, specifying the condition occurring either on that left side, the right side, or bilateral. The right side is usually assigned character number one. The left side is usually character number two. And in a case where the bilateral code option is available, that's usually assigned number three. So you can see here in this example, the I70.213, that's peripheral vascular disease, bilateral legs with claudication. So again, there's many combination codes for these, like I was just talking about in the last slide. So there's another series of these that can be unilateral or bilateral. And again, depending on the symptomatic approach that's documented from the physician, can change your code here too. So there's one for resting pain. There's one with an ulcer. If the patient has ulcer or gangrene, those types of details are, there are code options for all that. So if the laterality, excuse me. So for this last example, if there is no bilateral code given and both sides are involved, then you would code both conditions individually. So big example here that we see, patient does not have known disease yet in their extremities, but they're complaining of bilateral leg pain. So there is no bilateral code available for those specific complaints. So what we would have to do is code them individually. So you would code the right and left leg here. All right. So sequela, which is also called known as a late effect. So a late effect is a residual effect or condition produced after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in a cerebral infarction, or it may occur months or years later. Following coding of sequela generally requires two codes sequenced in the following order. The condition or nature of the sequela is sequenced first. Then the sequela code is sequenced second. And this example here that you can see, we have a patient that has a history of a stroke that was two years ago. They're now presenting with dysphagia. The correct code assignment would be the I69321, which is that dysphagia following that cerebral infarction. Signs and symptoms. So we do kind of live in this area also in cardiology. So a lot of times if their patient has a new complaint or they're a new patient to the practice in general, physician's gonna order for their workup for whatever their signs and symptoms might be. So we don't have that definitive diagnosis yet. So in those kinds of examples, we would just code the signs and symptoms that the patient's complaining of. All right, conditions that are part of a disease process. So signs and symptoms that are associated routinely with the disease process should not be assigned as additional codes unless otherwise instructed by that classification. So good example here. And we do see this kind of example a lot. Patient presents with chest pain and the provider documents known coronary artery disease with angina. So the correct code assignment here would be the I25119, which is that coronary artery disease of the native coronary artery with unspecified angina. Chest pain would not be separately coded because chest pain is part of that disease process. So conditions that are not part of a disease process. So those additional signs and symptoms that might not be associated routinely with a disease process can be coded separately. So for this example, we have a patient with shortness of breath and they're coming in for followup of known hypertension. So the provider documents in their assessment and plan, both the hypertension and the shortness of breath, and they're gonna go ahead and order an echo to see maybe what's going on with that shortness of breath symptom. So correct code assignment here would be the R06.02, which is that shortness of breath. And then that I10 for our hypertension. So we can code that shortness of breath separately because it's not routinely associated with hypertension. Use of signs and symptoms and of course, unspecified diagnosis codes. So these are guidelines that are actually printed within the updated yearly ICD-10-CM guidelines for coding and reporting. So these do have acceptable, even necessary uses. So ICD-10 of course, wants the most specified codes selected if possible, but there are times where the provider just doesn't have that detail yet until they get that further diagnostic testing complete. So of course, while that specific diagnosis code should be reported when that documentation supports, there are gonna be cases though, where the signs and symptoms or even that unspecified code may be the best option that accurately would be reflecting that patient encounter. Each encounter should be coded to the level of certainty known at the time. So you never want to select unspecified if there's more specified detail within the note. If a definitive diagnosis again has not yet been established by the provider, it would totally be appropriate to report just the signs and symptoms or again, unspecified. Borderline diagnosis. So in the ICD-10 guidelines, they state that if the provider documents a borderline diagnosis at the time of discharge, the diagnosis is coded as confirmed unless the classification provides a specific entry. Example of that here would be a borderline diabetes. There is a particular code that is specific to borderline diabetic, which is that R73.03. So we could select that in this particular example because we have that code. If you're ever not sure, I always encourage you to communicate with the provider. If you have to send them a query, just asking for that additional clarification, there's no harm in doing that. All right, so now we're going to cover chapter nine coding guidelines specifically. So this will apply to the diseases of the circulatory system. So remember a few slides back, we were talking about hypertension and the combination. So now I'm going to dive deep into what the actual guidelines state with that. I do like to talk about hypertension often because it's a big area that I see miscoded often. So we're going to touch up again in detail what the guidelines state. So they do state again that there is a presumed casual relationship between hypertension, heart involvement, and between hypertension and kidney involvement as those conditions are linked by the term with in that alphabetic index. So these conditions should be coded as related even in the absence of provider documentation specifically linking them together. So these particular guidelines state the provider would have to document that they are not related to code them as unrelated. So breaking that down further, so guidelines here state that hypertension with heart conditions classified to these codes that you see here, it would be the I50, the I51.4 through I51.7, that I5189, and again, that I519. So those are assigned to category I11 for that hypertensive heart disease. And then you would code additional codes as supported behind that. So if you have a patient with known chronic systolic heart failure, you would select that code I10.0, which is that hypertensive heart disease with heart failure, along with the I50.22, which is that chronic systolic congestive heart failure. So again, that's linking the two conditions together and of course, applying those guidelines as appropriate. Hypertensive chronic kidney disease. So this is another area. So when you're looking at these guidelines, guidelines state you would select hypertension category from I12, which is a hypertensive chronic kidney disease category. You would then also code the chronic kidney disease that's present. And again, that level of specificity would need to be in the documentation for you to accurately code it. So to give you an example here, say we have a provider document and their assessment and plan that a patient has hypertension and they also have stage four chronic kidney disease. So here, your correct code assignment would be I12.9, which is that hypertensive chronic kidney disease with stage one through four, or an unspecified chronic kidney disease. Then we would also select the N18.4, which is that chronic kidney disease stage four. And when you go to those codes within the actual book in the tabular list, you're gonna see that there are instructional notes that tell you to use the additional code to identify one another. So if you go to the I12, you'll see under there that it tells you to use that additional code to identify the stage of the chronic kidney disease and vice versa. So if the patient is also in acute renal failure, you would code that also the N17.9. And guidelines do state that you would sequence those according to the circumstances of that admission or that encounter. Hypertensive heart and chronic kidney disease. So this is when all three conditions are documented within that patient's chart. So here, if you go under I13 in your book, so that will show you that it's a combination code that would include hypertension, congestive heart failure, and chronic kidney disease. So if all three are documented, that you would go to I13. So that would be a combination of the I11 and I12 together. So again, you would go just to I13 under that combination series, and then you would code based on what's documented. So here, let's get an example here. We have a provider, say they documented, patient has hypertension, maybe they have end stage renal disease. The patient's currently on dialysis, and they have that acute on chronic combined systolic and diastolic heart failure. So now we have all these combined conditions. So first we are going to select that I13.2, which is that hypertensive heart and chronic kidney disease with heart failure with stage five or end stage renal. So in this example, we had end stage renal. Then we're going to code the N18.6, which is our end stage renal disease. We're also going to code that congestive heart failure that we had. So they had stated that they had acute on chronic combined systolic and diastolic. So that's I50.43. And then also mentioned was the patient was on dialysis. So we would also code the Z99.2, which is that renal dialysis status. And again, looking at those instructional notes under that I13 series, it does tell you to code all those additional details if it is known. So in that example, we had multiple codes. I remember they're all combinations, but it's accurately following the guidelines and we're accurately coding to the level of specificity that we know. These are some other hypertension guidelines. I don't see them a lot in our cardiology world. So if a patient has that hypertensive cerebral vascular disease, it tells you, you would select the code from the I60 to I69 series. I haven't seen a lot of the others. Transient hypertension. So this is an elevated blood pressure reading without a diagnosis. So this is a reading without a diagnosis of hypertension that's been established from the physician. There are times where you may see that documented until they further do diagnostic workup on that patient. Other hypertension guidelines. So under the controlled, so this diagnostic statement usually refers to an existing state of hypertension under control by therapy. So you would assign the appropriate code from that I10 through I15 category. Again, if they just state hypertension controlled, it would just go to that I10 code with no further detail behind it. Uncontrolled kind of falls under the same. So again, if you just provide our documents uncontrolled or malignant hypertension, it's just gonna fall under that I10 without further specificity documented behind that. Hypertensive crisis. So that was that example we gave a few slides back. If they have that, that would fall under that three category, the I16 for that hypertensive crisis. Again, you would code the identified hypertension or hypertensive disease behind that I16 series if known. So if the patient has known hypertension and they're having that hypertensive urgency, you would code the appropriate I16 code and then you would code the I10 code behind it. So now let's look at our coronary artery disease. So there again, combination codes to choose from if they're applicable at that visit, depending if the patient has, just their native coronary arteries, if they've had bypass grafts in the past, if they've had their heart transplanted, there's multiple different areas to coronary artery disease, just depending on the level of detail you have. A casual relationship can be assumed in both patients with both the atherosclerosis and angina, unless again, that documentation indicates otherwise. I can tell you being in cardiology for many, many years, I've never seen a provider state angina was unrelated to the coronary artery disease. So again, just following those guidelines. Again, there's further specificity if there's graft involvements. Again, if the patient has just known bypass grafts, they have known disease within those grafts, that's just, but there's no documented angina or anything, that would go to code I25.810, which is known bypass graft coronary artery disease. So if the patient, one thing I wanna stress, if a patient has coronary artery disease, they have a history of having bypass grafts, but there's no disease in those grafts, they're all patent, then you would not select a code from the I25.810. So that would be coded as I25.10, which is coronary artery disease. And then you would code Z95.1, which is history of bypass grafts. So sometimes I see that coded wrong, where the provider will state the patient has known grafts, there's no disease though, he clearly documents all the grafts are patent, but sometimes I'll see that incorrect category selected of the I25.810. So that's stating to the carrier that the patient has disease in their graft. So you, again, wanna be careful when you're looking at the code, of course, just applying the guidelines appropriately. Acute MIs, we're definitely gonna take a diaper deep into these in the upcoming slides, because there's different types of MIs, type one, type two. So we'll cover the definition of all those to help you better understand how to code them. So encounters occurring while the myocardial infarction is equal to or less than four weeks old, you would code it as the acute phase, the I21 series. So if it's after the four week timeframe and the patient is still receiving care that's related to that myocardial infarction, you would appropriately code the aftercare code rather than that I21 series. Now, if they're no longer requiring active treatment after that four week period has passed, then from there you just code it as an old or healed myocardial infarction. And that just correlates to the code I25.2. So again, just depending on the timeframe and the treatment that's still being provided is gonna depend on whether you're coding it still as an acute condition or as aftercare, or if it's just gonna be coded as an old or healed. All right, so type one versus type two. So a type one MI is an event related to atherosclerotic plaque that's ruptured, ulcerated, fissuring, erosion or dissection with resulting intraluminal thrombus and one or more of the coronary arteries, which then leads to a decreased myocardial blood flow or distal platen emboli that then cause necrosis within the heart. So the patient may have had underlying severe coronary artery disease, but there are occasions where about five to 20% of these patients have non-obstructive or even no coronary artery disease may be found by that angiography, particularly so in women. So the myocardial infarction, secondary to an ischemic imbalance, which is called our type two MI, these account for up to about 25% of all the MIs that we see. So in instances of a myocardial injury with that necrosis, where a condition other than coronary artery disease contributes to that imbalance, again, between that myocardial oxygen supply, then that term MI type two would be employed. And the physicians are very good at detailing that when it's present. So, you know, you shouldn't have any issue as far as when you're trying to code the correct MI code. I have no issues that I see. And, you know, we look at notes all over the country for our member practices. And usually if a type two MI is involved, it's very clearly documented from the provider. Okay, so let's look at type one. So there are multiple codes. If you go to the I21 series in your book, there's multiple codes to choose from, depending on the site identified. It can go into further subcategories of specifically referencing the coronary artery that's involved with that MI. So again, having that detail is important. You definitely wanna try to not code the unspecified MI if possible. Usually in these patients, the provider's bringing the patient to that cath lab urgently, and they're going straight in for cardiac cath. So typically it's not an issue finding that specificity, you know, with being able to reference back to that cardiac cath report. So if a type one non-STEMI evolves to a type one STEMI, guidelines do tell you that you would code the type one STEMI code instead of that non-STEMI. Type two. So again, as I stated, we don't usually see issues with physicians documenting this clearly, but just again, these do account up to about 25% of all the acute MIs that we see. Again, this is what a type two MI is, is the myocardial injury with that necrosis where a condition other than coronary artery disease contributes to that imbalance. So then they would deploy that type two MI. In critically ill patients or patients undergoing major surgery, sometimes those elevated values of those cardiac biomarkers may appear. Also coronary vasospasm could also be the potential to cause that MI. So again, if you see that type two, you know you're gonna go to that I21.8A1, and that is our type two MI. Now we have further types of MIs. So again, just to give you a definition of what these look like. So a type three MI is the result of a coronary thrombus with sudden cardiac death before those biomarker results are available. A type four MI is caused by a complication from a PCI, which is that percutaneous coronary intervention. So a type four A is periprocedural MI. A type four B would be related to an instant thrombosis. So this would be a patient that had a stent placed and now they have thrombus within that stent itself, and that's what's causing the MI. A four CMI is due to restenosis that's greater than 50% after that initially successful PCI was performed. And then a type five MI is related to complications from that patient having bypass surgery. Subsequent acute myocardial infarction. So if a subsequent infarction of one type occurs within four weeks of an MI of a different type, then the guidelines do state that you would assign the appropriate code from the I21 category to identify each type. You would not assign code I22, which is that follow-up subsequent MI code. You would not assign that code to this particular example here. All right, so now let's go over some of the cardiology coding tips. So with valve disease, when you're looking at like an echocardiogram for instance, you're looking at the findings documented from the provider. You know, they're looking at all the cardiac valves. You have your aortic, your mitral, your tricuspid, your pulmonary. So what the guidelines state with valve disease in ICD-10. If the provider does not specifically document them as non-rheumatic, and you have multiple valve disease involved, the index for ICD-10 will guide you to code it as rheumatic disease. So when I'm working with providers, I kind of stress to them, rheumatic disease is not something that's highly common in the United States. So, and physicians, you know, will tell you that too. So you have to educate them and let them know you have to clearly say non-rheumatic disease for me to code them as non-rheumatic. If you don't, and there's multiple, you know, disease involved with the valves, then I have to code them as a combination code and they have to be coded as rheumatic. So in this example here on the slide, say we have mitral valve insufficiency documented and then tricuspid insufficiency documented. So because they weren't clearly documented as non-rheumatic, if you go to your index under the valve diseases, you'll see it guide you to the I08.1, which is a combination code for that disease of the mitral and tricuspid valve. So you would only code it with the one code, which would, you know, it would describe both conditions to the carrier, but again, they may not have rheumatic, but because the documentation didn't specifically state otherwise, that's what we have to code it as. Arrhythmias, there are multiple different types of arrhythmias. So again, knowing that location, the specific name, whether it's fibrillation, flutter, sick sinus syndrome, those types of details, acuity, the cause, sometimes it's called, it could be caused by a medication or alcohol use from the patient, or sometimes their hypertension gets so uncontrolled that it will then cause other problems with the patient. So all those details are important when you're looking at, you know, your arrhythmia coding. Again, there's, you got your atrial fib, your atrial flutter, you have your ventricular fib. There's so many to choose from. So again, just having that level of specificity will help you in selecting the correct arrhythmia code. Different types of AFib. So quite a few years ago, we got further specificity of these codes. So just kind of explain what they all mean. Usually providers are pretty good at giving you that detail, but I, as a coder, I always kind of like to understand a little bit clinically to just kind of help my brain understand what's going on with the patient. So when you're looking at proximal AFib, some patients may have symptoms that come and go. Usually it can last for a few minutes or up to a few hours. Sometimes symptoms occur for as long as a week. Episodes can happen repeatedly. So your symptoms might go away on their own or the provider might have to initiate treatment. With persistent AFib, this often requires a pharmacological or electrical cardioversion and does not stop within a week. So that would be a patient that's continuously in that AFib for at least a week, you know, and sometimes they may give them a medication to get that to stop, or they just may bring them in to the hospital as an outpatient and do that electrical cardioversion and shock the patient back into sinus rhythm. Long-standing persistent AFib. This is persistent and continuous, and it lasts longer than one year. So that's how it's defined. Chronic AFib or permanent AFib. This is a term that has long been used to describe the condition in people where that abnormal heart rhythm can't be restored. So they'll likely have AFib permanently and often require medications to control that heart rate and to prevent the blood clots. Usually with a chronic or permanent AFib being present, cardioversion usually is not attempted, or if they do try to attempt it more commonly, it's not successful. So again, I wanna stress that it's up to your providers to document that highest degree of specificity known. So again, if you see one that's not specified, there's no harm in querying that provider just to ask for that clarification. Preoperative clearance. This is another area that I can sometimes see coded missed often, so the reason for the visit is for that preoperative clearance. You're gonna code that Z01.810 as your primary diagnosis. A lot of the Z codes cannot be listed as a primary diagnosis, but this is one that guidelines specifically state has to be primary. So if your provider is seeing them for a pre-op clearance, you're gonna list that Z code first, then guidelines state that your secondary diagnosis should be for the reason the patient's having surgery. So this sometimes might be not related to cardiology. They could be needing a pre-op clearance for something unrelated to cardiology. So maybe they had like a fracture and they're having to have surgery from orthopedic or something. You would list that Z code first, reason for the surgery second, then you would list any underlying cardiac conditions additionally after that. So that would be the correct sequencing for a pre-op visit. Cardiomyopathy. Again, we have many codes to choose from here. So having that degree of specificity is important. Again, there's many different types, many different causes. So again, a lot of these patients sometimes will end up needing a defibrillator implanted. So having that degree of specificity will definitely help with making sure that the reason for that implant is following the NCD requirements from Medicare, which is that national coding. They put out guidelines for those. So it's the national coding determinations. So again, having that level of detail is important with having these types of conditions. Again, congestive heart failure. I know we touched up on this a lot. There are so many different codes. If you even just open your book to that I-500 series, you're gonna see like all the codes. You have left ventricle, right ventricle. There's also codes now for biventricle. What is the cause? Is it systolic, diastolic, combination? Again, and then that severity is also available now. There's the acute chronic, acute on chronic. There's now codes for end stage heart failure. So lots of different options, knowing that level of specificity in the documentation is extremely important. All right, so now let's just briefly look at definition and defining the national coverage determination and then the local coverage determinations from the Medicare carriers. So it is important to improve your understanding and again, reduce the repayment risks. So NCD rulings specify the Medicare coverage of specific services on a national level. All Medicare contractors are obligated to follow the national coverage determination that's published by National Medicare. If an item or service is new or not defined by an NCD, the local Medicare contractor is responsible then for making a decision for coverage. So you may see some CPT codes that would have a national coverage determination assigned to them. And an example of that, just one that we see common in cardiology is a TAVR. So that's when the patient has their aortic valve replaced. There is an NCD that is specific to that procedure and it gives you all the guidelines and requirements in order to bill for that procedure. There's no local coverage determination for that particular condition, so that policy. So all the local contractors would have to follow the national policy from Medicare itself. So with the local coverage determination, so remember the NCD decisions are binding on all Medicare contractors and an LCD, which is that local coverage determination policy. It can be no more restrictive than the NCD itself, but although it can be less restrictive. So in the absence of an NCD policy being available for a particular CPT code, the local Medicare contractors can develop what they call a local coverage determination. So a lot of your diagnostic testing, like your echocardiograms, your nuclear studies, a lot of those have a local coverage determination policy from all the different Medicare contractors across the country. So it's important to definitely get comfortable with your Medicare contractor, with their website, know where to find these local coverage determination policies. They're very detailed, very helpful. It's great information to give back to the provider so they understand what these carriers are looking for clinically. And again, it lists a lot of details, tells you when you can bill a service, when it wouldn't be billable or appropriate or covered by the policy. So this is Medicare's definition of medical necessity. So Medicare will normally cover services deemed medically necessary. They do define medical necessity as healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or symptoms and that meets acceptable standards of medicine. In any of those circumstances, if your condition produces debilitating symptoms or side effects, then it is also considered medically necessary to treat. No payment will be made under Part A Medicare or Part B Medicare for expenses incurred for items or services, which would not be considered reasonable and necessary under that local coverage determination, or again, that national coverage determination. So it really just depends. Sometimes, even if they do fall within that local or national coverage determination, there may be times where Medicare may be flagging that particular condition or service being provided. And then there are sometimes you just have to appeal it even though it's meeting the requirements. So again, just keep that in mind. The AMA, this is their definition of medical necessity. So they say healthcare services are products that a physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or symptoms in a manner that is in accordance with generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, and site. So what that means, and Medicare also applies that within their local coverage determination, so with the frequency. They might say like with the carotid duplex study, that's our 93880. They may have a frequency limitation of how often you can report that service. So if the patient has known disease in their carotid arteries, but they're not symptomatic at the time, then depending on what the policy might say, it may say you can't bill more than one every two years or something. But if the patient becomes symptomatic, then it may be appropriate to bill it more frequently because the patient is showing symptoms. So again, important to just kind of look at those individual policies of the services that your practice is providing and just educating the providers on what those policies might say. So just wanted to leave with some tips on selecting those proper diagnosis codes. Again, describe the condition that prompted the visit that should be listed as your first condition on your claim form. So the primary reason the provider is seeing the patient should be first. Conditions, again, coded to the highest degree of specificity known. Never want to select an unspecified if there is greater detail documented. You can code based on signs and symptoms if an undefinitive diagnosis has not been made yet. Cannot code for conditions that are documented as rule out, probable, possible, or questionable. So remember if the patient has chest pain, the provider wants to do workup for possible coronary artery disease, you would not code that coronary artery disease if it's not known that the patient has it. You would just code the chest pain. You do want to also include secondary conditions affecting treatment during that current visit. So what that means is sometimes a provider may document non-cardiac related conditions that could though affect the cardiac conditions that they are treating. So you would want to include those if they're addressed during the visit. So example would be diabetes. So we know diabetes can definitely affect our cardiac patients in many ways. So if they document that the patient has diabetes and they kind of go into a little detail about the condition, whether it's stable at the time they're seeing them, if they're managed on insulin, or they manage it with diet, those types of details documented, then you would want to include that diabetes diagnosis on your claim form. All right, and with that, we are going to end this module. If you have any questions, please feel free to reach out to the email on the screen and we'll be happy to help you further. Thank you so much for listening.

ICD-10-CM

Cardiovascular Diagnosis Coding

differences

coding systems

diseases

hypertension

coronary artery disease

acute myocardial infarction

valve disease

arrhythmias