1. Seminar #5 – Cardiovascular Conditions Deborah A. Balentine, M.Ed., RHIA, CCS-P Kaplan University

2. Agenda  Announcements  Coding for Cardiovascular Conditions, Part 1  ICD-9-CM Coding for Diagnoses  Hypertension (HTN)  Myocardial Infarction (MI)  Chronic Ischemic heart disease (CAD)  ICD-9-CM Coding for Procedures  Coronary Bypass Procedures (CABG)  Cardiac Catheterizations  Percutaneous Transluminal Coronary Angioplasty (PTCA)

3. Coding for Cardiovascular Conditions Hypertension Hypertension is coded to Categories 401-405 4 th digits identify the type of hypertension: 0 – Malignant 1 – Benign 9 – Unspecified There is a special table for hypertension in the Alphabetical Index to Diseases (Volume 2)

4. Coding for Cardiovascular Conditions Code Structure – Combination Codes If a patient has hypertension and certain other conditions/manifestations combination codes are used to describe the condition. Terms or phases that imply a cause and effect include: “Hypertensive” “due to” “caused by” Relational terms like “and” and “with” do not always imply cause and effect when coding for hypertension.

5. Coding for Cardiovascular Conditions Hypertension and Heart Disease If a patient has hypertension and heart disease and a causal relationship is established between the two conditions, the hypertension is coded to Category 402.x 4 th digits identify the type of hypertension (i.e. benign, malignant, etc.) 5 th digits identify whether the patient has heart failure If heart failure is present, then an additional code is needed to describe the type of heart failure present.

6. Coding for Cardiovascular Conditions Examples: Benign hypertensive heart disease 402.10 Chronic hypertensive heart disease with chronic diastolic heart failure 402.91 and 428.32 Congestive heart failure and benign hypertension 428.0 and 401.1

7. Coding for Cardiovascular Conditions Hypertension and Chronic Kidney Disease (CKD) If a patient has hypertension and chronic kidney disease you can make the assumption that there is a causal relationship between the two diseases. Hypertension and Chronic Kidney Disease is coded to Category 403. 4 th digits identify the type of hypertension (i.e. benign, malignant) 5 th digits identify the stage of the Chronic Kidney Disease And addition code is needed to identify the Chronic Kidney Disease

8. Coding for Cardiovascular Conditions Examples: Malignant hypertension and Stage III CKD 403.00 and 585.3 Hypertensive chronic kidney disease 403.90 and 585.9 Hypertension and acute renal failure 401.9 and 584.9

9. Coding for Cardiovascular Conditions Hypertension with CKD and Heart Disease If a patient has hypertension, heart disease and CKD and a causal relationship is established between the conditions, the hypertension is coded to Category 404.x 4 th digits identify the type of hypertension (i.e. benign, malignant) 5 th digits identify the presence of CKD and heart failure. Additional codes are needed to identify the type of heart failure and the stage of the CKD

10. Coding for Cardiovascular Conditions Example: Hypertensive heart disease. The patient also suffers from End Stage Renal Disease 404.92 and 585.6 Malignant hypertensive heart disease with acute systolic heart failure and Stage 5 CKD 404.03, 428.21 and 585.5 A patient is diagnosed with benign hypertension, congestive heart failure and Stage II kidney disease 403.10, 428.0 and 585.2

11. Coding for Cardiovascular Conditions Secondary Hypertension Secondary hypertension is a condition in which the hypertension is caused by an underlying condition as opposed to the hypertension being the underlying cause in itself. Secondary hypertension is coded to Category 405.x 4 th digits identify the type of hypertension (i.e. benign, malignant, etc.) 5 th digits identify if the underlying cause is of a renovascular nature. The underlying cause is reported as the primary/first-listed diagnosis.

12. Coding for Cardiovascular Conditions Secondary Hypertension Hypertension due to renal artery stenosis 440.1 and 405.91 Malignant hypertension due to hypothyroidism 244.9 and 405.09

13. Coding for Cardiovascular Conditions Myocardial Infarctions Coded to Category 410.xx 4 th Digits identify the wall involved in the infarction 5 th digits identify the episode of care Example: 410.01 – Myocardial infarction of the anterolateral wall, initial episode of care Example: 410.92 – Myocardial infarction, unspecified wall, subsequent episode of care.

14. Coding for Cardiovascular Conditions 5 th Digits for Myocardial infarctions: 0 – Episode of care unspecified; use this digit when the source document does not contain enough information to assign a more specific digit 1 – Initial episode of care; used for a newly diagnosed MI until the patient has been discharged from acute care 2 – Subsequent episode of care; used to identify any episode of care following the initial episode of care

15. Coding for Cardiovascular Conditions Myocardial Infarctions (cont.) 412 – Old myocardial infarction, used when the MI is described as healed and presenting with no symptoms (8 weeks from date of onset) 414.8 – Chronic MI, used when the MI is over 8 weeks old and is still symptomatic.

16. Coding for Cardiovascular Conditions Chronic Ischemic Heart Disease Coded to Category 414.xx 4 th digits identify the type of disease (arteriosclerosis vs. aneurysm) 5 th digits identify the vessels involved (native vs. autologous vs. non autologous) Examples: CAD of native artery – 414.01 CAD of internal mammary bypass graft – 414.04 Aneurysm of the heart – 414.10

17. Cardiovascular Conditions ICD-9-CM Procedure Codes

18. Coding for Cardiovascular Procedures Remember that ICD-9-CM procedure codes are used for hospital facility services. Codes are found in Volume 3 of the ICD-9-CM. Volume 3 has a separate Alphabetical and Tabular List Codes are found by referring to the name of the Procedure Bypass Angioplasty Repair Insertion

19. Coding for Cardiovascular Procedures Coronary Bypass Grafts Main term(s): Bypass, coronary (aortocoronary) Coded to Category 36.x Code selection is based on the number of vessels involved in the bypass. If Mammary grafts are used to perform the bypass they are coded separately. Example: CABG procedure using one saphenous vein to bypass the RCA and one internal mammary graft – 36.11 and 36.15 CABG procedure involving two coronary vessels – 36.12

20. Coding for Cardiovascular Procedures ICD9-CM Coding for Bypass Grafts – Questions to Consider What types of grafts were used? (Saphenous vs. Internal Mammary) Saphenous vein harvesting is included in the code for the procedure. Internal mammary artery is coded separately. How many structures were bypassed?

21. Coronary Circulation Right Coronary Artery (RCA) Right marginal Right posterior Descending Left Main Coronary Artery (LCA) Left anterior descending branch DiagonalSeptal Left Circumflex (LC) Obtuse Marginal (OM) Posterior Descending (PDA) Posterolateral

22. Documentation Example “…The acute marginal branch was grafted with continuous 6-0 Prolene and the saphenous vein. The graft was brought to the ascending aorta. The heart was turned over; significant disease was seen in the proximal PDA. A segment of saphenous vein was sewn in with 7-0 Prolene. The mid OM was opened; and anastomosis was created. The graft was brought up to the aorta. Then the diagonal branch of the artery was grafted side-to-side with the left mammary. The distal LAD was opened and grafted to the tip of the left mammary…”

23. Documentation Example (cont.) marginal branch – Right marginal branch proximal PDA – Posterior descending mid OM – Obtuse Marginal diagonal branch of the artery – Left diagonal distal LAD – Left Anterior Descending branch Five structures were bypassed Two grafts were used - saphenous (included in code) and Mammary (coded separately) Code(s): 36.14 and 36.15

24. Coding for Cardiovascular Procedures Cardiac Catheterizations A diagnostic test used to identify, measure and verify intracardiac conditions. Also used in conjunction with more definitive procedures (i.e. angioplasties). Coded to Category 37.2x 4 th digits identify the area/side of the heart being studied. Example: 37.21 – Right heart catheterization 37.22 – Left heart catheterization 37.23 – Combined right and left heart catheterization

25. Coding for Cardiovascular Procedures Percutaneous Transluminal Coronary Angioplasty PTCA Used to relieve obstruction of coronary arteries. When performed on non-coronary vessels it is referred to as a PTA (Percutaneous Transluminal Angioplasty) Needs several codes to fully report the procedure. A code for the PTCA procedure A code for the stent insertion (drug vs. non drug eluting) A code for the number of stents inserted A code for the number of vessels treated Codes for any adjunct procedures

26. Coding for Cardiovascular Procedures Example: PTCA of left anterior descending artery and circumflex vessels with insertion of three non-drug eluting stents 00.66, 36.07, 00.41, 00.47

27. Coding for Cardiovascular Procedures Coding Practice: 1. PTCA of left anterior descending artery with insertion of single drug eluting stent. 2. CABG using double internal mammary coronary artery grafts to bypass three coronary arteries

28. Coding for Cardiovascular Procedures Coding Practice: 1. 00.66, 36.07, 00.40, 00.45 2. 36.13 and 36.16

29. Looking Ahead Seminar Topic: Study Smart!