Scenario 3: Chest Pain

Chief Complaint 

• Chest pain

History 

• 70 year old female patient presents with complaints of chest pain that awoke her from sleep last night. Patient describes the pain as midsternal “tight, squeezing” and pressure in the epigastric region. Patient reports that the pain was accompanied by diaphoresis and lasted approximately 5-10 minutes before spontaneously resolving. Patient states she tried sitting up, walking, and taking some liquid antacid but experienced no relief with these measures. Denies change in diet, or any unusual foods yesterday. 

• She also reported experiencing some intermittent attacks of chest pain and tightness approximately 2-3 times over the last six months, that previous episodes were shorter in duration with less severe pain, and usually occurred when she was “emotional” or “tired”. Pain with prior episodes was relieved by rest. 

• Recent widowed status – husband died seven months ago; states increasing anxiety and difficulty sleeping. 

• Medical history significant for hypertension and hyperlipidemia. Negative for stroke, myocardial infarction, bleeding disorders, GERD, anxiety, and depression. 

• Social history: Nonsmoker, occasional social drinking, denies illicit drug use. She only engages in sedentary activities at this time. 

• Family history: Father died of heart attack at age 50, mother is 95 years old and in good health, two siblings both in good health, otherwise negative family history. 

• Influenza and pneumococcal immunizations up to date. No known allergies.

• Current medications: Hydrochlorothiazide and atorvastatin; Denies OTC medications. 

• Comprehensive review of systems negative for significant symptoms.

Exam 

• T: afebrile, P 90, R 16, BP 160/94 (sitting) 128/78 (lying), 132/82 (standing) Ht: 68in. Wt: 201 lbs BMI: 30.6 (obese)

• HEENT & NECK: normal to exam. 

• CHEST: Clear to exam 

• CV: RRR without murmur, gallop, or rub, No JVD. Carotids clear bilaterally. 

• PERIPHERAL VASCULAR: Skin warm and dry with good pulses to all extremities. No edema bilaterally. 

• ABDOMEN: normal to exam. 

• NEURO: Patient A&Ox3. Moves all extremities well.

Assessment and Plan 

• Worsening neuropathy with foot ulcer and slow healing shin wound. 

• Will debride and treat wounds here and refer to Wound Care Center for ongoing care and management. 

• Discussed importance of foot care, and the need to routinely inspect lower legs and bottoms of feet because of the bilateral peripheral neuropathy. 

• Counseled patient about the importance of tight, stable glycemic control to slow the progression of neuropathy and nephropathy; advised to keep a log of his blood sugars for two weeks for our review. 

Summary of ICD-10-CM Impacts 

Clinical Documentation 

1.Angina, acute coronary syndrome and post-infarction angina are classified under Ischemic Heart Disease. The subsection for angina disorders is now titled “angina pectoris,” the subsection for acute coronary syndrome is now classified as “other acute ischemic heart disease,” and the subsection for post-infarctional angina is now categorized as “certain current complications following myocardial infarction”. This last selection would be used in conjunction with a code from the category of acute myocardial infarction or the category of subsequent myocardial infarction, if applicable. 

2.Angina without coronary atherosclerosis requires documentation regarding specific characteristics such as stable, unstable, or the presence of spasm. In this example, angina pectoris, unspecified is coded as the information in the medical record is insufficient to assign a more specific code. “Other” [forms] is used when the information in the medical record provides detail for which a specific code does not exist. For example, there is no specific code for angina decubitus in ICD-10-CM, as is the case in ICD-9-CM. Angina decubitus is reported with the code for other forms of angina pectoris. 3.Additional differences to note when documenting cases of angina alone in ICD-10-CM include:

 • Unstable angina encompasses the older terms intermediate coronary syndrome and pre-infarction syndrome. 

• Prinzmetal angina and variant angina are coded as angina pectoris with documented spasm.

 4.In ICD-10, hypertension has undergone a definitional change. It is defined as essential (primary) and the concept of “benign or malignant” as it relates to hypertension no longer exists.

Coding

ICD-9-CM Diagnosis Codes

413.9     Other and unspecified angina pectoris 

401.9     Essential hypertension, unspecified 

272.4     Other and unspecified hyperlipidemia 

278.00   Obesity, unspecified 

V85.30  Body mass index (BMI) 30.0 – 30.9, adult

ICD-10-CM Diagnosis Codes

I20.9     Angina pectoris, unspecified 

I1Ø       Essential (primary) hypertension 

E78.5    Hyperlipidemia, unspecified

E66.Ø9 Other obesity due to excess calories 

Z68.3Ø Body mass index (BMI) 30.0- 30.9, adult

Other Impacts 

No specific impact noted.