Scenario 4: Subsequent AMI (continued)

ICD-9-CM    Diagnosis Codes 

410.72           Subendocardial infarction, subsequent episode of care 

414.01           Coronary atherosclerosis of native coronary artery 

403.91           Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified 

585.9             Chronic kidney disease, unspecified 

443.9             Peripheral vascular disease, unspecified 

428.30           Diastolic heart failure, unspecified 

401.9             Hypertension, unspecified 

785.2             Undiagnosed cardiac murmurs

785.9             Carotid bruit 

496                Chronic airway obstruction, not elsewhere classified 

405.91           Unspecified renovascular hypertension 

440.1             Renal artery stenosis 

272.4             Other and unspecified hyperlipidemia 

305.1             Tobacco use disorder

ICD-10-CM Diagnosis Codes

I22.2   Subsequent non-ST elevation (NSTEMI) myocardial infarction 

I21.4       NSTEMI myocardial infarction 

I25.1Ø   Atherosclerotic heart disease of native coronary artery              without angina pectoris 

I12.9        Hypertensive chronic kidney disease stage 1 thru stage 4 chronic kidney disease, or unspecified chronic kidney disease 

N18.9        Chronic kidney disease, unspecified 

I5Ø.32        Chronic diastolic (congestive) heart failure 

I1Ø          Essential (primary) hypertension 

RØ1.1      Cardiac murmur, unspecified 

RØ9.89   Carotid bruit 

I73.9       Peripheral vascular disease, unspecified 

I15.Ø      Renovascular hypertension 

I70.1       Renal artery stenosis 

J44.9      Chronic obstructive pulmonary disease, unspecified 

E78.5      Hyperlipidemia, unspecified 

F17.21Ø Nicotine dependence, cigarettes, uncomplicated

Other Impacts 

The I12 category can be assumed when the documentation includes hypertension and chronic renal disease. The I11 category cannot be assumed between hypertension and heart disease unless the documentation supports a “cause and effect” relationship between the two such as a statement of “hypertensive heart disease” or “heart disease due to hypertension”.

Scenario 4: Subsequent AMI

Chief Complaint 

• Follow up after my second heart attack.

History 

• 81 year old male retired professor presents for follow up visit after hospital admission for NSTEMI; he was discharged five days ago. Currently denies chest pain, shortness of breath. Able to walk without symptoms.

• Medical history remarkable for CAD requiring CABG times four, PVD, bilateral carotid stenosis, hypertension, dyslipidemia, COPD, emphysema, renal artery stenosis, CHF with diastolic dysfunction, and NSTEMI. 

• NSTEMI #1 while patient was on a cruise about three weeks ago. Limited data indicates ECG findings included ST depression, rise in troponin. 

• NSTEMI #2: myocardial infarction with rise in cardiac biomarkers with no ST changes on EKG, seven days ago. Partially reversible inferorposterior wall defect by perfusion study. Probably represents disease of vein graft to RCA. 

• Prior evaluation: Extensive vascular disease. Multiple revascularization procedures done in staged manner due to chronic renal failure. Catheterization: patent grafts. Peripheral angiogram: stenosis of renal arteries and lower extremity circulation. Duplex of renal arteries: bilateral renal artery stenosis. • Social History: cigarette smoker for 64 years, ½ pack per day. No alcohol or drug use.

 • Family History: cancer, diabetes, kidney disease. 

• Current medications: hydrochlorothiazide – telmisartan, simvastatin, clopidogrel, amlodipine, metoprolol succinate, aspirin. 

• Review of Systems: Denies fever, chills, cough, nausea, vomiting, TIA, syncope, rash, or melena. 

Exam

 • Pleasant elderly male in no acute distress. 

• Vital signs: BP 150/80. HR: 74. Respirations: 18/min. Afebrile. 

• HEENT: EOMI, PERRLA. 

• NECK: Supple. No JVD. Positive right carotid bruit. 

• CHEST: Clear to auscultation. Bilateral equal breath sounds. Has cough. 

• CV: RRR, S1 and S2 present. No S3. Positive S4. Crescendo-decrescendo systolic murmur 3/6 heard in aortic valve/apex area. 

• PERIPHERAL VASCULAR: Skin pink, warm and dry and well perfused. No clubbing or cyanosis. Plus 2 pitting ankle edema. 

• ABDOMEN: Soft, non-tender without masses, or organomegaly. Active bowel sounds. 

• NEURO: Patient A&Ox3, appropriate. No focal deficits noted.

Assessment and Plan 

• Hemodynamically and clinically stable today. 

• Continue medical therapy. 

• Schedule doppler echocardiogram to evaluate of new murmur.

 • Discussed with patient the need for optimal compliance including pharmacologic regimen and lifestyle modifications. 

• Patient continues to smoke, albeit less, and is not interested in quitting at this time. 

Summary of ICD-10-CM Impacts 

Clinical Documentation 

1.In ICD-10, there are numerous changes for cardiac related medical conditions. The changes include but are not limited to: 

• Inclusion terms of ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction are made to reflect the national standard guidelines of The American College of Cardiology and the American Heart Association for classifying patients with acute coronary syndrome For example, the non-ST elevation MI term replaces the older terminology of non-Q wave MI. 

• The time frame for acute myocardial infarction codes has changed from 8 weeks or less in ICD-9-CM to 4 weeks or less in ICD-10-CM. 

• When the patient has a new AMI within the 4 week time frame of the initial AMI, this information should be documented. 

• Delineate in your documentation whether an MI no longer requires further care. That information allows a clinical coder to determine whether the patient has an old or a healed MI. If after 4 weeks they still need care use “aftercare” in ICD-10-CM. 

2.If applicable, note items such as presence or absence of an increase in cardiac enzymes or troponin, or ECG findings (e.g., ST elevation, ST depression, T inversion, new pathological Q waves) in your documentation. 

3.In coding this scenario we assumed that the carotid stenosis is resolved as well as the renal artery stenosis, since this encounter is post revascularization procedure. While it may be controversial, we do not think that a code for the CABG is sufficiently supported in the documentation, although we recognize that the stress test findings may be interpreted as supporting atherosclerosis of the grafts as well as of the native arteries. 

4.In ICD-9, the clinician needs to document that the patient smokes tobacco or uses tobacco. In ICD-10-CM the amount of detail increases as there are 20 choices for nicotine dependence. In ICD-10, the required documentation includes the type of tobacco product used and whether or not there are nicotine-induced disorders such as remission or withdrawal present. Classifications for nicotine dependence include: uncomplicated, in remission, with withdrawal, or present with other nicotine induced disorders. In this note, even though the patient’s health condition is complicated and he has multiple comorbid conditions, his nicotine dependence is classified as uncomplicated as it does not meet the other classifications since as he is not attempting to quit.

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.

Scenario 2: Syncope

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 episode1 . 

• 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 purging2 .

 • No medication or allergies. Denies alcohol, drugs, supplements, or diuretics use.

Exam

• Looks exhausted. No apparent distress. Afebrile. 

• Orthostatic VS: 

1.  Lying BP 116/78 with HR 56, 
2.  Sitting BP 107/60 with HR 74, 
3.  Standing BP 92/49 with HR 1123

• 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 tachycardia4 .

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 bulimia2 .• 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.

Summary of ICD-10-CM Impacts

 Clinical Documentation

1.Since the etiologies for syncope and collapse scenarios are multifactorial, clear documentation is required to support your clinical thinking and judgment. Quantify the number of syncope or pre-syncope episodes. 

2.Note if the purging behavior is recurring or if it is a one-time occurrence (e.g., in this case due to the need for the significant weight loss of 11 pounds). 

3.Orthostatic hypotension should be supported in the record with specific vital signs or measurements, and clinical manifestations whenever possible. This note provided clear documentation to support the orthostatic hypotension and the link with the patient’s initial dehydration and hypovolemia. Given the patient’s presentation, and the resolution of the orthostatic intolerance with IV fluids, addressing the coding for autonomic dysfunction syndrome is not relevant. 4.Ideally, if the note is to stand alone, then more detail needs to be provided to document sinus tachycardia. 

Coding

ICD-9-CM Diagnosis Codes

780.2         Syncope and collapse 

785.0         Tachycardia, unspecified  

458.0         Orthostatic hypotension  

276.51       Dehydration

276.52       Hypovolemia

ICD-10-CM Diagnosis Codes

R55        Syncope and collapse 

R00.0     Tachycardia, unspecified 

I95.1      Orthostatic hypotension 

E86.0     Dehydration 

E86.1     Hypovolemia

Other Impacts 

Documenting the vital signs and lab results supports the medical necessity for administering intravenous normal saline and an EKG.

Clinical Scenarios

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.

Scenario 1: Hypertension/Cardiac Clearance

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 surgery1 .

 • 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 it2 . 

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 insufficiency3 .

Assessment and Plan 

• Will have PCP monitor BUN & Creatinine for renal function and nephrology referral if necessary. 

• HTN4 is likely due to patient’s noncompliance with metoprolol succinate. Will coordinate with Dr. Smith as unclear if he was aware of financial situation. Change to propranolol 20 mg, 2 tab PO daily, first dose administered in office. Provided 30 day supply of free propranolol samples. 

• Reevaluate HTN4 in 3 days; if improving then clear for surgery.

Summary of ICD-10-CM Impacts

1.Clinical Documentation 1.Documenting why the encounter is taking place is important, as the coder will assign a different code for a routine visit vs. a surgery clearance vs. an initial visit. 

2.If known, it is important to document whether or not patients are compliant with their medications. “Underdosing” is a new concept in ICD-10-CM and can be captured along with the diagnoses, such as this case for metoprolol succinate. When an issue with underdosing is noted, document if the matter is new or has been recurrent. The ICD-10-CM terms provide new detail as compared to the ICD-9-CM code V15.81, history of past noncompliance. In this case there was no noted history of noncompliance. 

3.Documentation indicates that lab results reveal “a slight increase his baseline and possibly indicating early renal insufficiency. Guidelines allow the reporting of additional diagnosis to support the abnormal test result. 

4.In ICD-10 CM coders are provided the “Use Additional Code” note under the Hypertensive diseases (I10-I15) block. If known, document whether or not the patients have the following: exposure to environmental tobacco smoke, history of tobacco use, occupational exposure to environmental tobacco smoke, tobacco dependence, and or tobacco use. In this case there was no noted history of the above.

Coding

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

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.