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Cardiovascular System

ICD-10-CM/PCS Coding Guildlines

ICD-10-CM General Guidelines

Locating a code in ICD-10-CM

◦ Locate the main term in the alphabetic index

◦ Verify the code in the tabular list

◦ Read and be guided by instructional notations

in the index AND tabular

◦ Selection of a full code including laterality and

7th digits can only be done in the tabular list

◦ A dash “-” at the end of an index entry means

additional digits are required


Placeholder

◦ X is used as a placeholder when required,

without it, code is considered invalid

7th Characters

◦ When instructed to use a 7th character it is

required for all codes in that category or as

notes instruct

◦ If the code is not 6 characters use the

placeholder X to “fill-in” the empty spaces


Excludes Notes

◦ Excludes1

“Not coded here”

Indicates code excluded should never be used at the same time as the code above

The two conditions cannot occur together

◦ Excludes2

“Not included here”

Indicates condition excluded is not part of the condition above HOWEVER the patient may have both conditions and therefore both can be coded


“Code also note”

◦ This instruction means that two codes may be required to fully describe a condition but this note DOES NOT provide sequencing direction

Default Codes

◦ The alphabetic index has a code listed next to the main term considered a default code

This represents a condition that is most associated with the main term or is the unspecified code for the condition


Sequela (Late Effects)

◦ The residual effect after the acute phase of an illness or injury has terminated

◦ There is no time limit on when a sequela code can be used

◦ Sequence first the condition or nature of the sequela followed by the sequela code second

◦ Exceptions:

Sequela is followed by a manifestation code

Sequela code has been expanded to include the manifestation


Laterality ◦ If no bilateral code is provided and the condition

is bilateral assign separate codes for both the left and right sides

Documentation of BMI and Ulcer Stage ◦ BMI, non-pressure ulcers and pressure ulcers may

be coded from clinician documentation

◦ The associated diagnosis must come from the physician

◦ If the documentation is conflicting between clinicians the physician should be queried

◦ BMI is only acceptable as a secondary diagnosis


Documentation of Complications of Care

◦ This guideline extends to any complications of

care, regardless of the chapter the code is

located in.

◦ Must be a cause-and-effect relationship

between the care provided and the condition

Borderline Diagnosis

◦ A “borderline” diagnosis listed at the time of

discharge is coded as confirmed unless there

is a specific index entry for “borderline”

ICD-10-CM Cardiovascular

Guidelines Hypertension

◦ Hypertension with Heart Disease

Heart conditions (I50, I51.4-I51.9) are assigned a

code from I11 hypertensive heart disease when a

causal relationship is stated if not they are coded

separately

◦ Hypertension with Chronic Kidney Disease

Assign codes from I12 hypertensive chronic kidney

disease when both hypertension and a condition in

category N18 are present. N18 category is

sequenced second


Guidelines ◦ Hypertension with Heart and Chronic Kidney

Disease

Assign combination code from I13 if both heart and

kidney are stated as hypertensive if they are not

code kidney disease and hypertension together

with a code from N18 as secondary

If heart failure is present use an additional code

from I50

If a patient has acute renal failure and chronic

kidney disease both conditions are coded


Guidelines ◦ Hypertensive Cerebrovascular Disease

First assign code from I60-I69(cerebrovascular

diseases) followed by hypertension code

◦ Hypertensive Retinopathy

H35.0 retinopathy should be used with I10-I15

hypertension code. Sequencing depends on reason

for encounter

◦ Hypertension, Secondary

Secondary hypertension is due to an underlying

condition therefore two codes are required


Guidelines ◦ Hypertension, Transient

Assign code R03.0 elevated blood pressure

For OB code O13.-gestational [pregnancy induced] hypertension without significant proteinuria or O14 pre-eclampsia for transient hypertension of pregnancy

◦ Hypertension, Controlled

Refers to hypertension under control by therapy assign code from I10-I15 hypertension category

◦ Hypertension, Uncontrolled

Refers to untreated or hypertension not responding to therapy assign code from I10-I15


Guidelines Atherosclerotic Coronary Artery Disease

and Angina

◦ Category I25.11 atherosclerotic heart disease

of native coronary artery with angina pectoris

◦ Category I25.7 atherosclerosis of coronary

artery bypass graft(s) and coronary artery of

transplanted heart with angina pectoris

◦ Assume causal relationship between

atherosclerosis and angina pectoris unless

stated otherwise


Guidelines Acute Myocardial Infarction

◦ ST elevation MI (STEMI) and non ST elevation

MI (NSTEMI)

STEMI I21.0-I21.2, I21.3 ; NSTEMI I21.4

Code by site identified

If NSTEMI evolves to STEMI code to STEMI code

If STEMI converts to NSTEMI due to thrombolytic

therapy code to STEMI

◦ Acute MI, Unspecified

Assign code I21.3


Guidelines ◦ AMI documented as nontransmural or

subendocardial but site provided

Nontransmural and subendocardial AMI’s are coded

to subendocardial even if site is provided

◦ Subsequent acute MI

Assign a code from category I22 when a patient

who has suffered an AMI has a new AMI within the

4 week time frame of the initial AMI

Sequencing depends on circumstances of encounter

ICD-10-PCS General Guidelines

Valid Code is 7 Digits

Valid Code includes all combinations

within the row of the table

“And” means and/or

Coder’s responsibility to determine what

the documentation equates to in PCS

Definitions


Body System

◦ Anatomical region system

Use when procedure is performed on region rather

than a specific body part

Use when no information available to support a

specific body part

Upper and Lower specifies body parts located

above or below the diaphragm


Root Operation

◦ Procedural steps necessary to reach the

operative site and close the operative site

including anastomosis of a tubular body part

are not code separately

◦ Multiple Procedures

Same root operation is performed on different

body parts with distinct values

Same root operation is repeated at different body

sites within the same body part


◦ Multiple Procedures continued…

Multiple root operations with distinct objectives

done on same body part

Intended root operation is attempted using one

approach but then converted to another approach

◦ Discontinued Procedures

Code to the root operation performed if

procedure is discontinued before any root

operation is performed code to inspection of body

part or anatomical region


◦ Biopsy followed by more definitive treatment

If a diagnostic excision, extraction, or drainage is followed by a more definitive procedure both procedures are coded

◦ Overlapping body layers

Roots – Excision, Repair or Inspection of Musculoskeletal system is code to deepest layer

◦ Bypass Procedures

Coded by body part bypassed “from” and then the body part bypassed “to” 4th character is “from”

7th character is “to”


◦ Bypass Procedures Continued…. Coronary Arteries

Classified by number of distinct artery

Body part character identifies number of coronary arteries bypassed to

Qualifier identifies the vessel bypassed from

Multiple coronary artery sites are coded separately for each site that uses a different device and/or qualifier

◦ Control vs. more definitive root operations If control of postprocedural bleeding is unsuccessful and a

definitive root operation is done to control the bleeding then the definitive root operation is used rather than “control”

◦ Excision vs. Resection PCS subdivides some body parts such as lobes of lung and

liver and regions of the intestine – code resection of the subdivsion


◦ Excision for Graft

Code separately the autograft taken from a different body part in order to complete the objective of a procedure

◦ Fusion procedures of the spine

There are distinct body part values for a single vertebral joint and for multiple vertebral joints at each spinal level

For each vertebral joint that uses a different device and/or qualifier is coded separately

Combinations of devices – 1st interbody fusion device, 2nd autologous, 3rd nonautologous bone graft


◦ Inspection procedures Not coded when inspection is done in order to achieve

the objective of a procedure

Multiple tubular parts code to most distal

Multiple non-tubular parts code to entire area

When an inspection procedure is done with another procedure on the same body part code separately ONLY if different approaches

◦ Occlusion vs. Restriction for vessel embolization procedures Embolization done to completely close a vessel use root

“occlusion”

Embolization done to narrow a vessel use root “restriction”


◦ Release Procedures The body part value is assigned to the body part being freed

not the part being cut

◦ Release vs. Division Objective is to free a body part without cutting use root

“release”

Objective is separating or transecting use root “division”

◦ Reposition for fracture treatment Reduction of displaced fx use root “reposition”

Cast is not coded separately

Non-displaced fx code to procedure performed

◦ Transplantation vs. Administration Putting in autologous or nonautologous cells go to

administrative section

Putting in living body part use root “transplantation”


Body Part

◦ General Procedures performed on a portion of a body part that

does not have a specific value code to the whole body part

When “peri” is combined with a body part code to the whole body part

◦ Branches of body parts

If a specific branch of a body part does not a specific value code to closest proximal branch with a value

◦ Bilateral body parts values

If no bilateral body part value exists, each procedure is coded separately

Lateral plantar artery Use: Foot Artery, Right Foot

Artery, Left

Lateral plantar nerve Use: Tibial Nerve

Lateral rectus muscle Use: Extraocular Muscle, Right

Extraocular Muscle, Left

Lateral sacral artery Use: Internal Iliac Artery, Right

Internal Iliac Artery, Left

Lateral sacral vein Use: Hypogastric Vein, Right

Hypogastric Vein, Left

Lateral sural cutaneous nerve Use: Peroneal Nerve

Lateral tarsal artery Use: Foot Artery, Right Foot

Artery, Left


◦ Coronary Arteries

Classified as single body part then number of sites

treated NOT by name or number of arteries

◦ Tendons, Ligaments, Bursae and Fascia near a

joint

Procedures done on supporting joint structures are

coded to the respective body system that is the

focus of the procedure

Procedures done on the joint itself are coded to

the joint body system


◦ Skin, subcutaneous tissue and fascia overlying

a joint

Procedure done on skin, subcutaneous tissue or

fascia overlying a joint code to the following body

part:

Shoulder > upper arm

Elbow > lower arm

Wrist > lower arm

Hip > upper leg

Knee > lower leg

Ankle > lower leg


◦ Fingers and toes

Procedures without fingers listed as a body part

value code to hand

Procedure without toes listed as a body part value

code to foot

◦ Upper and Lower Intestinal Tract

Roots – Change, Inspection, Removal and Revision

Upper intestinal tract is from esophagus down to and

including the duodenum

Lower intestinal tract is from the jejunum down to and

including the rectum and anus


Approach ◦ Open approach with percutaneous endoscopic

assistance Open procedures done with the assistance of

percutaneous endoscopy are coded to “open”

◦ External approach Procedures done on structures that are visible without

the aid of instrumentation are coded to “external”

Application of external force through the intervening body layers are coded to “external”

◦ Percutaneous procedure via device Procedures performed percutaneously through a device

placed for the procedure are coded to “percutaneous”


Device

◦ General Code device only when device is left in after the

procedure

Sutures, ligatures, radiological markers, and temporary postoperative wound drains are not considered devices

Use Root Operations change, irrigation, removal, and revision for procedures done on devices and not a body part

◦ Drainage Device When a separate procedure is done to place a drainage

device code to root “drainage” with device value drainage device

References

www.cms.gov

www.nchs.gov

www.ahima.org

www.ohima.org

Dee Mandley, RHIT, CCS, CCS-P

◦ 330-677-5630

◦ [email protected]

http://www.cms.gov/

http://www.nchs.gov/

http://www.ahima.org/

http://www.ohima.org/

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