Updated on: March 16, 2016

Clinical Documentation Improvement by Service Part II– Cardiology/Cardiovascular Surgery

Original story posted on: August 21, 2014

EDITOR’S NOTE: This article is the continuation of a series of articles on clinical documentation improvement by clinical service —cardiology and cardiovascular surgery.   

Cardiology and cardiovascular surgery services are frequently more impacted by the inpatient prospective payment methodology using ICD-10-CM/PCS. What are the documentation changes.


Myocardial Infarction: 

The acute phase definition has changed between ICD-9-CM and ICD-10-CM. The acute phase in ICD-10-CM is four weeks while in ICD-9-CM it was eight weeks. The term “subsequent” has a new meaning. A subsequent myocardial infarction (MI) is an infarction that occurs within the acute phase. In ICD-9-CM, the term was used in relationship to episode of care. The documentation of MI site and the type of MI (STEMI and NSTEMI) continue to provide specificity in both classification systems.

Congestive Heart Failure (CHF):

While coders/clinical documentation specialists frequently ask for the type and severity of congestive heart failure in ICD-9-CM, they will continue to do so in ICD-10-CM. The classification system update has not impacted this condition significantly as the code set still has diastolic, systolic, combined diastolic/systolic, acute, chronic, and acute on chronic modifiers for CHF.

Coronary Artery Disease:  

This condition has associated conditions that were coded separately in ICD-9-CM. Coronary artery disease (CAD) can occur in native or bypassed vessels. At one time, the sequencing of CAD and unstable angina was a frequent query. In ICD-10-CM, CAD and unstable angina are one code that removes the sequencing dilemma. ICD-10-CM introduces the concept of coronary spasm which was coded to angina in ICD-9-CM. Coronary spasm has a separate code in ICD-10-CM.

Cardiac Catheterization:

This diagnostic procedure is coded in ICD-10-PCS under Cardiac Measurement that is a new approach for coding this test. What is familiar is that the type of catheterization is right, left, or bilateral (right and left). Another thought process for the coders is the approach that is normally percutaneous, but there is also an open approach. The coder can code both the surgical portion of the procedure as well as the imaging portion. The imaging portion will be found in another section of the PCS Manual – Imaging, Fluoroscopy. The ventriculogram and the coronary artery and bypass grafts angiograms are coded from this section.   

The most difficult documentation here is identifying the type of radiology contrast – high osmolar, low osmolar, or other contrast. It is recommended to visit the Radiology Department to collect details regarding the various contrasts that are used so that the information can be provided to the coders.   This approach will reduce their research time and create additional efficiency.

Percutaneous transluminal coronary angioplasty (PTCA):  

The documentation for this procedure will impact code assignment in ICD-10-PCS. The code will reflect the number of sites treated, use of a stent (drug-eluting and/or bare metal), and if the treatment involved the bifurcation. Angioplasties will require fewer codes to capture all aspects of the procedure.

Coronary Artery Bypass Grafts:

There are lots of changes on the procedure side from a documentation perspective. There is an ICD-10-PCS guideline that states that the procedures performed to obtain an autograft must be coded and it was assumed in ICD-9-CM Volume 3. The documentation should be specific regarding the vessels that are harvested and the approach. For example, endoscopic harvesting of the radial artery or harvesting the greater saphenous vein via an incision would specify approaches and specific vessels. 

The grafts can be autologous (from the patient) and non-autologous (from a tissue bank). Veins, arteries, or synthetics can be used as grafts. The other documentation need is to understand the origin of the coronary bypass – aorta, left internal mammary, right internal mammary, or a pedicled graft as the origin impacts the code assignment. There is a code to designate the use of the heart-lung machine (5A1221Z) that equates to 39.61 in ICD-9-CM.

Cardiac Arrhythmias:

The documentation for cardiac arrhythmias has not significantly changed. The ICD-10-CM code can be impacted regarding the type of arrhythmia (e.g., fibrillation vs. flutter vs. tachycardia vs. bradycardia) and the location (e.g., atrial vs. ventricular). The severity can also change the code assignment with the use of chronic vs. acute. For example, there is an ICD-10-CM code for chronic atrial fibrillation (I48.2).

The exploration of cardiology/cardiovascular surgery indicates that there are some changes regarding the diseases but more significant changes on the procedure side. Will we continue to see this trend as we explore other services? The next article will discuss musculoskeletal diseases/orthopedic surgery.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an American Health Information Management Association (AHIMA) approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and makes frequent appearances on Talk Ten Tuesdays.