Updated on: March 16, 2016

ICD-10-CM/PCS CASE STUDY: Cardiac Catheterization

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Original story posted on: September 4, 2011

According to the Centers for Disease Control and Prevention, coronary heart disease is the most common type of heart disease, having killed 445,687 people in 2005.

Coronary artery disease, or CAD, occurs when a substance called plaque builds up in the arteries that supply blood to the heart (the coronary arteries). Plaque is made up of cholesterol deposits, which can accumulate in the arteries. When this happens, the arteries can narrow over time; this process is called atherosclerosis.

 

Cardiac catheterization checks the inside of the coronary arteries for blockage by threading a thin, flexible tube through an artery in the groin, arm or neck to reach the coronary artery. Cardiac catheterization also is used to measure blood pressure and flow in the heart's chambers, to collect blood samples from the heart, and/or to inject dye into the coronary arteries.

Coronary angiography monitors blockage and flow of blood through the heart by using X-rays to detect dye injected via cardiac catheterization.

The incidence of CAD in the United States is so prevalent that it is imperative that coding specialists know how to code CAD and cardiac catheterization accurately in ICD-10-CM and ICD-10-PCS. A real-life case study is provided below.

 

CARDIAC CATHETERIZATION REPORT

 

 

PREOPERATIVE DIAGNOSIS:

Coronary artery disease.

 

POSTOPERATIVE DIAGNOSIS:

Coronary artery disease, proximal left anterior descending coronary artery.

 

PROCEDURE(S) PERFORMED:

Left heart catheterization;

Bilateral selective coronary arteriography; and

Percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery with intracoronary stent placement.

 

INDICATIONS:

Mr. J. is a 67-year-old gentleman with a history of hypertension, hyperlipidemia and type 2 diabetes. Recent cardiac evaluation for symptoms of presyncope included an exercise dual isotope myocardial perfusion study performed on April 1, 2011, a test that demonstrated a large region of exercise-induced anteroapical ischemia. His previous cardiac history is negative for documented coronary artery disease or previous myocardial infarction. Cardiac catheterization is being performed at present to evaluate the extent and severity of his underlying coronary artery disease and to determine optimal management.

 

DESCRIPTION OF PROCEDURE:

Following premedication with Valium, 10 mg p.o., and Benadryl, 25 mg p.o., the patient was brought to the cardiac catheterization laboratory and prepped and draped in the usual sterile fashion. Under local anesthesia, the right femoral artery was entered via a modified Seldinger technique and a 6 french right Judkins catheter was advanced through the proximal aorta and left ventricle, where pressures were recorded. This catheter was employed to perform selective right coronary arteriography in a variety of axial and hemiaxial projections using small amounts of hand-injected contrast. The right Judkins catheter then was exchanged for a 6 French 4 left Judkins catheter, which was employed to perform selective left coronary arteriography in a similar fashion.  Following completion of diagnostic angiography, the decision was made to proceed with coronary intervention for the critical stenosis demonstrated in the proximal left anterior descending coronary artery.

The left Judkins catheter was exchanged for a 6 French JL-4 guiding catheter. Following the systemic administration of 5,000 units of heparin intravenously, the guiding catheter was advanced to the proximal aorta and satisfactory engagement of the left main coronary artery was established. A 3.0 x 20-mm Voyager balloon dilation catheter with a 0.014 inch BMW guide wire was advanced through the guiding catheter. The guide wire was advanced cautiously down the left anterior descending coronary through the site of subtotal occlusion in the proximal LAD. The tip of the wire was positioned far distally in the left anterior descending coronary. The balloon dilation catheter was advanced over the guide wire to the site of occlusion in the proximal LAD. Optimal position was confirmed with inlet pressure inflation. Two balloon dilatations were performed at that site to a maximum of eight atmospheres for a maximal duration of 45 seconds. The Voyager balloon dilation catheter then was exchanged for a 3.5 x  20-mm drug-eluting stent; the stent was advanced over the guide wire to the site of stenosis in the proximal LAD. Optimal position was confirmed angiographically. The stent was deployed, with nine-atmosphere inflation of 45 seconds in duration. A single post dilatation to 11 atmospheres for 30 seconds of duration was performed. Final angiography demonstrated an excellent angiographic result.

The following codes were assigned using the 2011 version of the ICD-10-CM and        ICD-10-PCS indices and tables, which are available on the CMS website at https://www.cms.gov/ICD10/

 

ICD-10-CM DIAGNOSIS CODES:

To code the coronary artery disease, proximal left anterior descending coronary artery, see the ICD-10-CM index entry that appears below:

“Disease artery coronary I25.10”

 

Verification of the code in the ICD-10-CM tabular list of diseases and injuries confirms that it is appropriate for this case:

I25.10        Atherosclerotic heart disease of native coronary artery without angina pectoris

 

To code the hypertension, see the ICD-10-CM index entry that appears below:

“Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) I10”

 

Verification of the code in the ICD-10-CM tabular list of diseases and injuries confirms that it is appropriate for this case:

I10    Essential (primary) hypertension

 

To code the hyperlipidemia, see the ICD-10-CM index entry that appears below:

“Hyperlipidemia, hyperlipidemia E78.5”

 

Verification of the code in the ICD-10-CM tabular list of diseases and injuries confirms that it is appropriate for this case:

E78.5         Hyperlipidemia, unspecified

 

To code the type 2 diabetes, see the ICD-10-CM index entry that appears below:

“Diabetes, diabetic (mellitus) (sugar) Type 2 E11.9”

 

Verification of the code in the ICD-10-CM tabular list of diseases and injuries confirms that it is appropriate for this case:

E11.9         Type 2 diabetes mellitus without complications

ICD-10-PCS CODES:

 

To code the left heart catheterization, see the ICD-10-PCS index entry below:

“Catheterization Heart see Measurement, Cardiac 4A02”

 

Since the index only provides four of the seven digits for a complete code, go to ICD-10-PCS table 4A0 and complete the code number using the information from the cardiac catheterization report. The correct code is 4A023N7 (Measurement and Monitoring, Physiological Systems, Measurement, Cardiac, Percutaneous, Sampling and Pressure, Left Heart).

 

 

 

 

 

 

 

 

 

 

To code the bilateral selective coronary arteriography, see the ICD-10-PCS index entry below:

“Arteriography:

see Fluoroscopy, Heart B21”

Since the index only provides three of the seven digits for a complete code, go to ICD-10-PCS table B21 and complete the code number using the information from the cardiac catheterization report. The correct code is B211YZZ (Imaging, Heart, Fluoroscopy, Coronary Arteries, Multiple, Other Contrast).

 

 

 

 

 

 

To code the percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery with intracoronary stent placement, see the ICD-10-PCS index entry below:

“Angioplasty:

see Dilation, Heart and Great Vessels 027”

Since the index only provides three of the seven digits for a complete code, go to ICD-10-PCS table 027 and complete the code number using the information from the cardiac catheterization report. The correct code is 027034Z (Heart and Great Vessels, Dilation, Coronary Artery, One Site, Percutaneous, Drug-eluting Intraluminal Device, No Qualifier).

 

 

Lolita M. Jones, MSHS, RHIA, CCS

Lolita M. Jones, MSHS, RHIA, CCS has provided Product Consultant services to a warehousing and analytics start-up that developed and marketed decision support software, health outcomes services, and regulatory compliance toolsets. Her goal is to combine her medical coding expertise with data mining-pattern recognition, to help improve data accuracy and compliance in medical coding and reimbursement (i.e., ICD-10-CM, ICD-10-PCS, CPT, HCPCS Level II, modifiers, DRGs, APCs, and eAPGs). Ms. Jones also provides remote and on-site training/consulting in her newly developed Healthcare Data Mining Clinic educational series. She is currently pursuing a Graduate Certificate in Healthcare Data Analytics from a top university. Ms. Jones is based in New York and can be reached at .