Coders Have Solutions for Common Inpatient Circulatory System Coding Dilemmas

Vol. 12 •Issue 7 • Page 8
CCS Prep!

Coders Have Solutions for Common Inpatient Circulatory System Coding Dilemmas

In today’s coding world, coders are faced with difficult coding scenarios with increasing specific guidelines affecting correct code assignment. The Coding Clinic, published by the American Hospital Association since 1984, addresses many of the dilemmas faced by coders. Sometimes the advice is confusing and does not make sense to coders. Although coding is not always black and white, sometimes similar concepts can be carried over to a new coding dilemma based on advice given from old, once difficult coding scenarios.

In this issue of CCS Prep! we will discuss some circulatory issues that cause problems for inpatient coders. Some of the issues also affect outpatient coding, but in this column, we will address the inpatient dilemmas.

Coronary Artery Disease and Angina
Many coders cringe when this topic comes up. Much has been written on the coding challenges of patients with coronary artery disease, angina and other heart conditions. The following list of Coding Clinics (listed by year, quarter and page number) address these issues and should be reviewed thoroughly prior to taking the examinations:

2001 3Q, p. 15-16 2001 2Q, pp. 8-9

2000 1Q, p. 10 1999 4Q, pp. 4-5

1997 3Q, pp. 15-16 1996 4Q, p. 31

1995 2Q, pp. 17-19 (new CAD codes) 1994 4Q, p. 49

1994 2Q, p. 15 1993 4Q, pp. 43-44

1984 July-August, p. 6

As you can see by the long listing of Coding Clinics, coronary artery disease (CAD) coding is a much-discussed topic. CC 3Q 1997 states that if a patient has CAD and there is no mention of a history of CABG that this is assumed to be CAD of the native vessels, and 414.01 is assigned. However, if this is unclear, the coder should query the physician. In a different scenario, if only CABG is mentioned, but CAD is not, the coder cannot assume that the patient still has CAD. Only V45.81 can be assigned in this case. Per CC 2Q 1995, atherosclerosis in a bypass graft is considered a progression of the disease rather than a mechanical complication and is coded to 414.0X.

Ischemic heart disease is a general term that is frequently used to describe other conditions such as arteriosclerotic heart disease, coronary ischemia, coronary artery disease and coronary arteriosclerosis. The coder should be careful to code accurately to the condition documented by the physician.

Heart Valve Diseases and Disorders
Another area of confusion involves coding of heart valve condition and diseases. The coding rules change depending on how the condition is documented and whether or not it is considered rheumatic or of rheumatic origin. Rheumatic heart disease occurs as the result of an infection with group A hemolytic Streptococcus. The coder must determine if there is an acute fever, or if it is quiescent, and then also determine if there is heart involvement. In addition, if the diagnosis includes more than one heart valve, and more than one condition affecting the heart valves, the coder must take that into consideration. For example, a patient with mitral valve stenosis and mitral valve insufficiency is assumed to be of rheumatic origin and 394.2 is assigned. If the physician only documents mitral valve insufficiency, then code 424.0 is assigned. Pay attention also to the terminology that the physician uses. Aortic stenosis (747.22) is not the same as aortic valve stenosis (424.1) The following Coding Clinics also address heart valve coding:

2000 2Q, pp. 16-17 1995 1Q, p. 6

1988 4Q, p. 8 1987 Nov.-Dec., p. 8

1984 Nov.-Dec., p. 8

The above two topics are just one of several circulatory problem areas. I recommend that coders thoroughly review all Coding Clinics by circulatory system topic. Also review the “Diseases of the Circulatory System” chapter of Faye Brown’s ICD-9-CM Coding Handbook to understand all of the coding concepts in the circulatory system.

Now, take the quiz below to test your knowledge.

1. Dressler’s Syndrome is another name for:

a) coronary artery disease

b) postmyocardial infarction syndrome

c) atrioventricular block

2. Chronic ischemic heart disease is coded:

a) 414.00, Coronary artery disease, unspecified

b) 429.9, Heart disease, unspecified

c) 414.9, Unspecified chronic ischemic heart disease

3. A patient has coronary artery disease, with no previous history of bypass surgery. Assign code:

a) 414.00, CAD, unspecified type of vessel

b) 414.01, CAD, native vessel

c) 414.9, Unspecified chronic ischemic heart disease

4. A patient has coronary artery disease, with history of bypass surgery four years ago. Assign code:

a) 414.00, CAD, unspecified type of vessel

b) 414.01, CAD, native vessel

c) 414.9, Unspecified chronic ischemic heart disease

5. A patient has known CAD and is admitted to the hospital with angina. No previous history of any procedures being done. What sequence and codes are correct?

a) 413.9, Angina; 414.00, CAD, unspecified type of vessel

b) 414.00, CAD, unspecified type of vessel; 413.9, Angina

c) 414.01, CAD, native vessel; 413.9, Angina

6. A patient has rheumatic aortic valve insufficiency with mitral valve stenosis and congestive heart failure. Assign the correct codes based on the information above.

a) 396.1, Mitral valve stenosis and aortic valve insufficiency; 398.91, rheumatic heart failure

b) 424.0, Mitral valve disorders; 424.1, aortic valve disorders, 428.0, CHF

c) 396.1, Mitral valve stenosis and aortic valve insufficiency; 428.0, CHF

d) 396.9, Multiple involvement, mitral and aortic valves; 398.91, rheumatic heart failure.

7. A patient has mitral valve insufficiency, tricuspid insufficiency and congestive heart failure. What codes are assigned?

a)394.1, Rheumatic mitral valve insufficiency; 397.0, Diseases of the tricuspid valve; 398.91, rheumatic heart failure

b)424.0, Mitral valve disorders; 424.2, Tricuspid valve disorder specified as nonrheumatic; 428.0, CHF

c)424.0, Mitral valve disorders; 397.0, Diseases of tricuspid valve; and 428.0, CHF n

Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, coding education and contract coding for hospitals. The corporate office is headquartered in Pawley’s Island, SC.


1. b,

2. c,

3. b (See CC 1997 3Q, p. 15),

4. a,

5. c (See CC 1995 2Q, p. 18),

6. a (See CC 1995 1Q, p. 6),

7. c (See CC 2000 2Q, pp. 16-17)