Class 9 Circulatory

8/9/2019 Class 9 Circulatory

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CirculatoryCirculatoryCVA’s/Late/Effects CVA

TIA’s/HypertensionCHF/Dysrhythmias

CardiomyopathyHeart Valve/Acute MI

CVACVA*Are included in codes 430 – 438.9*Codes in this category are classified as the third leading cause of death*The term stroke and CVA are used interchangeably*Stroke, CVA and cerebral infarction are indexed to the default of 434.91*Official Coding Guidelines Section I.C.7.b.

CVACVACause: any process innate to vessels – ASCVD, arteritis, etc.

a process originating remotely – pulmonary embolism, heart valvethrombus, etc.

a process causing inadequate blood flow – anoxic brain injury

a process involving ruptured vessel traumatic or nontraumatic

CVACVAThe process can be an infarct or hemorrhageLook for documentation defining type of stroke, and sight of diseased vessel

Category 438Category 438A late effect is a residual effect after the acute phase of the illness or injury has passedThe patient must be discharged or transferred out of the acute setting before

considering collecting a late effectCategory 438Category 438

The general rule for collecting and sequencing late effect is to code the manifestationfollowed by the code(s) for the late effect

Example: Scar secondary to previous healed burn to hand – 709.2 – 906.6

Official Coding Guidelines Section I.B.12.Category 438Category 438

Exceptions to this rule are: 1) in those instances where the code for the late effect isfollowed by a manifestation code e.g. Scoliosis due to poliomyelitis duringchildhood 138 and 737.43 (two codes, but late effect first)

OROfficial Coding Guidelines Section I.7.d)

Category 438Category 4382) That where the late effect code has been expanded (at the fourth and fifth digit

levels) to include the manifestation(s). The code for the acute phase of the illness

or injury that led to the late effect is never used with a code for the late effect(single code) Example: aphasia sequelae of previous CVA 438.11

OR

Official Coding Guidelines I.B.12.

Category 438Category 4383) When there is a “use additional code” statement such as with codes 438.5- and

438.89



These codes are to be collected before the codes for the paralytic syndrome or the lateeffect manifestation (e.g. seizure 780.39)

Code V12.54 is use when the patient has a history of a CVA without any neurologicaldefects

CC 4/98 p39-40

CVACVA*Explanation of fifth digits for categories 433 and 434*The rules governing the ICD-9-CM require that fifth-digits modify the fourth digit to

which they are applied*The fifth-digits "O" without mention of cerebral infarction, and " I " with cerebral

infarction, apply only to the code to which they are assigned.Coding Clinic 2/95 p14-15

CVACVA*Adding the fifth-digit " I " to 433. 1, Occlusion of carotid artery, indicates that there is an

infarction of this artery during the current episode of care

* It does not mean that the patient also is having a cerebral infarction of any other artery,or that the patient has had a cerebral infarction in the past

*The fifth-digit applies only to the site to which it is added, the carotid artery, and itapplies only to the current episode of care - use of the fifth-digit “0" added to code433.1 indicates that during the current episode of care the carotid artery does nothave an infarction

Coding Clinic 2/95 p14-15

CVACVAQuestion: A patient is admitted with sudden

onset of severe headaches and increased lethargy. The diagnosis of large rightembolic hemorrhagic infarct temporal lobe was given. Would you assign 431 or 434.11?

CC 3/97p11CVACVA

Answer: Assign code 434.11, occlusion of cerebral arteries, cerebral embolism, withcerebral infarction. The hemorrhage is a component of the occlusion – do notassign 431

CC 3/97p11CVACVA

*Postoperative cerebrovascular accident is coded to 997.02

*The documentation should clearly specify the cause and effect relationship betweenthe medical intervention and the CVA

*A second code from 430-432 or 433-434 with a fifth digit of one should be collectedalso

*Official Guidelines Section I.C.7.c.

TIATIATIA is defined as a sudden neurological deficit that completely clears generally in less

than 24 hours



Precerebral arteries are included in 435.0-8 with cerebral arteries being also .8 and .9A TIA will have complete resolution – that does not mean it will not reoccur The coding clinic also defines the diagnosis of RIND ‘reversible ischemic neurological

deficit’ as being confined to code 435

HypertensionHypertension

Prior to 10/1/92 malignant hypertension with hypertensive crisis was 401.0 and 437.2hypertensive encephalopathy

Presently hypertensive crisis is present in the code for hypertension in non essentialterms

HypertensionHypertensionMalignant hypertension is associated with acute vascular lesions in the kidney is an

extended form of accelerated hypertensionMalignant hypertension usually results in renal failureThe ICD-9-CM classifies accelerated hypertension as malignant

HypertensionHypertensionHypertension with heart disease has a combination code 402.xx

A causal relationship must be stated (e.g. cardiomyopathy due to hypertension) or implied (i.e. hypertensive cardiomyopathy) for the coder to collect the combinationcode (402.XX) and the underlying condition (425.8)

Official Guidelines – Section I.C.7.a)HypertensionHypertension

In category 402, Hypertensive heart disease, the fourth digit subcategory describeswhether the hypertensive condition is malignant, benign, or unspecified – the fifthdigit states the absence or presence of heart failure

HypertensionHypertensionIf a patient has hypertensive heart disease with congestive heart failure, it is appropriate

to assign a code for the appropriate hypertensive heart disease along with anadditional code for the congestive heart failure even though heart failure is stated inthe fifth digit. Additional codes should be added if the heart failure is known to besystolic, diastolic or a combination of both

CC 4/02 p 49-52HypertensionHypertension

Question: “Coding Clinic, First Quarter 1993, pages 19-20, advised us to code adiagnosis of congestive heart failure due to diastolic dysfunction due tohypertension with code 402.91…. Now that the heart failure codes have beenrevised …how would this condition be coded with the new codes?”

CC 4/02 p 49 - 52

HypertensionHypertension“Answer: You will now need three codes to completely describe this diagnosis. 402.91

…, 428.30 …, and 428.0 …. The two additional codes provide the specificityrequired to report that the heart failure was diastolic type and congestive”

CC 4/02 p 49 - 52HypertensionHypertension

*Assign codes from category 403 when conditions classified to category 585 arepresent – a cause and effect relationship is presumed



*Category 403 excludes acute (584.x) renal failure

Official Guidelines – Section I.C.7.3)HypertensionHypertension

Hypertensive heart and renal disease has a combination code 404.xxA causal relationship must be stated for the heart disease and hypertension, but again

the relationship is presumed if renal disease is classified to category 585

Official Guidelines – Section I.C.7.4)HypertensionHypertension

*Assign additional code(s) from 428 for the type of heart failure*Also the appropriate code from category 585 should be assigned for the CKD

Official Guidelines – Section I.C.7.4)

HypertensionHypertensionHypertension controlled and uncontrolled

No specific code has been assigned to this type of diagnostic dataCollect the appropriate code from the 401-405 category

Official Guidelines – Section I.C.7.10)Congestive Heart FailureCongestive Heart Failure

Congestive 428.0Systolic 428.20-428.23Diastolic 428.30-428.33Combined systolic and diastolic 428.40-428.435th digits: Unspecified, Acute, Chronic and Acute on Chronic

Congestive Heart FailureCongestive Heart FailureHeart failure occurs when the heart is unable to pump sufficient blood throughout the

bodyThe term congestive is often mistakenly used interchangeable with heart failureCongestion, pulmonary or systemic fluid build-up, is one feature of heart failureCommon symptoms are edema fatigue and dyspnea at rest or during exerciseCC 4/02 p 49-52

Congestive Heart FailureCongestive Heart FailureThere are two main categories of heart failure – systolic and diastolicSymptoms may differ from patient to patientDifferentiating between systolic and diastolic is essential because long term treatments

differ

CC 4/02 p 49 - 52

Congestive Heart FailureCongestive Heart FailureSystolic heart failure occurs when the ability of the heart to contract decreasesThe heart is unable to pump out adequate amounts of blood during contraction

(systole)Blood coming from the lungs into the heart may back up and cause fluid leakage into

the lungs causing pulmonary congestionRX: ace inhibitors, digoxin, diuretics and beta blockersCC 4/02 p 49 - 52

Congestive Heart FailureCongestive Heart Failure



Diastolic heart failure occurs when the heart has a problem relaxing betweencontractions (diastole) to allow enough blood to enter the ventricles

The heart cannot fill with sufficient blood because the heart muscle is stiff This may lead to fluid accumulation especially in legs, ankles and feetCC 4/02 p 49 - 52

Congestive Heart FailureCongestive Heart Failure

Some patients may also have lung congestionRX depends on underlying causeBeta blockers and calcium channel blockers are often used when diastolic dysfunction

is due to ischemia or hypertension

CC 4/02 p 49 - 52Congestive Heart FailureCongestive Heart Failure

QuestionPt. admitted for heart transplant because of end-stage CHF due to dilated

cardiomyopathy secondary to rheumatic heart dx. with mitral valve compromise.She previously had mitral valve replacement with an AICD. Pt. developedcardiomyopathy and CHF. Would CHF be coded as rheumatic heart failure

CC 2/05 p14-15Congestive Heart FailureCongestive Heart Failure

Answer – Assign 398.91, Rheumatic Heart Disease as the principal dx for the end-stage CHF. A diagnosis of heart failure in a patient with rheumatic heart disease isclassified to code 398.91, unless the physician specifies a different cause

CC 2/05 p 14-15DysrhythmiasDysrhythmias

427.5 Cardiac Arrest - may be used as a principal diagnosis if patient arrives at ED instate of cardiac arrest and dies before the underlying condition can be established

And if the patient is resuscitated, admitted and dies before a work-up can establish theunderlying cause of the arrest

CC 2/88p8DysrhythmiasDysrhythmias427.5 may be used as a secondary diagnosis when the patient is admitted and the

underlying condition (e.g. ventricular tachycardia) is established with the arrestcollected secondary

May be established as a secondary diagnosis (with exception of excludes) when arrestoccurs during the hospitalization and the patient is resuscitated. Should not be usedif death occurs

CC 2/88p8DysrhythmiasDysrhythmias

When documentation indicates that the arrest is during or due to a procedure alsocollect the 997.1

DysrhythmiasDysrhythmiasIs it appropriate to code atrial fibrillation, even though the patient isn’t experiencing

atrial fibrillation during this admission? The patient is maintained on Lanoxin.

CC 3/95p8DysrhythmiasDysrhythmias

Yes, it would be appropriate to add atrial fibrillation as an additional code, when thephysician has documented the condition in the record and has listed it in the final



diagnostic statement. The patient now requires ongoing medication administrationto control the conditionCC 3/95 p 8

DysrhythmiasDysrhythmias“A patient was prescribed medication to control his atrial fibrillation. The patient quit

taking his prescribed medication on his own one week ago, because he said the

medication made him nauseous. He is now admitted for control of atrial fibrillationand medication adjustment. Is the principal diagnosis atrial fibrillation or poisoning? I understood the definition of poisoning to be the improper use of amedication.”

CC 2/99 p17DysrhythmiasDysrhythmias“Assign code 427.31 Atrial fibrillation, and code V15.81, Noncompliance with medical

treatment. If a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction of the dose, then the medicalcondition itself can be coded. In this case the atrial fibrillation is not due to apoisoning, but the original condition for which the patient was prescribedmedication.”

CC 2/99 P17DysrhythmiasDysrhythmias

*31 Y/O admitted with ventricular tachycardia and substernal chest pain. He has adual-chamber pacemaker placed 2 years ago. The diagnosis is: Pacemaker-mediated tachycardia – Code?

*996.01 and 427.1

*CC 2/06 p 15-16CardiomyopathyCardiomyopathy

Refers to disease in the heart muscle independent of other diseases such as vascular or valvular

CardiomyopathyCardiomyopathyHypertrophic cardiomyopathy causes ventricular hypertrophy, fibrosis, myofibril

disorganization which leads to uncoordinated ventricular contractionsSigns include exertional dyspnea, orthopenea, paroxysmal nocturnal dyspnea, angina,

fatigue, syncope, palpitations, ankle edema, mild cardiomegaly, apical systolic thrilland heave, and systolic murmur that increases with Valsalva’s maneuver

CardiomyopathyCardiomyopathyThrill – a vibration accompanying a cardiac or vascular murmur that can be palpatedHeave – symptoms include a wheezy cough and dyspnea, especially when exercisedValsalva maneuver – any forced expiratory effort (“strain”) against a closed airway,

whether at the nose and mouth or at the glottis, because high intrathoracicpressure impedes venous return to the right atrium, this maneuver is used to studycardiovascular effects of raised peripheral venous pressure and decreased cardiacfilling and cardiac output

CardiomyopathyCardiomyopathyCongestive (dilated) cardiomyopathy presents with large flabby ventricular muscle with

contractility abnormalities resulting in ventricular overload with symptoms of CHFThis disorder has been linked to multiple MI’s, alcoholism, chronic myocarditis

hypertension, viral infection and heart disease in pregnancy



CardiomyopathyCardiomyopathyCongestive cardiomyopathy is treated with steroids, immunosuppressant, CHF regimeCarries a poor prognosis may meet criteria for transplantOnset of symptoms is gradual - CHF, dyspnea, fatigue, weakness, systemic or

pulmonary emboli, signs of alcoholism, cardiomegaly, valve insufficiency

CardiomyopathyCardiomyopathyCongestive cardiomyopathy, more commonly referred to as “dilated” cardiomyopathy,

is a myocardial disease characterized by ventricular dilation, contractiledysfunction, and symptoms of CHF - In most cases treatment revolves aroundmanagement of CHF and in those instances the heart failure is the principaldiagnosis

CC 2/90p19CardiomyopathyCardiomyopathy

Restrictive is the least common - causing limited ventricular filling from myocardial cellinfiltrates and fibrosis

Ventricular compliance decreases and heart becomes stiff Faltering of the myocardial contractility, reducing cardiac output with systemic and

pulmonary congestion

CardiomyopathyCardiomyopathyThe coding of the terms of congestive and restrictive are found in the non essential

termsThus restrictive and congestive/dilated are coded 425.4There is a sub term for hypertrophic obstructive 425.1, alcoholic 425.5 etc.Many other sub terms appear - also note brackets and yield for sequencing

CardiomyopathyCardiomyopathyThe term “ischemic” cardiomyopathy is sometimes used to designate the condition in

which ischemic heart disease can cause diffuse fibrosis or multiple infarctions and

leads to heart failure with left ventricular dilation - It may or may not be associatedwith angina - All ischemic heart disease is classified to 410-414. Without better clarification ischemic cardiomyopathy is coded 414.8

CC 2/90p19CardiomyopathyCardiomyopathy

Hypertensive cardiomyopathy without further specification is coded as 402.– and 425.8cardiomyopathy in other diseases classified elsewhere-Although there are noindex entries that specify hypertensive cardiomyopathy, the coder must be guidedby the physician’s documentation of heart disease due to hypertension

CC 2/93p9Heart ValveHeart Valve

How do you code mitral insufficiency with tricuspid insufficiency with no mention of

rheumatic disorder?

CC 2/00 p16Heart ValveHeart Valve

Collect 424.0 and 397.0Exclude note – indicates that if disease listed in 424 is associated the rheumatic



endocarditis then see 391.1, 394.0-397.9Coders should be cautious and follow all instructional notes (i.e., excludes and

includes) to accurately assign codes for theses conditions


“If the physician documentation lists severe aortic stenosis, moderately severe mitralregurgitation and moderately severe tricuspid regurgitation, what codes should beassigned?”


“Assign codes 396.2, Mitral valve insufficiency and aortic valve stenosis, and 397.0,Diseases of tricuspid valve. When the cause of the tricuspid regurgitation is notspecified, code 397.0 is assigned.”

CC 2/00 p16Acute Myocardial InfarctionAcute Myocardial Infarction

Myocardial infarction is the development of ischemia and necrosis of heart muscleOften the source of an MI is arteriosclerosis, but may occur from any other type of

obstruction which limits oxygen to muscle causing progressive ischemiaMost MI’s are at left ventricle which has a thicker wall, more perfusion and vascular MI’s are identified as either transmural (full myocardial thickness) or subendocardial

(inner lining of ventricle)Transmural are collected to 4th digit subcategory for site

Acute Myocardial InfarctionAcute Myocardial Infarction*There are over 5 million visits per year *Ischemic heart disease is the leading cause of death among adults*There are 6 million in the US with coronary artery disease*500,000 death annually*5% of all ED visits are for chest pain*$100 billion economic impact*Missed MI’s are the leading dollar loss in malpractice suites

Acute Myocardial InfarctionAcute Myocardial InfarctionThe goal of the ED is to identify and treat all serious causes of chest pain, such as:

*Pulmonary embolism*Aortic dissection*Pericarditis*Acute coronary syndrome (MI, angina)*Pneumothorax*Esophageal rupture*Pneumonia

Acute Myocardial InfarctionAcute Myocardial Infarction



Some non-life threatening causes of chest pain are:*Musculoskeletal pain*Hiatal hernia*Gastritis*GERD*PUD

*AnxietyAcute Myocardial InfarctionAcute Myocardial Infarction

Acute MI is collected to the 410 categoryInclusion notes indicate this category includes thrombosis, embolism, occlusion and

rupture, rupture heart, myocardium or ventricle.There are 3 fifth digits to the subcategory

0 – unspecified whether initial event or subsequent1 –acute phase, initial event regardless of how many times the patient is

transferred2 – subsequent encounter, observation, treatment, evaluation within 8 wks of

initial event

Acute Myocardial InfarctionAcute Myocardial Infarction*Codes for myocardial infarctions identify the sites of the MI codes 410.0-6X, and

410.8X specify sites that equate to STEMI (ST segment elevation MI) on ECG*Code 410.7X subendocardial includes non-transmural MI should be used for NSTEMI

(non-ST-segment elevation)*Code 410.9X unspecified does not indicate site or whether the is ST elevationCC 4/05 p 69-72

Acute Myocardial InfarctionAcute Myocardial Infarction*410.9X is the default for “acute MI” – if only STEMI or transmural MI is documented

without the site use this code or query the provider for the site*If an MI is documented as non-transmural or subendocardial but a site is provided it is

still coded as 410.7X

*If a STEMI converts to a NSTEMI due to thrombolytic therapy, it is still coded as aSTEMI

CC 4/05p69-72 & Official Guidelines I.C.7.e. 1)-3)Acute Myocardial InfarctionAcute Myocardial Infarction

*Please note that these codes are for acute myocardial infarctions, only*Coders should not confuse this with documentation of abnormal findings ST-segment

elevation without AMI as AMI is not the only cause of ST-segment elevation(pericarditis, hyperkalemia, left bundle branch block, etc.)

CC 4/05 p69-72Acute Myocardial InfarctionAcute Myocardial Infarction

Initial diagnostic test may be

*EKG – help determine site for 4th digit assignment*Creatine CK elevated 6 to 8 hours post MI – however may be false/positive due

to chest trauma*CK MB elevated 2 to 8 hours post MI - levels peak with 18-24 – at norm 36-72

hours - tested every 2-4 hours seen rising indicate MI

Acute Myocardial InfarctionAcute Myocardial InfarctionInitial diagnostic test continued



*LDH elevated 24-28 hours post MI peak at 4-6 days and return to norm 7-10days

*Troponin I and Troponin T measure cardiac muscle proteins and increase within3-12 hours post MI and remain so up to 190 hours post MI

*SGOT measurements are not used for MI’s

Acute Myocardial InfarctionAcute Myocardial InfarctionArrhythmias and conduction disorder complications of MI’s

*Paroxysmal supraventricular tachycardia – 427.0 rx digoxin or Lanoxin plusInderal

*Paroxysmal tachycardia – 427.2 rx quinidine or procainamide (Procan,Pronestly)

*Atrial flutter - 427.32 rx digitalis*Atrial fibrillation – 427.31 rx digitalis plus propranolol (Inderal) or verapamil

(Calan, Isoptin) with maintenance therapy using quindine

Acute Myocardial InfarctionAcute Myocardial Infarction

Complications of MI*Ventricular fibrillation – 427.41 rx lidocaine, bretylium, or cardioversion*Premature ventricular tachycardia – 427.1 rx lidocaine, bretylium, procainamide

(Procan, Pronestyl)*Cardiogenic shock – 785.51 rx Dobutamine, Dopamine, or Glucagon, diuretics

and vasodilators*Heart blocks 426.0 complete – 426.12

Mobitz II – 426.13 2nd degree/Mobitz I rx temporary or permanent pacemakers

Acute Myocardial InfarctionAcute Myocardial InfarctionIf a myocardial infarction occurs at more than one site, assign a separate code for

each individual site.

Journal of AHIMA 7/8-96

Acute Myocardial InfarctionAcute Myocardial Infarction*Documentation of “aborted MI”*These are cases where a patient presents with severe chest pain resembling an MI

but after TPA is administered shows no myocardial injury*What codes should be use – 410.XX acute myocardial infarction – 411.81coronary

occlusion without MI – 411.1 intermediate coronary syndrome*CC 2/01 p 7-8

Acute Myocardial InfarctionAcute Myocardial Infarction*Assign 411.1 Intermediate coronary syndrome for an aborted MI – code assignment

should be based on physician documentation – when documentation supports nomyocardial damage and an acute MI has been averted

*CC 2/01 p 7-8



Acute Myocardial InfarctionAcute Myocardial Infarction*To make a determination of an acute MI the physician reviews patient’s history, utilizes

tests such as EKGs, Troponins, CPKs – when the heart muscle dies, the deadcells release certain chemicals in the blood – indicated with test results – the levelsof these chemicals present give an indication whether the heart muscles isdamaged and when it occurred

*CC 2/01 p 7-8Acute Myocardial InfarctionAcute Myocardial Infarction

*Question: A patient with know history of CAD – status post MI 5 years ago is admittedfor treatment of impending MI – the patient was stabilized via thrombolytic agentand progression of the MI averted – the patient was discharged homeasymptomatic without any diagnostic or surgical intervention – how should this becoded?

*CC 2/01 p 9Acute Myocardial InfarctionAcute Myocardial Infarction

Assign 414.01 CAD of native artery as principal diagnosis because the patient hadCAD as an established diagnosis and 411.1 Intermediate Coronary Syndrome for the aborted MI, 412 for the previous MI and 99.10 for the infusion of thethrombolytic agent.

CC 2/01 p 9Acute Myocardial InfarctionAcute Myocardial Infarction

If a patient had and inferior infarction and then had a second involving another part of the heart such as anterolateral, would it be correct to assign both specified sitecodes?

CC 5/93p14

Acute Myocardial InfarctionAcute Myocardial InfarctionYes, it would be correct to assign both codes 410.41 and 410.01

CC 5/93 p 14

Acute Myocardial InfarctionAcute Myocardial InfarctionA patient had an acute inferior MI. Later in the admission, the patient had another

acute inferior MI (reinfarction) described as an extension. The hospital coded410.41 and 410.91. Is this correct?

CC 5/93p13

Acute Myocardial InfarctionAcute Myocardial InfarctionNo. The correct answer would be to assign 410.41 once to describe an acute inferior

MI with reinfarction of the same site described as an extension. It is incorrect touse a nonspecific code with a specified code from the same series

CC 5/93p13

Class 9 Circulatory

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