Cardiology Coding Alert

When a patient has atherosclerosis, you must look for numerous details in the documentation including the specific type of atherosclerosis and if they also have angina pectoris. If you miss any of this vital information, you could choose the wrong ICD-10-CM code for your claim and risk a denial.

Take a look at how you can solidify your atherosclerosis coding.

Learn What Atherosclerosis Is

Question 1: What is atherosclerosis?

Answer: With atherosclerosis, the walls of the arteries lose flexibility and elasticity. Plaque, which can be composed of fatty deposits, cholesterol, etc., forms in the arteries and slowly causes the blood flow passageways to narrow.

Don’t miss: You may see the terms “atherosclerosis” and “arteriosclerosis” used interchangeably in medical documentation. Arteriosclerosis is the stiffening or hardening of the artery walls, and atherosclerosis is a specific type of arteriosclerosis.

You may also see coronary artery disease (CAD) in the documentation. CAD occurs when atherosclerosis causes a buildup of plaque in the arteries in or leading to the heart. CAD is commonly referred to as atherosclerotic heart disease or arteriosclerosis.

Pinpoint Dx Codes for Atherosclerotic Heart Disease of Native Coronary Artery

Question 2: Which ICD-10-CM codes should I report if the patient has atherosclerotic heart disease of native coronary artery?

Answer: You have several code options in this case.

First, for atherosclerotic heart disease of native coronary artery without angina pectoris, report I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris). This code also includes atherosclerotic heart disease NOS, per ICD-10-CM.

On the other hand, if the patient has atherosclerotic heart disease of native coronary artery with angina pectoris, look to the following codes:

• I25.110 (Atherosclerotic heart disease of native coronary artery with unstable angina pectoris)
• I25.111 (Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm)
• I25.112 (Atherosclerosic heart disease of native coronary artery with refractory angina pectoris)
• I25.118 (Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris)
• I25.119 (Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris). This code also includes atherosclerotic heart disease with angina NOS and atherosclerotic heart disease with ischemic chest pain.

Don’t miss: When you report a code from category I25.1-, you may also report an additional code, if applicable, to identify I25.83 (Coronary atherosclerosis due to lipid rich plaque) or I25.84 (Coronary atherosclerosis due to calcified coronary lesion). Report code I25.82 (Chronic total occlusion of coronary artery) if there is documentation of a chronic total occlusion of the coronary artery, says Robin Peterson, CPC, CPMA, manager of professional coding and compliance services, Pinnacle Enterprise Risk Consulting Services, LLC in Centennial, Colorado.

Rely on I70.1 for Atherosclerosis of Renal Artery

Question 3: Which code should I report for atherosclerosis of the renal artery?

Answer: Report I70.1 (Atherosclerosis of renal artery). Use an additional code to identify exposure to environmental tobacco smoke Z77.22; history of tobacco dependence Z87.891; occupational exposure to environmental tobacco smoke Z57.31; and tobacco dependence F17-, or tobacco use Z72.0.

Don’t Forget to Turn to Combo Codes

Question 4: My colleague said that some of the atherosclerosis codes are combination codes I should report if the patient has angina pectoris. Can you explain what this means?

Answer: Your colleague is correct. When a patient has atherosclerotic heart disease along with angina pectoris, you do not need to report more than one code. Instead, you would look to a combination code. For example, if you’re the patient has atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm, you would report I25.111 (Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm).

Include These Documentation Details

Question 5: If a patient has atherosclerotic heart disease with angina pectoris, what are some details required within the documentation?

Answer: Required details for atherosclerotic heart disease with angina pectoris diagnosis include that the cause is assumed to be atherosclerosis. It should be noted if there is another cause. Additionally, the documentation should specify if the angina pectoris is stable or unstable. Also, the arteries involved should be noted and whether they are native or autologous. You should also know if there is any graft involvement.

Mark Down Risk Factors

Question 6: What are some of the risk factors for atherosclerosis?

Answer: Risk factors for atherosclerosis include smoking, being sedentary, poor diet, and family history.