Primary Care Coding Alert

Question: If a patient has atherosclerotic heart disease with angina pectoris, do I report each separately, or does one code imply the other?

Nevada Subscriber

Answer: When a patient has atherosclerotic heart disease along with angina pectoris, you should look to a combination code. If the patient suffers atherosclerotic heart disease of the native coronary artery along with angina pectoris, for example, you’ll turn to a code from I25.11- (Atherosclerotic heart disease of native coronary artery with angina pectoris). Look at the supporting details within the documentation for clues as to which specific code to report. For example, if the patient also has documented spasm, you would report I25.111 (… with documented spasm).

Note: The primary care practitioner may not have enough details at the ready for you to code to the specificity required in the ICD-10. For example, I25.1- (Atherosclerotic heart disease of native coronary artery) requires you code to the 6th character. That requires you have documented information regarding the absence or presence of angina pectoris and form of angina pectoris (e.g., unstable, refractory, with documented spasm) when present. In this situation, it’s likely that you may have to resort to I25.119 (Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris).