Coding Coronary Artery Disease
Here's the official coding rule from the second quarter, 1995 issue of Coding Clinic for ICD-9-CM:
Question: Is it appropriate to assign code 414.01, Coronary atherosclerosis, of native coronary artery, if the medical record documentation does not indicate that the patient has a history of prior coronary artery bypass surgery?
Answer: Assign code 414.01, Coronary atherosclerosis, of native coronary artery, if medical record documentation shows no history of prior coronary artery bypass. If the documentation is unclear concerning prior bypass surgery, query the physician.
Again, Third quarter, 1997 issue of Coding Clinic for ICD-9-CM:
Question: A patient has coronary artery disease. There is no mention of a past history of CABG. Should this be coded to 414.00, Coronary atherosclerosis of unspecified type of vessel, native or graft, or 414.01, Coronary atherosclerosis of native coronary artery?
Answer: Assign code 414.01, Coronary atherosclerosis of native coronary artery. Since there is no history of CABG, this is a native coronary vessel. However, if the documentation is unclear concerning prior bypass surgery, query the physician. This is consistent with advice previously published in Coding Clinic, second quarter 1995, page 17.
So, based on this guidance, it is correct to use 414.01 when the documentation states "coronary artery disease", and there is no documentation to indicate that the patient has anything other than native coronary arteries.