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shobhit.malik

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How should we code this report, if patient is admitted for Chest pain, diagnosed as it is due to CAD in Native artery (Dr is specifying that CAD is in Native artery), and Patient has history of CABG., should we code as 414.00 or 414.01.
 
According to http://health-information.advanceweb.com/ :

"Code 414.01 is assigned if the documentation specifies that the CAD is of a native coronary artery or if there is no history of a previous coronary artery bypass graft (CABG)."

However in your scenario, the doctor documents hx of CABG. In this case, code 414.01, because the visit is for the native vessel, not the grafted one.

As for a secondary code v45.01, I believe it would be ok to document it being as the doctor mentioned it, however the visit is not for the CABG, according to what you wrote. IT's a grey scale issue, one that might require another post from a more experienced coder to correct me on, but definitely use 414.01.
 
I agree...CAD of native artery is coded 414.01.
V45.81 may be used as "support" for CAD. History of CABG, stent, cardiac catheterization etc., is also support for CAD, whether the diagnosis is documented in past history or current assessment.
 
Default code changes
Coding Clinic, Fourth Quarter 2004, instructs coders using ICD-9-CM to default to code 414.01 (CAD of a native artery) for patients with CAD who have never undergone a CABG procedure. The publication also instructs coders to default to 414.00 (CAD of unspecified artery) for patients with CAD who have undergone a CABG when documentation doesn't indicate whether the CAD is in the native artery or the bypass graft.
 
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