Circulatory System

HS317b – Coding & Classification of Health Data

Acute Myocardial Infarction

Folio lookup myocardium, myocardial (acute or with a stated

duration of 4 weeks or less) I21 – – chronic or with a stated duration of over 4

weeks I25.8 – – healed or old I25.2 – – nontransmural I21.4 – – other – – – complications I23.88 – – past

Terminology - confusing MI Non Q Wave Non-ST elevation MI ST elevation MI Q Wave Anterior MI Inferior MI

Terminology-See Inclusions I21.0-I21.3 Acute myocardial

infarction (includes Q Wave) I21.4 Acute subendocardial myocardial

infarction (Includes:Non-Q-wave myocardial infarction)

I21.9Acute myocardial infarction, unspecified (Myocardial infarction (acute) NOS)

Coding Myocardial Infarctions

Overlapping sites classified to ‘other sites’ Either I21.2 or I21.42 …’other sites’

Acute phase is 28 days After 28 days consider it a chronic condition I25.8 Other forms of chronic ischaemic heart disease

Any condition in (I21-I22) and (I24.-) specified as chronic or with a stated duration of more than 4 weeks (more than 28 days) from onset.

Code this if patient currently receiving acute care (observation, evaluation or treatment)

Re-infarction > 28 days

I22.~ Subsequent myocardial infarction Criteria;

Includes: further extension of myocardial infarction recurrent

Diagnosis typing based on ‘significance’

Excludes: specified as chronic or with a stated duration of more than 4 weeks (more than 28 days) from onset (I25.8)

Other conditions following MI

I23 Certain current complications following acute myocardial infarctionHaemopericardiumAtrial or Ventricular septal defectRupture of cardiac wall, chordae tindineae, or

papillary muscleThrombosis, Papillary muscle dysfunction,

pericarditis, postmyocardial infarction angina, etc

Exclusions to using I23.~

Used for specific complications that may occur following acute MI (usually 2-7 days post MI)

When condition is concurrent with acute myocardial infarction (I21-I22)

It is included in the acute myocardial infarction code, don’t code separately

Old Myocardial Infarction

I25.2Old myocardial infarctionConsidered a ‘history of’Assign if:

The old MI occurred more than four weeks ago (28 days)

The patient is currently not receiving care (observation, evaluation or treatment) for the OLD MI

I24 Other acute ischemic heart diseases

Use for terms:Missed MIAborted MIAverted MI

Mandatory Intervention

1.ZZ.35.HA-C1 Pharmacotherapy, total body NEC, using antithrombotic agent Intent: reperfusion of heartExamples: Streptokinase or UrokinaseMandatory

Ms. M. who was known to have coronary atherosclerosis presented to the emergency department with unstable angina. She was subsequently admitted to undergo coronary artery bypass grafting (CABG).

Final Dx: CAD with unstable angina

What is MRDx?

Coronary Artery Disease

Terminology: chronic ischemic heart disease, atherosclerotic heart disease (ASHD), coronary artery disease (CAD), coronary atherosclerosis, arteriosclerotic heart disease

All coded to I25.1~ atherosclerotic heart disease. specificity – native/graft vein/artery

Angina & CAD A history of angina with no documented

episode occurring during the patient’s stay in hospital is simply a risk factor and may be coded at the facility’s discretion with diagnosis type 3

RULE: angina may only be coded as a significant diagnosis when there is a documented episode of angina on admission or at any given time during the hospital stay

Diagnosis typing for CAD

In scenario where physician writes CAD with angina as MRDx ask yourself where is treatment being directed.

Patients can be treated with either percutaneous transluminal coronary angioplasty or coronary artery bypass graft

Depends on circumstances and whether course of treatment was directed at unstable angina.

CABG – 1.IJ.76.~~

Tissue used for the bypass is codedi.e.: procurement for saphenous vein or radial artery

When pedicled and free autografts are used the qualifier for combined grafts should be selected

Inherent in CABG code are hypothermia, cardioplegia and chest tube insertions

Code cardiopulmonary bypass (Mandatory) Affects CMG assignment

Other Interventions

1.IJ.50.~~ Angioplasty (Dilation, coronary arteries)Mandatory to include cardiac catheterization

with attribute intraoperative

1.IJ.57.~~ Endarterectomy (Extraction, coronary arteries)

Complications of CAD

Follow postprocedural conditions and complications rules

If occlusion, thrombosis or stenosis of coronary artery grafts occur:Consider it T82.8 Other complications of

cardiac and vascular prosthetic devices, implants and grafts.

If due to an atheroma—indicative of natural process of disease rather than a complication of bypass graft

Natural progress of disease versus occlusion complication Thrombus formation

Within a month T82.8Over a year likely natural progression

Atherosclerosis changesWithin a month—possibly due to a technical

errorOver a year natural progression

Heart Failure/Cardiac Insufficiency

Following surgery, patient was taken to the ICU for post-operative monitoring where she developed congestive heart failure within the first 24 hours.

The CHF was not a pre-existing condition

Folio look-up for CHFFailure heart (acute) (sudden) I50.9 – – complicating – – – anesthesia (general) (local) or other sedation – – – –– – – surgery T81.8 – cardiorespiratory (see also Failure, heart) R09.2 – – specified, during or due to a procedure T81.8 – – – long term effect of cardiac surgery I97.1

T81.88 (2) Other complications of procedures, NEC

I50.~ (3) Heart failureY83.9 (9) Surgical procedure, unspecified as

the cause of abnormal reaction of the patient, or of later complications,…..

Rationale

Complication of CHF is within the

postoperative monitoring period of 96 hoursExternal cause mandatory. Cause-effect

relationship. Not a pre-existing condition

What if patient developed an episode of congestive heart failure on day 8 of her stay and Lasix was added to her treatment, how would you code this?

CHF is not pre-existing

Which Rules to Apply?

I97.1 Other postprocedural disorders of circulatory system, NEC

I97.8Other postprocedural disorders of circulatory system, not elsewhere classified

T81.88 Other complications of procedures, not elsewhere classified

I50.0Congestive heart failure

Late complication I97.1 (2) other postprocedural disorders of

circulatory system, NEC I50.0 (3) Congestive heart failure. Rationale:

Occurring during hospitalization External cause not required

> 96 hours, < 15 days No documented evidence of any relationship to the

intervention. Apply External Cause if physician indicates postop.

Pleural Effusion & CHF

Patient comes into hospital with exacerbation of CHF and pleural effusion.

Thoracentesis is done to treat the pleural effusion.

Rules for Pleural Effusion

(M or 1) I50.0 Congestive heart failure (1) J90 Pleural effusion, not elsewhere

classified 1.GV.52.HA Drainage pleura

Rules for Pleural Effusion

Rationale: If Pleural effusion is documented on X-ray

only & no intervention this diagnosis should not be coded. (Included in diagnosis of CHF)

If treatment is directed to effusion by therapeutic thoracentesis or chest tube drainage

the pleural effusion may be coded as an additional diagnosis

Atrial Fibrillation Classified as a functional disturbance

Any code in range of I44 – I50 is a functional disturbance

AF following open-heart surgeryOccurs within postop monitoring period or

chart documentation indicates related to surgery

Not pre-existing

Atrial Fibrillation

I97.1 (2) Other functional disturbance following cardiac surgery

I48.0 (3) Atrial FibrillationY83.~ Surgical operation

AF > 95 hours, < 15 days

Not related to surgery by documentation No assumed cause & effect relationship

I97.8 (2) other postprocedural disorders of circulatory system, NEG

I48.0(3) AF

Folio lookup – Cardiac Arrest

Arrest, arrested-Cardiac I46.9- - complicating- - - surgery T81.8- - postoperative I97.8- - - long term effect of cardiac surgery I97.1Cannot use both I97.8 and T81.88

Cardiac Arrest

Not occurring postprocedural Only code if resuscitative intervention is

undertaken I46.0 Cardiac arrest with successful resuscitation I46.9 Cardiac arrest unspecified

Occurring as expected terminal eventCode only underlying or contributing

condition.

Cardiac Arrest following Intervention

< 96 hoursDocumentationT81.88 (2) Other complications of procedures,

NEC > 96 hours, < 15 days

I97.8 (2) other post-procedural disorders of circulatory system

I46.0 (3) Cardiac arrest with successful resuscitation

Resuscitation, heart New for April 2006

Code resuscitation, heart NEC when CPR is performed, regardless of outcome.

Code 1.HZ.09.~~ Stimulation, heart NEC when CPR is followed by defibrillation.

Resuscitation, heart – why?

In 2006 the Grouper is going to use high cost interventions as a factor in the Resource Intensity Weights methodology. This will not affect the CMG but will be applied at the RIW stage. CPR is such an intervention. It will be

mandatory to code anytime it is performed.

Interventions Cardiac Catheterization

Affects CMG assignmentMandatory

Cardiopulmonary bypass Affects CMG assignmentMandatory

Classification based on MRDx

MCC 5 Diseases and Disorders of the Circulatory SystemMCC 5A Cardiac Diseases and DisordersMCC 5B Vascular Diseases and DisordersCMG assigned based on whether procedure

was undertaken or not (surgical or medical partition)

CMG Examples Heart or Lung Transplant – CMG 175 Tracheostomy and Gastrostomy procedure

– CMG 40

Surgical Procedures broken down based on heart pump usage and/or cardiac catheterizations

CABG

No to heart pumpNo to cardiac cath – CMG 184 Major Cardio-

Thoracic Procedures without heart pump and without cardiac cath

Yes to heart pumpYes to cardiac cath – CMG 183 Major Cardio-

Thoracic procedures with Heart Pump with Cardiac Cath

Acute Myocardial Infarction

Factors influencing CMG Assignment If shock or pulmonary embolismLOS > 4 days If CHF present Is there ventricular tachycardiaAngina presentCardiac Catheterization