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18 Cards in this Set
- Front
- Back
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Explain when to code hypertension or abnormal blood pressure reading |
Hypertension must only be coded when a patient has a diagnosis of hypertension. Raised or elevated BP with no diagnosis of hypertension is coded to a sign and symptom code R03.0 |
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Explain how to code renal disease and heart disease due to hypertension |
Codes from I11-I13 must only be used when a clear link has been stated between hypertension and heart disease or renal disease. If no link is made code separately. If a patient has a condition in I11 and I12 a code from I13 must be used instead. If the hypertensive renal disease is from N18 a code from N18 is assigned to identify the stage followed by a code from I12-I13. Modifiers include hypertensive or due to hypertension |
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Explain how to code a Myocardial Infarction |
A code from I21 must always be assigned everytime a patient has had an acute MI unless a subsequent MI occurs with 4 weeks of the onset of a previous Infarction in which case a code from I22 must be used.
Where a new acute is diagnosed more than 4 weeks (28 days) after a previous MI a code from I21 must be used. NSTEMI is coded to I21.4 non st segment elevation Myocardial Infarction. St segment elevation Myocardial Infarction (STEMI) is coded depending on the site of the damage to the heart documented in the medical record. |
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How must a subsequent MI be coded |
Category I22 must only be used to code an MI occurring within four weeks (28 days) from onset of a previous Infarction, regardless of site and includes the following: °Extension to an existing MI °Recurrent MI °Reinfarction A subsequent NSTEMI must be classified to I22.9 subsequent MI of unspecified site. A subsequent STEMI is coded depending on the site of the damage, if this is unkown code I22.8 other subsequent MI of other sites must be assigned. If a patient has multiple subsequent MI's all occurring within four weeks (28 days) of the original Infarction a code from I22 must be assigned for each subsequent MI. |
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How must a chronic MI and ongoing treatment of an MI after 4 weeks be coded |
If an MI is stated as chronic or the patient is admitted after 4 weeks from onset of an MI code I25.8 other forms of ischemic heart disease is used. |
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Explain how to code a patient who is within 4 weeks of an MI but is admitted for treatment of another condition |
When a patient is admitted within 4 weeks (28 days) of an acute MI for treatment or investigation of another condition code I24.9 acute ischemic heart disease must be used in a secondary position |
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When coding an MI and the site is documented but no mention of 'transmural' what must the coder consider when indexing |
If the site is stated but no statement of transmural the coder must continue past the essential modifier of transmural in order to assign the correct code |
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Explain sequencing when a patient has coronary artery disease and acute Myocardial Infarction |
If a patient has coronary artery disease and is admitted with an acute MI and is transferred from one hospital provider to another for an intervention to treat the coronary artery disease, the coronary artery disease is coded as primary. If the patient undergoes all treatments at the same trust the acute MI is recorded as the primary diagnosis. |
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Explain how to use I23 certain current complications following acute Myocardial Infarction |
This code must be assigned when the complications occurred following an acute MI. Where a complication occurs concurrently with the MI a code from I21-I22 is assigned instead. A code from I23 can be coded in the same episode as I21 or I22 as long as the complication is not concurrent with the MI. Current complications are not subject to the four week rule. |
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Explain the use of I25 - chronic ischaemic heart disease |
I25.2 Old Myocardial Infarction is used to classify an old MI a previous MI a past MI and a personal history of an MI and must be used when when the patient is not being treated for the previous MI and either the old Myocardial Infarction occurred more than four weeks ago or the length of time has not been stated and it is documented as previous, old or past MI. When a history of MI and IHD are documented together both must be coded. If a patient has angina and IHD both must be coded |
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How must cardiac arrest (I46) be coded |
Cardiac arrest with successful resuscitation must always be assigned when a cardiac arrest with successful resuscitation has occurred. This includes a patient who is admitted following a cardiac arrest outside the hospital. As any patient who survives a cardiac arrest will have received resuscitation it must be coded to cardiac arrest with successful resuscitation (I46.0). If the underlying cause of the cardiac arrest is known this must be sequenced before I46. Sudden cardiac death, so described must only be coded when it has been specifically documented as such by the responsible clinician, unless the cardiac death is due to conditions listed as exclusions at this code e.g MI in which case sudden cardiac death is not required. Cardiac arrest with unsuccessfull resuscitation and not described as sudden cardiac death must be coded to I46.9 cardiac arrest unspecified |
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Explain how to code heart failure |
If both congestive cardiac failure (ccf) and left ventricular failure (lvf) are documented in the medical record only assign a code for ccf (I50.0) as it includes right and left failure |
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How must pulmonary oedema and heart failure be coded |
If both pulmonary oedema and ccf or lvf are documented only code the ccf or the lvf. If pulmonary oedema is mentioned with a condition listed below assign I50.1 instead of pulmonary oedema and a code for the specific heart condition. °Acute rheumatic fever °Chronic rheumatic heart disease °Hypertensive disease °Ischaemic heart disease °Endocarditis °Mitral valve disease °Aortic valve disease °Myocarditis °Cardiomyopathy °Arrhythmia °Other heart conditions (I51-I52) If pulmonary oedema is documented with hypertensive heart disease with heart failure (I11.0) or a condition classified to hypertensive heart and renal disease (I13) only assign the code for I11.0 or I13. If pulmonary oedema is mentioned with one of the following assign J81.X pulmonary oedema and a code for the heart condition °Rheumatic chorea °Pulmonary heart disease °Pericarditis °Tricuspid valve disorder °Pulmonary valve disorder |
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How must strokes be coded |
Strokes are classified by type, either haemorrhage or Infarction (ischaemic) when known. Code I64.X stroke, not specified as haemorrhage or Infarction does not indicate the type of stroke. The coder must always endeavour to obtain results from a ct scan or similar report which should confirm the type of stroke. Whilst a coder must not interpret test results to form a diagnosis it may have a definitive diagnosis in the report. Where a stroke is due to thrombosis or embolism this must be coded to I63 cerebral Infarction. A documented diagnosis of lacunar Infarction must be coded to I63.5 cerebral Infarction due to unspecified occlusion or stenosis or cerebral artery. |
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Explain how to code stroke with hemiplegia, dysphagia and dysphasia |
On emergency admissions for strokes the code for the stroke must be primary and the hemiplegia must be in a secondary position to the stroke as indicated by the note at G81. Symptoms of a stroke must only be coded when they have been treated as a problem in their own right e.g PEG for dysphagia |
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When must cerebral atherosclerosis be coded |
When given a diagnosis of cerebral atherosclerosis. It must also be coded when it exists with I63 cerebral Infarction or I66 occlusion and stenosis of cerebral arteries not resulting in cerebral Infarction. |
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What condition in chapter IX requires a fifth character |
Atherosclerosis, fifth character subdivisions are for use with this code to indicate presence or absence of gangrene. If no information is available default to without gangrene (0). |
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When must peripheral vascular disease not be coded |
If the cause of the PVD is known only code the cause, I73.9 is not required. This information can commonly be Indentified from an ateriogram verified by the responsible clinician. |
