Coding & Reimbursement Network, Inc.

The Coding Sleuth 16

by Tara Conklin

There is a vile criminal on the streets that you may be an unaware victim of. This criminal is cunning, patient, and deadly at epic proportions. The worst thing about this mastermind fiend is so many people are focused on some of his lesser partners in crime, by the time he strikes many people it’s too late to save them. He’s unbiased in his crimes. He attacks people of every race, creed, sex, and color and is the number one killer of women in the United States.

With these statistics, what comes to mind... cancer perhaps… maybe even breast cancer, but you would be wrong. His name is Coronary Artery Disease and he lies in wait for any person willing to give him a key to the front door of their heart. All it takes is a bad diet, an inactive lifestyle and in some, a genetic trait. Unfortunately the latter is not a prerequisite to giving him access to your life; it only helps him along a little bit.

Sure, you’ve heard of him. You know his methods and exactly how he works. The best thing you can do is learn how to protect yourself. Eat sensibly, exercise and for heaven's sake, put down those stinkin’ twinkies and that double latte with extra cream!

But we’re not here to lecture you on CAD (how fitting for a name, don’t you think? The definition of CAD is “one whose behavior is unprincipled or dishonorable.”) but to help thwart that all too familiar cohort of his…. Unpaid Claim; UC for Ugly Criminal is better suited, I think.

There are so many codes in the ICD-9 to use for this disease it’s easy to get used to one or maybe two codes that are utilized as “trump codes”. If we look under the surface there is much more to them and if we get a clear understanding of these codes we can confidently thwart UC. Let’s put on our sleuthing hats and see what we have.

Most of the codes we are dealing with are found in the 414 section of our ICD-9. A little education and help from our documenting physicians helps the coder narrow this list of codes down to something specific to each patient. This is how they look:

Pretty impressive, huh? But don’t be alarmed; we’ll look at each one.

The first one is probably the one you are most familiar with because it’s unspecified. Admit it, how often does your doctor actually tell you which type of vessel in the heart is effected. However as coders we are allowed a little leeway with figuring out the best code on our own. WHAT?! You say, we can think for ourselves without the doctor’s documentation?!

Yes, you can… at least in this circumstance. Let’s say the physician doesn’t document the patient’s natural or native coronary artery is effected, but you notice that the patient does not have a history of having had a previous bypass procedure (in the heart, of course). You, as the coder, can actually be the coding sleuth and make the determination based on your exemplary skills of deduction that the effected artery MUST be native. How can it possibly be anything else. So you can code it to 414.01 all on your own. How do you like them apples??

Now, with the next codes it’s not so simple. If the record shows a history of previous bypass and CAD is present, no assumptions can be made here. You have to look at any available documentation such as a recent heart cath (remember Dr. Stan Osis. He was such a nice guy and his claims and payments look much better, I hear). Keeping on the subject, these next codes deal with people who have had bypass graft. Knowing what type of graft they have is a key factor in making the correct coding choice. Remember these codes deal with the vessel affected by CAD. 414.02 is used for CAD in a bypass graft made of the patient’s own vein, commonly the saphenous vein from their leg. 414.03 is used for grafts from somewhere else, sometimes man-made or from a cadaver. Some grafts are made from arteries instead of veins. The most common arteries used for coronary bypass grafting are the patient’s internal mammaries; either the left or right. These are referred to as LIMA or RIMA for short and when affected by CAD are coded with 414.04. 414.05 is used when the documentation shows CAD of a bypass graft but not specifically which one.

The last two are used when the patient has had a previous heart transplant and now has CAD in the coronary vessels of the transplant; 414.06 if the vessels are native… no history of CABG here, and 414.07 if the transplant has also been previously bypassed with either arteries or veins, (oh, and uh, that’s after the transplant obviously).

Now that you know the difference between these codes, don’t go running off and arbitrarily using them just because you see the patient has had a bypass. The same patient could have CAD in native and/or bypass vessels. That’s where any cardiac catheter reports or asking the doc for some clarification is the best way to know which vessels are affected.

There are two other codes in the ICD-9 that likes to trick unwary coders into thinking it’s the correct code for stenosis or occlusion of coronary bypass grafts. It’s 996.03 Mechanical complication due to coronary bypass graft and 996.72, other complications due to other cardiac device, implant, and graft. These may look like a duck and talk like a duck but they are definitely not ducks. Using these codes for coronary bypass stenosis is… well, to put it bluntly… the work of a lazy coder. The number one rule of thumb in coding is to READ your coding books. Understand what the punctuation marks mean, read the “excludes” and “includes” notes in the category sections. All the information is there for you; don’t be lazy and use it. With this said both of these codes have notes directly underneath each one which tell you plain and simple “for occlusion, stenosis or atherosclerosis of coronary bypass grafting use codes from 414.02-414.06”. This is, of course, a paraphrase but the point is the code points you directly to the right place.

Oh, and one last thing, please do not use 414.8 for unspecified CAD. If the record shows “coronary artery disease”, use 414.00-414.07. 414.8 is used for other ischemias of the heart such as chronic symptoms (chest pain, shortness of breath etc) after 8 weeks out from a heart attack.

The same type of coding is used for arterial disease in the other vessels of the body. These codes are found in the 440 category. Look at them carefully and you will find many parallels to the coronary artery codes of 414.

So you see, the coding of CAD is actually a pretty simple case to crack. Prying that super sized double cheeseburger and fries out of your hand and getting you to turn off Days of Our Lives is a whole other battle altogether. All you have to do is with every bite conjure up the sounds of a deep fat fryer and imagine that sound in the vessels of your body. Eeeww! I don’t know about you, but the sound of fresh running water is a whole lot more comforting. So what are you having for lunch today?

Until next time, mighty coders, here’s to your health and happy coding!

--Tara