ICD-10-CM Raises the Clinical Bar


Walk through real cases to help you strengthen A&P.

Preparing for ICD-10-CM implementation requires a strategy to minimize productivity losses. Remember how painfully slow it was to search the ICD-9-CM codebook when you first started to learn coding? Although ICD-10-CM may be familiar to you (if you are well versed in ICD-9-CM), the educational bar has been raised. To remain productive, coders need a good understanding of anatomy and pathophysiology (A&P), as they relate to clinical specificity in ICD-10-CM.
Physicians do not write in coding terms; they document for the patient’s clinical condition. The clinical terms do not match up entirely with the coding descriptors—meaning that you need to be able to uncover the pertinent information and assign codes appropriately.

Do Your Skills Measure Up?

Will you be able to interpret the clinical documentation? Or will you be constantly searching and querying your provider? Worse yet, will you just assign unspecified codes? Answering yes to either of the latter two questions will cost you. Either your provider will question your ability to code, the practice will lose revenue by using unspecified codes, or both.
To assess your readiness, review these clinical documentation examples and then choose the correct ICD-10-CM code.

Case No. 1: Debilitating Migraine

Subjective: Patient complains of intermittent headaches. He has had similar headaches for eight years. He comes in now because the headaches used to occur 3-4 times a year, and now they are occurring 3-4 times a month. The headaches are so severe that he is unable to work. He describes them as a throbbing pain behind his right eye. The headaches are often accompanied with nausea, and in the last few months he has occasionally vomited during an episode. Light aggravates his symptoms, but he has no associated visual symptoms.
Objective: His neurologic exam is unremarkable.
Assessment: Chronic migraine
ICD-10-CM choices for chronic migraine:
G43.701  Chronic migraine without aura, not intractable, with status migrainosus
G43.709  Chronic migraine without aura, not intractable, without status migrainosus
To figure out which code is correct, you must know the answer to these questions:
What is an aura?
What is the definition of intractable, or status migrainosus?
Here’s some help:
An aura is a physiological warning sign that a migraine is about to begin. Migraines with auras occur in about 20-30 percent of migraine sufferers. An aura can occur one hour before the attack of pain and last for 15-60 minutes. The symptoms always last less than an hour. Visual auras include:

  • Bright flashing dots or lights
  • Blind spots
  • Distorted vision
  • Temporary vision loss
  • Wavy or jagged lines

Auras also can affect the other senses. These auras may be described simply as having a “funny feeling,” or the person may not be able to describe the aura. Other auras may include ringing in the ears or changes in smell, taste, or touch.
Status migrainosus refers to a rare and severe type of migraine that can last 72 hours or longer. The pain and nausea are so intense that people who have this type of headache often need to be hospitalized. Certain medications, or medication withdrawal, can cause this type of migraine syndrome.
Intractable headaches are those that don’t respond to medications or therapy, and require intervention outside of the standards.
In this case, the patient has had the condition for eight years, and it has gotten progressively worse. Light bothers the patient, but he has no visual impairments. There is no note that medications are not working, or that the headaches last longer than 72 hours. Based on this information, we can assign code G43.709.

Case No. 2: Coronary Heart Disease, Myocardial Infarction

A second, more complex example requires multiple diagnosis codes:
Chief complaint: CAD, MI.
History of present illness: An 85-year-old male, new patient who has a history of coronary artery disease with previous myocardial infarction and inducible monomorphic ventricular tachycardia. He has a dual chamber cardio defibrillator model and a dual chamber cardioverter with an atrial lead. He presents for evaluation of a recent myocardial infarction and inducible monomorphic ventricular tachycardia. He was walking in his house when suddenly, without warning, his device fired. He had no symptoms of palpitations or heart racing prior to the event. He felt the same before and after the event, aside from anxiety related to shock. His device was interrogated and demonstrated the shock occurred for atrial fibrillation with a rapid ventricular response. This resulted in slowing of his ventricular response, but did not convert him from his chronic atrial fibrillation. As a result of this shock, his Inderal® has been increased from 80 mg once daily to 120 mg daily. He does not notice any difference in the increased dose of Inderal®. He has no symptoms of chest pain or angina. He has mild symptoms of exertional dyspnea and NYHD Class II symptoms, but no symptoms of rest dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema.
Medications: Medicines were reviewed and include Inderal® LA – 120 mg daily, Cozaar® – 25 mg daily, aspirin – 325 mg daily, a multivitamin – one daily, and valium – as needed.
Examination: Vital signs: Pulse 78 bpm and irregular; blood pressure 118/74; respirations 16; height 5′ 6″; weight 165 lbs.
Cardiovascular: The cardiac apex is not displaced. The first and second heart sounds are normal. There is a grade systolic murmur of mitral insufficiency. The JVP is normal at 3 cm. The carotids have normal upstrokes without bruits.
Respiratory: The chest expands normally. There is good air entry to both bases. No adventitious sounds are heard.
Laboratory data: His device was evaluated and his battery voltage is currently 2.64 volts with a replacement indicator at 2.62 volts. His atrial fibrillation is noted with a ventricular response about 80 bpm. An echocardiogram from Aug. 21, 2009, showed a dilated left atrium at 4.9 cm. His left ventricular function was normal with an ejection fraction of 60 percent.
Impression: 1) ICD shock secondary to paroxysmal atrial fibrillation with rapid ventricular response. 2) Normal functioning cardioverter defibrillator – nearing end of life. 3) Ventricular tachycardia. 4) Coronary artery disease. 5) lschemic cardiomyopathy – EF 60 percent, NYHD class II. 6) Hypertension. 7) Allergy to ACE inhibitors.
Recommendations: This gentleman received an implantable cardiac defibrillator shock because of a rapid response from his underlying atrial fibrillation. He recently had his beta blocker dose increased, but his ventricular response is still somewhat rapid. I have recommended he increase his Inderal® to Inderal LA® 80 mg twice daily. If hypotension ensues, lowering his dose of Cozaar® would be appropriate. His CHADS2 score is only one; therefore, I would continue with aspirin for his anticoagulation. It is interesting to note that the defibrillator shock did not convert his atrial fibrillation to sinus again, supporting the idea that this is chronic atrial fibrillation. He should have his defibrillator changed when he reaches an elective replacement indicator of 2.6 volts. I will be pleased to change out his device at the appropriate time. I hope this letter is useful to you in the management of this patient.
ICD-10-CM coding:
I48.0       Paroxysmal atrial fibrillation
I47.2       Tachycardia, ventricular
I25.10     Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.5       Cardiomyopathy, ischemic
I10          Hypertension
I25.2       Old myocardial infarction
Z88.8      History, personal, allergy, other drugs, medicaments, and biologic substances
Here are some pathophysiology elements you need to understand to tie in the proper coding:
Coronary heart disease (CHD), also called coronary artery disease (CAD), is a condition in which plaque builds up inside the coronary arteries. It is the most common type of heart disease. The coronary arteries supply oxygen-rich blood to the heart muscle. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis. The buildup of plaque occurs over many years.
A common symptom of CHD is angina. Angina is chest pain or discomfort that occurs if an area of your heart muscle doesn’t get enough oxygen-rich blood. Angina may feel like pressure or squeezing in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back, and it may even feel like indigestion. The pain tends to get worse with activity and goes away with rest. Emotional stress also can trigger the pain.
Another common symptom of CHD is shortness of breath. This symptom happens if CHD causes heart failure. In the event of heart failure, the heart can’t pump enough blood to meet the body’s needs.
ICD-10-CM separates codes for ischemic heart disease by the type of vessel affected, and whether the patient is also experiencing angina.
Heart failure is coded by the type, such as systolic, diastolic, or a combination of both, as well as whether the condition is acute or chronic.
Systolic heart failure is a form of heart failure in which the heart’s lower chambers (ventricles) have become too weak to contract and pump out enough blood to meet the body’s needs, resulting in shortness of breath and other heart failure symptoms.
Diastolic heart failure is defined as symptoms of heart failure in a patient with preserved left ventricular function. A stiff left ventricle often is characterized with decreased compliance and impaired relaxation, which leads to increased end diastolic pressure.
The patient in this example has multiple diagnoses. He is diagnosed with paroxysmal atrial fibrillation, ventricular tachycardia, and CAD with no mention of previous coronary artery bypass graft (CABG); therefore, it’s coded as a native artery. There is no mention of angina, ischemic cardiomyopathy, hypertension (which is not described as due to heart disease), or history of myocardial infarction (MI). He also has an allergy to angiotensin-converting-enzyme (ACE) inhibitors.
Without a working knowledge of A&P, these two examples may have taken you quite awhile to look up everything necessary to make the appropriate code selections. By preparing now with a solid A&P course, you will be more effective in your coding, and worry less about productivity losses with the new coding system.

Rhonda Buckholtz, CPC, CPMA, CPCI, is vice president of ICD-10 Training and Education at AAPC.

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