Wiki 414.00 vs 414.01- can you elaborate

LouiseR1

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can you elaborate a little more on the question?

from what i am understanding, there is an order that lists 414.00, but you are unfamiliar with the patient, so to code 414.01 would not be accurate. if the vessels are not specified, do not assume that it is of native vessel

also remember to not get confused with 414.02-414.05 with v45.81. If there is no documented atherosclerosis of the graft then the appropriate code is v45.81 for history of CABG.

HTH
Louise
 
The Coding Clinic First Quarter 2004 page 24 posted guidance and clarification on coding for CAD in a patient who is status post CABG.

Coding Clinic Fourther Quarter 2003, page 106 advised using 414.01 for a patient with a history of CAD post CABG; however 414.00 is the appropriate code. Coding Clinic Second Quarter 1995 page 17 and Third Quarter 1997 page 15 code 414.01 is assigned when the medical record documentation does not indicate the patient has a history of a prior CABG and the physician has documented the presence of atherosclerosis in a native coronary artery.

The Clarification listed in the Secondary Quarter 1995 page 17 was based on a question:

Is it appropriate to assign code 414.01, coronary atherosclerosis of native coronary artery, if the medical record documentation does not indicate the patient has a history of prior coronary artery bypass surgery?

Answer: Assign code 414.01, coronary atherosclerosis of native artery if medical record documentation shows no history of prior coronary artery bypass. If the documentation is unclear concerning prior bypass, query the physician.



If the order is signed by the physician and the physician has indicated 414.00, I would use that code. I would not assume another diagnosis in the absence of documentation. There is guidance from Coding Clinic for coding from orders but it does not specifically refer to CAD. They state if the physician order documents a diagnosis, it is appropriate to code that condition.
 
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