Wiki Angina pectoris (use additional code to identify: Z77.22...)

[heartyoga]

I have a curious question:

I have noticed under I20 angina pectoris there is this note that says:
Use additional code to identify:
exposure to environmental tobacco smoke Z77.22
history of tobacco dependence Z87.891
occupational exposure.. Z57.31
....


Is this a MUST when coding I20.9? Typically, the report comes in without indications of any of tobacco related exposure/smoking history? We just interpret the stress test from referring facilities.

Should I start having the physician query for the above indications?

Is there an edit where if we don't put the additional Z code in, that it denies?

Any thoughts?

Thanks !

 

[thomas7331]

No, it is not required if it is not documented in the record. After all, if the patient has no history of smoking of exposure to smoke, then there would be code to add anyway. I have never seen any claim deny for this, but coding auditors would cite it as an error if the information was in the chart but the coder did not include it. I would absolutely not query a provider because they may not even have the information anyway.