True Blue
Birmingham, Alabama
Best answers
h&p states patient has angina and CAD with a previous heart cath. The indication on the heart cath being performed today states known cad, angina. The cath shows normal coronary arteries. the discharge summary states noncardiac chest pain. should the CAD be listed as a secondary code since he states it is known in the indication or should V12.59 be coded for history of CAD?? I was under the impression that once CAD was diagnosed it was always present even if it was treated with stents etc.

I agree with your impression, once a dx of CAD is made, that condition does not go away, regardless of the success of treatment. So, you have conflicting information from the H&P and indication and findings. I would question the source of the indication and H&P. I would also check the medical records for additional information supporting or eliminating the dx of CAD. It is an unfortunate truth that medical professionals make errors, especially in documentation.

HTH :)