Question Question regarding angina

mchaidez

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Hello,

Can I code I25.119 - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris

Does Angina have to be documented to code it? Please advise.


Our Provider documented the following:

Internal Medicine Admission History and Physical
CC: direct admit for chest pain
HPI:
73 year old male with history of DM, HLD, CAD hx of stent 2014 presented to Hospital for chest
pain and dyspnea on exertion. Symptoms have been going on for one month and worse in the past week. Patient
experienced palpitations day of admission to Alhambra Hospital. He was admitted to telemetry where troponin
trended which were initially negative but increased to Trop 0.05. Cardiology Dr. Kok was consulted who
recommended transfer to GMC for cardiac catherization
Patient currently without any chest pain; complains of chest pain on exertion

Assessment and Plan:
73 year old male with history of CAD, HLD, DM presented to Hospital for chest pain. Transferred to X hospital on 10/23 for cardiac catherization.
CAD
s/p stenting 2014
Plan
for cardiac cath tomorrow AM
cardiology following Dr. K
 
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