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Have a Heart – Cardiac Overview Part 2
We will continue the A&P spotlight on the heart for this month. We are going to finish our journey with the conduction system of the heart and the coronary arteries and how they will look in ICD-10-CM.
The heart is able to move blood throughout the body as a result of its conduction system. The system contains pacemaker cells, nodes, the bundle of HIS, and the Purkinje fibers. The pacemaker cells have the ability to generate an electrical impulse, to pass that impulse to other cells, and to shorten the fibers in the heart when receiving the impulse. An electrocardiogram (ECG) shows a graphic picture of the heart's electrical activity.
The sinoatrial (SA) node is located in the right atrium by the superior vena cava. It is the normal pacemaker of the heart and generates an impulse between 60 – 100 times per minute. The atrioventricular (AV) node is located lower in the septal wall of the right atrium. It slows the impulse conduction down between the atria and the ventricles to allow time for the atria to fill with blood before the ventricles contract. When there is an abnormality in SA impulse formation you may see a diagnosis of nodal dysfunction from the provider. The ICD-10-CM code for sinoatrial node dysfunction is I49.5, Sick sinus syndrome.
The impulse then travels to the bundle of HIS, which are muscle fibers that branch off into the right and left bundle branches. The left bundle branch further divides into the left anterior and left posterior fascicles. Blocks may occur between the atria to the ventricles, just the bundle branch(es). Examples of ICD-10-CM codes for these conditions include I44.1, Atrioventricularblock, second degree, I44.4, Left anterior fascicular block, and I45.0, Right fascicular block. Then the impulse arrives at the Purkinje fibers at the end of the bundle branches. These fibers lie across the surface of the ventricles and give the final signal for the ventricles to contract.
The coronary arteries are a network of arteries that supply blood to different parts of the heart muscle and electrical system. The left main coronary artery and the right coronary artery arise from the aorta. The left main coronary artery bifurcates into the left circumflex and left anterior descending arteries. The right marginal artery of the heart is a branch of the right coronary artery. It branches off at the inferior border of the heart and passes to the left towards the apex. It passes horizontally, branching and tapering along its route. It supplies the right ventricle. Coronary artery disease (CAD) is the result of the accumulation of atheromatous plaque within the walls of the coronary arteries. From an ICD-10-CM perspective, documentation should indicate whether angina is present and the whether the artery is native, bypass graft, or transplanted heart. ICD-10-CM codes include I25.110, Atherosclerotic heart disease of native coronary artery with unstable angina pectoris and I25.721, Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm.
The more you understand the structure and function of the organ systems, the more efficient and secure you will be in your coding in ICD-10-CM.
IN THE NEWS
CMS and WEDI Announce End-to-End Testing Webinar
To help the health care community prepare, CMS and the Workgroup for Electronic Data Interchange (WEDI) will host the End-to-End Testing Virtual Event on Thursday, February 28, 2013, 11 am – 5:30 pm ET. All members of the health care community are welcome to take part in this no-cost webinar, which will include sessions tailored for providers, clearinghouses, payers, and vendors. The webinar will provide information on how to participate in the ICD-10 National Pilot Program.
A 30 year-old man presents for follow-up from the emergency department. He presented to the ED with complaints of midsternal chest pain and a heart rate of 40/min. Cardiac monitoring indicated complete AV block with narrow QRS complexes. This was verified by findings on a 12-lead ECG. He is sent for pacemaker consideration. Patient was a 10-year, 2-pack-per-day cigarette smoker. Upon being diagnosed and sent here, the patient quit smoking "cold turkey" and also is having withdrawal issues. He is asking for some assistance with this at this time.
Patient states that he had been told prior that he had a "slow heartbeat" but he had not asked questions regarding this. He never received subsequent follow-up testing or ECG to diagnose the issue.
A resting ECG showed complete atrioventricular block (CAVB) with a junctional escape rhythm of 41/min. The QRS duration was 98 ms (normal, 80–120 ms), and the QT interval and the QTc were 524 and 432 ms, respectively (normal range, QTc >450 ms). An echocardiogram completed during this workup showed normal left ventricular systolic function and an ejection fraction of 72% (normal range, 50%–70%), indicating strong heart muscle function. The echocardiogram showed no left ventricular hypertrophy, normal right ventricle, and normal right and left atria. All valves appeared normal except the pulmonary valve, which was not visualized. Stress test and 24-hour recording from Holter monitor also indicated complete block.
Patient with complete heart block and nicotine dependence on cigarettes with withdrawal. Will proceed with placement of an atrioventricular sequential permanent pacemaker with the low rate limit set at 60/min. Will give patient script for 0.5mg Chantix and instructed on proper dosage.
I44.2 Atrioventricular block, complete
F17.213 Nicotine dependence, cigarettes, with withdrawal
Rationale: In ICD-10-CM, codes for heart block are broken down by type of block. In our example above the patient has a complete heart block. Nicotine dependence in ICD-10-CM requires documentation of the type of tobacco product and any complications in order to assign a code to the highest level of specificity. The documentation above states the patient is suffering from nicotine withdrawal.
ICD-10 IMPLEMENTATION STRATEGIES
We will be sharing a number of strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.
Assigning Committees to Oversee Implementation
Depending on the size of your practice, different committees (or teams) will need to be assembled in order to ensure a smooth transition to ICD-10. A project manager that understands the full scope of ICD-10 implementation should be assigned the ownership of the ICD-10 implementation project. The Executive Steering Committee will be "the keepers of the project". They are responsible for overseeing the other committees and reporting to administration. A Communication Committee or, in a smaller practice a communication liaison, should be given responsibility for updating the project manager, other committees, staff, vendors, etc. Communication may be by e-mail, newsletter, webinars, podcasts, staff briefings, etc. The Education Committee will take charge of the training needs of the facility and staff to ensure proper education on ICD-10-CM issues. They will be tasked with things like deciding who needs what training and how much, including schedules for trainings. Regular meetings should be scheduled to ensure everyone is on track to transition.
Non-Pressure Chronic Ulcers in ICD-10
ICD-10-CM will require new skills. AAPC has created a resource for the coding of non-pressure ulcers to help coders make the transition to coding with the new system. This downloadable sheet is a great desk reference for coders needing more information on the coding of ulcers in their practice.