Circulatory System

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Circulatory System

• HS317b Coding Classification of Health Data

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Acute Myocardial Infarction

• Folio lookup
• myocardium, myocardial (acute or with a stated
  duration of 4 weeks or less) I21
• chronic or with a stated duration of over 4
  weeks I25.8
• healed or old I25.2
• nontransmural I21.4
• other
• complications I23.88
• past

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Terminology - confusing

• MI
• Non Q Wave
• Non-ST elevation MI
• ST elevation MI
• Q Wave
• Anterior MI
• Inferior MI

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Terminology-See Inclusions

• I21.0-I21.3 Acute myocardial infarction (includes
  Q Wave)
• I21.4 Acute subendocardial myocardial infarction
  (Includes Non-Q-wave myocardial infarction)
• I21.9 Acute myocardial infarction, unspecified
  (Myocardial infarction (acute) NOS)

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Coding Myocardial Infarctions

• Overlapping sites classified to other sites
• Either I21.2 or I21.42 other sites
• Acute phase is 28 days
• After 28 days consider it a chronic condition
• I25.8 Other forms of chronic ischaemic heart
  disease
• Any condition in (I21-I22) and (I24.-) specified
  as chronic or with a stated duration of more than
  4 weeks (more than 28 days) from onset.
• Code this if patient currently receiving acute
  care (observation, evaluation or treatment)

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Re-infarction gt 28 days

• I22. Subsequent myocardial infarction
• Criteria
• Includes further extension of myocardial
  infarction
• recurrent
• Diagnosis typing based on significance
• Excludes specified as chronic or with a stated
  duration of more than 4 weeks (more than 28 days)
  from onset (I25.8)

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Other conditions following MI

• I23 Certain current complications following
  acute myocardial infarction
• Haemopericardium
• Atrial or Ventricular septal defect
• Rupture of cardiac wall, chordae tindineae, or
  papillary muscle
• Thrombosis, Papillary muscle dysfunction,
  pericarditis, postmyocardial infarction angina,
  etc

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Exclusions to using I23.

• Used for specific complications that may occur
  following acute MI (usually 2-7 days post MI)
• When condition is concurrent with acute
  myocardial infarction (I21-I22)
• It is included in the acute myocardial infarction
  code, dont code separately

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Old Myocardial Infarction

• I25.2 Old myocardial infarction
• Considered a history of
• Assign if
• The old MI occurred more than four weeks ago (28
  days)
• The patient is currently not receiving care
  (observation, evaluation or treatment) for the
  OLD MI

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I24 Other acute ischemic heart diseases

• Use for terms
• Missed MI
• Aborted MI
• Averted MI

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Mandatory Intervention

• 1.ZZ.35.HA-C1 Pharmacotherapy, total body NEC,
  using antithrombotic agent
• Intent reperfusion of heart
• Examples Streptokinase or Urokinase
• Mandatory

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• Ms. M. who was known to have coronary
  atherosclerosis presented to the emergency
  department with unstable angina. She was
  subsequently admitted to undergo coronary artery
  bypass grafting (CABG).
• Final Dx CAD with unstable angina
• What is MRDx?

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Coronary Artery Disease

• Terminology chronic ischemic heart disease,
  atherosclerotic heart disease (ASHD), coronary
  artery disease (CAD), coronary atherosclerosis,
  arteriosclerotic heart disease
• All coded to I25.1 atherosclerotic heart
  disease.
• specificity native/graft vein/artery

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Angina CAD

• A history of angina with no documented episode
  occurring during the patients stay in hospital
  is simply a risk factor and may be coded at the
  facilitys discretion with diagnosis type 3
• RULE angina may only be coded as a significant
  diagnosis when there is a documented episode of
  angina on admission or at any given time during
  the hospital stay

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Diagnosis typing for CAD

• In scenario where physician writes CAD with
  angina as MRDx ask yourself where is treatment
  being directed.
• Patients can be treated with either percutaneous
  transluminal coronary angioplasty or coronary
  artery bypass graft
• Depends on circumstances and whether course of
  treatment was directed at unstable angina.

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CABG 1.IJ.76.

• Tissue used for the bypass is coded
• i.e. procurement for saphenous vein or radial
  artery
• When pedicled and free autografts are used the
  qualifier for combined grafts should be selected
• Inherent in CABG code are hypothermia,
  cardioplegia and chest tube insertions
• Code cardiopulmonary bypass (Mandatory)
• Affects CMG assignment

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Other Interventions

• 1.IJ.50. Angioplasty (Dilation, coronary
  arteries)
• Mandatory to include cardiac catheterization with
  attribute intraoperative
• 1.IJ.57. Endarterectomy (Extraction, coronary
  arteries)

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Complications of CAD

• Follow postprocedural conditions and
  complications rules
• If occlusion, thrombosis or stenosis of coronary
  artery grafts occur
• Consider it T82.8 Other complications of cardiac
  and vascular prosthetic devices, implants and
  grafts.
• If due to an atheromaindicative of natural
  process of disease rather than a complication of
  bypass graft

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Natural progress of disease versus occlusion
complication

• Thrombus formation
• Within a month T82.8
• Over a year likely natural progression
• Atherosclerosis changes
• Within a monthpossibly due to a technical error
• Over a year natural progression

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Heart Failure/Cardiac Insufficiency

• Following surgery, patient was taken to the ICU
  for post-operative monitoring where she developed
  congestive heart failure within the first 24
  hours.
• The CHF was not a pre-existing condition

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Folio look-up for CHF

• Failure
• heart (acute) (sudden) I50.9
• complicating
• anesthesia (general) (local) or other
  sedation
• surgery T81.8
• cardiorespiratory (see also Failure, heart)
  R09.2
• specified, during or due to a procedure
  T81.8
• long term effect of cardiac surgery
  I97.1

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• T81.88 (2) Other complications of procedures, NEC
• I50. (3) Heart failure
• Y83.9 (9) Surgical procedure, unspecified as the
  cause of abnormal reaction of the patient, or of
  later complications,..

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Rationale

• Complication of CHF is within the postoperative
  monitoring period of 96 hours
• External cause mandatory. Cause-effect
  relationship.
• Not a pre-existing condition

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• What if patient developed an episode of
  congestive heart failure on day 8 of her stay and
  Lasix was added to her treatment, how would you
  code this?
• CHF is not pre-existing

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Which Rules to Apply?

• I97.1 Other postprocedural disorders of
  circulatory system, NEC
• I97.8 Other postprocedural disorders of
  circulatory system, not elsewhere classified
• T81.88 Other complications of procedures, not
  elsewhere classified
• I50.0 Congestive heart failure

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Late complication

• I97.1 (2) other postprocedural disorders of
  circulatory system, NEC
• I50.0 (3) Congestive heart failure.
• Rationale
• Occurring during hospitalization
• External cause not required
• gt 96 hours, lt 15 days
• No documented evidence of any relationship to the
  intervention.
• Apply External Cause if physician indicates
  postop.

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Pleural Effusion CHF

• Patient comes into hospital with exacerbation of
  CHF and pleural effusion.
• Thoracentesis is done to treat the pleural
  effusion.

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Rules for Pleural Effusion

• (M or 1) I50.0 Congestive heart failure
• (1) J90 Pleural effusion, not elsewhere
  classified
• 1.GV.52.HA Drainage pleura

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Rules for Pleural Effusion

• Rationale
• If Pleural effusion is documented on X-ray only
  no intervention this diagnosis should not be
  coded. (Included in diagnosis of CHF)
• If treatment is directed to effusion by
  therapeutic thoracentesis or chest tube drainage
• the pleural effusion may be coded as an
  additional diagnosis

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Atrial Fibrillation

• Classified as a functional disturbance
• Any code in range of I44 I50 is a functional
  disturbance
• AF following open-heart surgery
• Occurs within postop monitoring period or chart
  documentation indicates related to surgery
• Not pre-existing

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Atrial Fibrillation

• I97.1 (2) Other functional disturbance following
  cardiac surgery
• I48.0 (3) Atrial Fibrillation
• Y83. Surgical operation

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AF gt 95 hours, lt 15 days

• Not related to surgery by documentation
• No assumed cause effect relationship
• I97.8 (2) other postprocedural disorders of
  circulatory system, NEG
• I48.0(3) AF

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Folio lookup Cardiac Arrest

• Arrest, arrested
• -Cardiac I46.9
• - - complicating
• - - - surgery T81.8
• - - postoperative I97.8
• - - - long term effect of cardiac surgery I97.1
• Cannot use both I97.8 and T81.88

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Cardiac Arrest

• Not occurring postprocedural
• Only code if resuscitative intervention is
  undertaken
• I46.0 Cardiac arrest with successful
  resuscitation
• I46.9 Cardiac arrest unspecified
• Occurring as expected terminal event
• Code only underlying or contributing condition.

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Cardiac Arrest following Intervention

• lt 96 hours
• Documentation
• T81.88 (2) Other complications of procedures, NEC
• gt 96 hours, lt 15 days
• I97.8 (2) other post-procedural disorders of
  circulatory system
• I46.0 (3) Cardiac arrest with successful
  resuscitation

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Resuscitation, heart

• New for April 2006
• Code resuscitation, heart NEC when CPR is
  performed, regardless of outcome.
• Code 1.HZ.09. Stimulation, heart NEC when CPR
  is followed by defibrillation.

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Resuscitation, heart why?

• In 2006 the Grouper is going to use high cost
  interventions as a factor in the Resource
  Intensity Weights methodology. This will not
  affect the CMG but will be applied at the RIW
  stage.
• CPR is such an intervention. It will be
  mandatory to code anytime it is performed.

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Interventions

• Cardiac Catheterization
• Affects CMG assignment
• Mandatory
• Cardiopulmonary bypass
• Affects CMG assignment
• Mandatory

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Classification based on MRDx

• MCC 5 Diseases and Disorders of the Circulatory
  System
• MCC 5A Cardiac Diseases and Disorders
• MCC 5B Vascular Diseases and Disorders
• CMG assigned based on whether procedure was
  undertaken or not (surgical or medical partition)

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CMG Examples

• Heart or Lung Transplant CMG 175
• Tracheostomy and Gastrostomy procedure CMG 40
• Surgical Procedures broken down based on heart
  pump usage and/or cardiac catheterizations

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CABG

• No to heart pump
• No to cardiac cath CMG 184 Major
  Cardio-Thoracic Procedures without heart pump and
  without cardiac cath
• Yes to heart pump
• Yes to cardiac cath CMG 183 Major
  Cardio-Thoracic procedures with Heart Pump with
  Cardiac Cath

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Acute Myocardial Infarction

• Factors influencing CMG Assignment
• If shock or pulmonary embolism
• LOS gt 4 days
• If CHF present
• Is there ventricular tachycardia
• Angina present
• Cardiac Catheterization