Hypertension (HTN):

• Benign
• Malignant
• Unspecified

Coronary Artery Disease (CAD) (Atherosclerosis/Ischemia):

• Native Coronary Artery
• Graft type
• NonautologousAcute Myocardial Infarction (AMI) defined as duration of 8 weeks or less.

Cerebral Infarction / Cerebrovascular Accident (CVA):

• Occlusion
• Thrombosis
• Embolism

General Documentation:

• Site specificity, when applicable
• Laterality (right, left, bilateral), when applicable

HTN (no distinction of status/type), document if:

• With heart involvement (and with heart failure, if applicable)
• With kidney involvement, specify:
  –  Stage 1 thru 5, or ESRD
• Secondary

CAD, document:

• Specific artery (default is native artery)
• With angina (specify: stable or unstable) or without angina

AMI (redefined as duration of 4 weeks {28 days} or less), document:

• Location:
  –  Anterior wall (left main, left anterior descending or other coronary artery)
  –  Inferior wall (right or other coronary artery)
  –  Other sites (left circumflex coronary artery or other site)
• ST elevation (STEMI) or Non-ST elevation (NSTEMI)

CVA, document:

• Location:
• Precerebral artery
  –  (vertebral, basilar, carotid)
• Cerebral artery
  –  (right/left…middle, anterior, posterior, cerebellar)
• Due to:
  –  Thrombosis, embolism, occlusion or stenosis

Heart Failure/CHF, document:

•     Left ventricle, systolic, diastolic, combined
•    Acute, chronic, acute on chronic (decompensated)

Cardiomyopathy, document:

•    Dilated
•    Hypertrophic (obstructive, other)
•    Other Restrictive
•    Due to: alchohol, drug or external agent

   Atrial fibrillation, document:

• Paroxysmal, persistent or chronic

Atrial flutter, document:

• Typical or atypical

No distinction of HTN status/type.
CAD with or without angina inclusive in one code.
AMI redefined as duration of 4 weeks (28 days) or less.

• Severity

General Documentation:

• Document causal organism

Asthma, document:

• Severity:

– Mild intermittent
– Mild persistent
– Moderate persistent
– Severe persistent
– Other

• Complication:

– With acute exacerbation

– With status asthmaticus

– Uncomplicated
Bronchitis, document:

• Acute, and document causal organism
• Chronic, and document if simple, mucopurulent or mixed

Allergic rhinitis, document:

• Pollen
• Other seasonal
• Food
• Animal (cat)(dog) hair and dander
• Other

Sinusitis, document:

• Acute (and if recurrent) or chronic
• Site:

– Maxillary
– Frontal
– Ethmoidal
– Sphenoidal
– Pansinusitis

No documentation changes from ICD- 9-CM to ICD-10-CM. Column to the left are common documentation pitfalls that may have been missed while documenting I-9. Emphasizing the importance of documenting for I- 10.