Endocrinology

Ch 9: Circulatory

ICD-9-CM

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

Ch 9: Circulatory

ICD-10-CM Requirements

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

CVA, document:

  • Location:
  • Precerebral artery
    o  (vertebral, basilar, carotid)
  • Cerebral artery
    o  (right/left…middle, anterior, posterior, cerebellar)
  • Due to:
    o  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)
•    Endomyocardial
•    Endocardial fibroelastos

Ch 9: Circulatory

Notes

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.

Ch 10: Respiratory

ICD-9-CM
  • Severity

Ch 9: Circulatory

ICD-10-CM Requirements

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

CVA, document:

  • Location:
  • Precerebral artery
    o  (vertebral, basilar, carotid)
  • Cerebral artery
    o  (right/left…middle, anterior, posterior, cerebellar)
  • Due to:
    o  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)
•    Endomyocardial
•    Endocardial fibroelastos

Ch 9: Circulatory

Notes

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.

Ch 5: Behavioral Health

ICD 9

General Documentation:

  • Anatomical Site of pain
  • Pain that is exclusively related to psychological disorders
  • Psychological component for a patient with acute or chronic pain
  • If in remission, document based on provider’s clinical judgment and must indicate “in remission”

Psychoactive Substance, indicate:

  • “use”, “abuse” and/or “dependence”
  • If use is associated with a mental or behavioral disorder

Ch 9: Circulatory

ICD-10-CM Requirements

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

CVA, document:

  • Location:
  • Precerebral artery
    o  (vertebral, basilar, carotid)
  • Cerebral artery
    o  (right/left…middle, anterior, posterior, cerebellar)
  • Due to:
    o  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)
•    Endomyocardial
•    Endocardial fibroelastos

Ch 9: Circulatory

Notes

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.

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For more information contact the AMA.

Ch 9: Circulatory

ICD-9-CM

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

Ch 9: Circulatory

ICD-10-CM Requirements

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

CVA, document:

  • Location:
  • Precerebral artery
    o  (vertebral, basilar, carotid)
  • Cerebral artery
    o  (right/left…middle, anterior, posterior, cerebellar)
  • Due to:
    o  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)
•    Endomyocardial
•    Endocardial fibroelastos

Ch 9: Circulatory

Notes

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.

Ch 10: Respiratory

ICD-9-CM
  • Severity

Ch 9: Circulatory

ICD-10-CM Requirements

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

CVA, document:

  • Location:
  • Precerebral artery
    o  (vertebral, basilar, carotid)
  • Cerebral artery
    o  (right/left…middle, anterior, posterior, cerebellar)
  • Due to:
    o  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)
•    Endomyocardial
•    Endocardial fibroelastos

Ch 9: Circulatory

Notes

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.

Ch 5: Behavioral Health

ICD 9

General Documentation:

  • Anatomical Site of pain
  • Pain that is exclusively related to psychological disorders
  • Psychological component for a patient with acute or chronic pain
  • If in remission, document based on provider’s clinical judgment and must indicate “in remission”

Psychoactive Substance, indicate:

  • “use”, “abuse” and/or “dependence”
  • If use is associated with a mental or behavioral disorder

Ch 9: Circulatory

ICD-10-CM Requirements

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

CVA, document:

  • Location:
  • Precerebral artery
    o  (vertebral, basilar, carotid)
  • Cerebral artery
    o  (right/left…middle, anterior, posterior, cerebellar)
  • Due to:
    o  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)
•    Endomyocardial
•    Endocardial fibroelastos

Ch 9: Circulatory

Notes

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.

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