Cardio and Pulmonary

Ch 9: Circulatory


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:
    –  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

Ch 9: Circulatory


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

  • Severity

Ch 10: Respiratory

ICD-10-CM Requirements

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

Ch 10: Respiratory


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.