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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:
  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

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:

• 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

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.

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

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

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.