February 14, 2012
OI053

Mary Jo Groome, CCS-P, CPC-H
Sr. Coder Trainer
O1049

♥ Heart disease is a general term that involves a wide range of diseases affecting the heart and blood vessels, including the following:
Coronary artery disease (CAD) Category 414
Arrhythmias
Congenital heart defects
Cardiomyopathy
Heart infections
Valvular heart disease
Category 427
Categories 745 - 746
Category 425
Categories 420 - 424
Category 424
© OptumInsight, Inc. 3

 Etiology may be:
– Idiopathic
• Heart disease
– Arteriosclerosis
– Rheumatic heart disease
– Noncardiac
• Thyrotoxicosis
• Alcoholism
• Trauma
• IV drug use
© OptumInsight, Inc. 4

 Common symptoms of arrhythmias include:
– tachycardia (fast heartbeat)
– bradycardia (slow heartbeat)
– palpitations or skipped beats
– weakness or fatigue
– syncope or near syncope
 A heart arrhythmia may not cause any symptoms and may be identified only during a regular routine exam.
© OptumInsight, Inc. 5

 Many cardiac dysrhythmias are chronic
 Acute cardiac dysrhythmias can occur in
– Acute infection
– Digitalis toxicity
 The selection of dysrhythmia codes is dependent on documentation that could include disturbances in cardiac rate and rhythm, including abnormalities in the rate, regularity, and sequence of atrial and/or ventricular contractions.
 When there is no clear diagnosis, document and code SX/sx which may include fatigue, light-headedness, decreased exercise tolerance, or syncope, but often there are no symptoms.
© OptumInsight, Inc. 6


Can these cardiac dysrhythmias be documented and coded to a higher level of specificity?
– Specified Heart Arrhythmias
(HCC 92; Factor 0.293)
•
426.0
Atrioventricular block, complete - Third degree atrioventricular block
• 427.0
Paroxysmal supraventricular tachycardia – Rapid atrial rhythm
•
427.1
Paroxysmal ventricular tachycardia - Rapid ventricular rhythm
•
427.2
Paroxysmal tachycardia, unspecified
•
427.31
Atrial fibrillation - Irregular, rapid atrial contractions
•
427.32
Atrial flutter - Regular, rapid atrial contractions
•
427.81
Sinoatrial node dysfunction (severe sinus bradycardia, sinus bradycardia with tachycardia, or sinus bradycardia with atrioventricular block)
– Arrhythmic-Cardiac Failure
(HCC 79; Factor 0.578)
•
427.42
Ventricular flutter - Regular, rapid ventricular contractions
• 427.41
Ventricular fibrillation - Irregular, rapid ventricular contractions
•
427.5
Cardiac arrest
–Cardiorespiratory arrest
© OptumInsight, Inc. 8

Specified Heart Dysrhythmias
HCC 92 Factor 0.293
427.0
Paroxysmal supraventricular tachycardia
Rapid atrial rhythm
427.1 Paroxysmal ventricular tachycardia
Rapid ventricular rhythm
427.2 Paroxysmal tachycardia, unspecified
Idiopathic rapid heart action w/ sudden onset and cessation (Essential)
© OptumInsight, Inc. 9

Specified Heart Dysrhythmias
HCC 92 Factor 0.293
427.31
Atrial fibrillation
Irregular, rapid atrial contractions
427.32
Atrial flutter
Regular, rapid atrial contractions
427.81
Sinoatrial node dysfunction
- Appears as severe sinus bradycardia,
- sinus bradycardia with tachycardia or
- sinus bradycardia with atrioventricular block
© OptumInsight, Inc. 10

Specified Heart Dysrhythmias
HCC 79 Factor 0.578
427.42
Ventricular flutter
Regular, rapid ventricular contractions
427.41
Ventricular fibrillation
Irregular, rapid ventricular contractions
427.5
Cardiac arrest
Cardiorespiratory arrest
© OptumInsight, Inc. 11

427.89 Cardiac Dysrhythmia,
Other Specified
(i.e. rhythm disorder)
427.9
Cardiac
Dysrhythmia NOS
(i.e. cardiac arrhythmia)
Caution: These are type & location non-specific heart dysrhythmia codes.
• Coding dysrhythmias to a higher level by specific type & location of dysrhythmia places these members into the correct HCC category for expected medical resource utilization.
© OptumInsight, Inc. 12

 Cardiovascular Disease:
Atrial Fibrillation vs. Atrial Flutter
– Atrial Fibrillation (427.31) is the most common form of cardiac dysrhythmia, characterized by rapid, randomized contractions of the atrial myocardium causing a totally irregular , often rapid ventricular rate (400-600 per min) and may occur in patients with and without other heart disease. Medications may include Verapamil, Diltiazem, Digoxin, Metoprolol, and Lanoxin to name a few; and cardioversion may be necessary in some instances.
– Atrial Flutter (427.32) is a condition of cardiac dysrhythmia in which the atrial contractions are rapid (200-300 per min), yet regular .
The ventricles are unable to respond to each atrial impulse, so that a partial block is usually present. Atrial flutter frequently occurs in patients with COPD, CAD, and CHF.
Treatment may include Amiodarone, Sotalol, Bretylium, and cardioversion may be utilized, radiofrequency ablation may also be used for patients with chronic atrial fibrillation.
• Atrial flutter rarely occurs as an isolated rhythm; it is usually associated with atrial fibrillation .
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter .
Retrieved from http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%2
0Fibrillation.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
© OptumInsight, Inc. 14

 Atrial fibrillation (A-Fib) associated with underlying disease should be coded along with the underlying disease (e.g., hypertension, hyperthyroidism, congestive heart failure, valvular heart disease, cardiomyopathy), with the A-Fib considered a complication or endpoint 427.31
(I48.0) .
– This guideline addresses Lone A-Fib, a misleading term in the cardiac literature which would be better termed idiopathic A-Fib.
• Lone (or idiopathic) A-Fib is defined as A-Fib without structural heart disease, hyperthyroidism or hypertension in patients under age 60 at presentation .
• Lone A-Fib may occur as a single isolated episode, recurrent paroxysmal events or chronically persistent A-Fib .
– Single idiopathic episode often has an identifiable precipitating cause, such as acute abuse of alcohol and /or stimulants (holiday heart syndrome).
» Two sets of codes required (substance abuse & A-Fib)
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter . Retrieved from http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%20Fibrill ation.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
© OptumInsight, Inc. 15

 List first the diagnosis code for the condition, problem, or other reason for the encounter/visit to be chiefly responsible for the services provided.
– Also list additional codes that describe any coexisting conditions.
 Accurate reporting of ICD-9-CM codes is important, and the documentation should describe the patient’s condition, using terminology which includes:
– Specific diagnoses as well as symptoms, problems, or reasons for the encounter.
OptumInsight, 2012. Coders' Desk Reference for Diagnoses: Official ICD-9-CM Coding Guidelines for Coding and
Reporting . USA: Ingenix, 2011. 61-2. Print.
© OptumInsight, Inc. 16

 Even though the patient presents for care with condition(s) not chiefly regarding the A-fib, it is appropriate to assign a code for chronic A-fib ( 427.31
) as an additional code, providing the condition has been evaluated and is listed in the final diagnostic statement.
– The coding rationale is that the patient requires ongoing medication for control of this condition.
•
Do not assign codes solely from lab reports, medication sheets, (EKG,) etc.
•
If treatment of A-fib includes chronic use of anticoagulants (except aspirin), code also
V58.61
Longterm “current” use of anticoagulants.
AHA, Coding Clinic . 3rd Q. USA: American Hospital Association, 1995. Print.
© OptumInsight, Inc. 17

 Medications and/or radiofrequency ablation are used for long term management of paroxysmal and chronic A-Fib and atrial flutter.
– Paroxysmal and chronic A-Fib often require chronic treatment with an atrioventricular (AV) node blocking medication, such as a beta blocker, calcium channel blocker or digitalis for ventricular rate control.
– Atrial flutter can also be treated with AV node blocking medication, but control is often difficult to achieve.
– Both A-Fib and atrial flutter may also be treated by radiofrequency ablation .
• Ablation of atrial flutter is very low risk, technically simple and essentially 100% curative.
• Radiofrequency ablation for A-Fib is 70 to 85% effective in individuals with paroxysmal A-Fib and 50 to 70% in individuals with chronic A-Fib .
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter . Retrieved from http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%20Fibrillat ion.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
© OptumInsight, Inc. 18

 Coding Considerations – If the patient’s ablation
(electrophysiological procedure) has resolved the A-fib condition:
– Members that have undergone the ablation procedure can be considered “ cured ” only if clinical documentation supports a
“ resolved
” condition:
• Assign V12.50
(History of disease, cardiovascular system)
• Do not assign the A-Fib code ( 427.31
)
American Society of Aerospace Medicine Specialists, . (2011, January 12). Clinical practice guideline for atrial fibrillation and atrial flutter . Retrieved from http://webcache.googleusercontent.com/search?hl=en&q=cache:iJrL4UpyAb8J:http://www.asams.org/guidelines/Completed/NEW%20Atrial%20Fibrillat ion.htm+ICD-9+Coding,+A-fib,+as+a+chronic+condition,+after+ablation&ct=clnk
© OptumInsight, Inc. 19


729.92
Nontraumatic hematoma of soft tissue
427.31
Chronic atrial fibrillation
V58.61
Long-term (current) use of anticoagulants
E934.2
Drugs, medicinals causing adverse effects in therapeutic use
(anticoagulants)

782.7
Spontaneous ecchymoses (petechiae)
427.31
Chronic atrial fibrillation
V58.61
Long-term (current) use of anticoagulants
E934.2
Drugs, medicinals causing adverse effects
AHA , Coding Clinic . 4 th in therapeutic use
(anticoagulants)
© OptumInsight, Inc. 20

 Postop A-fib
997.1
Cardiac complications
427.31
Atrial fibrillation
Note: The instructions at the category heading of 997 in the Tabular of ICD-9-CM tell us to “Use additional code to identify complications.”
© OptumInsight, Inc. 21

 Cardiomyopathy is a disease
– involving changes in the heart muscle
– that may interfere with the heart’s ability to pump effectively
– that may lead to a chronic condition called heart failure
– that is sometimes associated with other chronic conditions
• High blood pressure
• Heart valve disease
 Cardiomyopathy presents a clinical picture of:
– Dilated heart
– Flabby heart muscle
© OptumInsight, Inc. 23

 The term “ cardiomyopathy ” may be used for a disease or disorder classified elsewhere. Indexing is essential.
– Examples:
• “Ischemic cardiomyopathy” indexes to 414.8 (Other specified forms of chronic ischemic heart disease)
– not a true cardiomyopathy; causes diffuse fibrosis or multiple infarction, leading to heart failure with left ventricular dilation
• “Stress induced cardiomyopathy” indexes to 429.83 (Takotsubo syndrome), found under 429.8 (Other ill-defined heart disease)
© OptumInsight, Inc. 24

Includes Myocardiopathy
425.0
Endomyocardial fibrosis
425.1x
Hypertrophic cardiomyopathy (HCM)
* 425.11
Hypertrophic obstructive cardiomyopathy
( Usually an inherited condition in which the heart muscle becomes thick without any obvious cause. Younger people usually present with a severe form of HCM that is frequently asymptomatic and a leading cause of sudden cardiac death in young athletes.) 1
* 425.18
Other hypertrophic (not described as obstructive)
425.2
Obscure cardiomyopathy of Africa
425.3
Endocardial fibroelastosis
(Congenital condition characterized by thickening of the endocardium with malformation of cardiac valves, hypertrophy of the heart and proliferation of elastic tissue in the myocardium.
Many patients due not survive infancy.) 2
* New code in 2012 – no RA designation
Ref: 1 F.Brown’sICD-9-CM Coding Handbook 2012 p 341
Ref 2: 2012 Coders’ Desk Reference p 412
© OptumInsight, Inc. 25

425.4
Other primary cardiomyopathies ( J42.8 Other cardiomyopathies )
NOS congestive constrictive familial idiopathic obstructive restrictive cardiovascular collagenosis
Note: Cardiomyopathy can result in diastolic dysfunction. If documentation identifies the diastolic dysfunction is due to cardiomyopathy, use code 425.4
425.5
Alcoholic cardiomyopathy
Heart disease as result of excess alcohol consumption
Note: If documentation indicates the patient is alcohol dependent
( 303.0x or .9x
), this should also be coded
2012 Coders’ Desk Reference p 413
© OptumInsight, Inc. 26

425.7
Nutritional and metabolic cardiomyopathy
Code first underlying disease, as: amyloidosis (277.30-277.39) beriberi (265.0) cardiac glycogenoisis (271.0) mucopolysaccharidosis (277.5) thyrotoxicosis (242.0-242.9)
425.8
Cardiomyopathy in other diseases classified elsewhere J43
Code first underlying diseases, as:
Friedreich’s ataxia (334.0) myotonia atrophica (359.21) progressive muscular dystrophy (359.1) sarcoidosis (135)
425.9
Secondary cardiomyopathy, unspecified
© OptumInsight, Inc. 27

 A patient is seen in the clinic for evaluation of treatment for hypertensive cardiomyopathy. Record documentation identifies that the cardiomyopathy was secondary to hypertensive heart disease.
– 402.90
Unspecified hypertensive heart disease without heart failure
– 425.8
Cardiomyopathy in other diseases classified elsewhere
 A patient is seen having congestive heart failure and congestive cardiomyopathy.
– 428.0
Congestive heart failure
– 425.4
Other primary cardiomyopathies
© OptumInsight, Inc. 28