Documentation Guidelines for Cardiology

Determining anatomical location and laterality needed by ICD-10 is simpler than you might suspect. This detail reflects how physicians and clinicians communicate and what they focus on – it involves guaranteeing the data is caught in your documentation. In ICD-10-CM, there are three fundamental classes of changes Definition Change; Terminology Differences; Increased Specificity. For cardiology, the center is increased specificity and documenting the downstream impacts of the patient's condition.

Acute Myocardial Infarction (AMI)

When documenting AMI, include the following:

Timeframe	An AMI is now considered “acute” for 4 weeks from the time of the incident, a revised timeframe from the current ICD-9 period of 8 weeks.
Episode of care	ICD-10 does not capture the episode of care (e.g. initial, subsequent, sequelae).
Subsequent AMI	ICD-10 allows coding of a new MI that occurs during the 4 weeks “acute period” of the original AMI.

(ICD-10 Code Examples: I21.02; I21.4; I22.1)

Hypertension

In ICD-10, hypertension is characterized as essential (primary). The idea of "benign or malignant" as it identifies with hypertension does not exist anymore. While documenting hypertension, incorporate the accompanying:

Type	e.g. essential, secondary, etc.
Causal relationship	e.g. Renal, pulmonary, etc.

(ICD-10 Code Examples: I10; I11.9; I15.0)

Congestive Heart Failure

The terminology utilized in ICD-10 precisely coordinates the sorts of CHF. On the off chance that your archive "decompensation" or "exacerbation," the CHF type will be coded as "acute on chronic." While documenting CHF, incorporate the accompanying:

Cause	e.g. Acute, chronic
Severity	e.g. Systolic, diastolic

(ICD-10 Code Examples: I50.23; I50.33; I50.43)

Underdosing

Underdosing is an important new concept and term in ICD-10. It permits you to distinguish when a patient is taking to a lesser extent a medication than is endorsed. While documenting underdosing, incorporate the accompanying:

Intentional, Unintentional, Non-compliance	Intentional, Unintentional, Non-compliance
Severity	Why is the patient not taking the medication? (e.g. Financial hardship, age-related debility)

(ICD-10 Code Examples: Z91.120; T36.4x6A; T45.526D)

Atherosclerotic Heart Disease with Angina Pectoris

When documenting atherosclerotic heart disease with angina pectoris, include the following:

Cause	Assumed to be atherosclerosis; notate if there is another cause
Stability	e.g. Stable angina pectoris, unstable angina pectoris
Vessel	Note which artery (if known) is involved and whether the artery is native or autologous
Graft involvement	If appropriate, whether a bypass graft was involved in the angina pectoris diagnosis; also note the original location of the graft and whether it is autologous or biologic

(ICD-10 Code Examples: I25.110; I25.710)

Cardiomyopathy

When documenting cardiomyopathy, include the following, where appropriate:

Type	e.g. Dilated/congestive, obstructive or nonobstructive hypertrophic, etc.
Location	e.g. Endocarditis, right ventricle, etc.
Cause	e.g. Congenital, alcohol, etc.

List cardiomyopathy is seen in other diseases such as gout, amyloidosis, etc.

(ICD-10 Code Examples: I42.0; I42.1; I42.3)

Heart Valve Disease

ICD-10 assumes heart valve diseases are rheumatic; if this is not the case, notate otherwise.

When documenting heart valve disease, including the following:

Cause	e.g. Rheumatic or non-rheumatic
Type	e.g. Prolapse, insufficiency, regurgitation, incompetence, stenosis, etc
Location	e.g. Mitral valve, aortic valve, etc.

 (ICD-10 Code Examples: I06.2; I34.1)

Arrhythmias/Dysrhythmia

When documenting arrhythmias, include the following:

Location	e.g. Atrial, ventricular, supraventricular, etc.
Rhythm name	e.g. Flutter, fibrillation, type 1 atrial flutter, long QT syndrome, sick sinus syndrome, etc.
Acuity	e.g. Acute, chronic, etc.
Cause	e.g., Hyperkalemia, hypertension, alcohol consumption, digoxin, amiodarone, verapamil HCl

(ICD-10 Code Examples: I48.2; I49.01)

Legitimate documentation is basic to defending medical necessity and the selection of codes for billing. It recounts the story of a patient visit by recording pertinent facts, findings, and observations. Payers will utilize this documentation to confirm coding choices, site of service, medical necessity, appropriateness, and accurate reporting of furnished services. Every office note should recount a total story and have the option to stand alone. 

Indeed, even little documentation errors can wind up causing claims denials, and with all the voluminous claims record that accompanies cardiology billing and coding, it very well may be a decent option for your training to re-appropriate your billing and coding. Through rethinking, numerous cardiology practices can improve billing and coding effectiveness so they're ready to invest more energy zeroing in on offering patients quality patient consideration. Medical Billers and Coders (MBC) is a legitimate medical billing and coding organization that offers the most excellent service for customers the nation over. To study cardiology medical billing and coding contact us today at 888-357-3226/info@medicalbillersandcoders.com 

Reference: Clinical Concepts for Cardiology

Get in Touch

Email: info@medicalbillersandcoders.com

Toll-Free no: 888-357-3226