Cardiology billing and coding comes with unique challenges such as frequent code changes, complex procedure guidelines, and varying payer rules. Knowledge about current cardiology medical billing codes and documentation and compliance updates is essential to report services correctly. ICD-10 offers specific codes that allow providers, staff, and coders to code as specifically as possible.
Causes and Symptoms
Caused mainly by high blood pressure, hypertensive heart disease is the leading cause of death for both men and women in the United States. Hypertensive heart disease is a group of disorders that includes heart failure, left ventricular hypertrophy (thickening of the heart muscle), coronary artery disease, and other conditions.
Symptoms of hypertensive heart disease vary based the severity of the condition and progression of the condition, though some patients experience no symptoms. Common symptoms include high blood pressure, enlarged heart and irregular heartbeat, fluid in the lungs or lower extremities, and unusual heart sounds. Signs that help physicians diagnose the condition include shortness of breath, chest pain (angina),tightness or pressure in the chest, fatigue, chronic cough, pain in the neck, back, arms, or shoulders, leg or ankle swelling, and nausea.
Hypertensive Heart Disease: ICD-10 Coding
ICD-10 presumes a causal relationship between hypertension and heart involvement since the two conditions are linked by the term “with” in the Alphabetic Index. The guidelines state that these conditions should be coded as related even if there is no provider documentation explicitly linking them. For hypertension and conditions not specifically linked by relational terms such as “with,” “associated with” or “due to” in the classification, provider documentation must link the conditions in order to code them as related. On the other hand, if the documentation clearly states the conditions are unrelated, they can be reported separately.
ICD-10 offers specific codes to report hypertensive heart disease and associated conditions.
Hypertension with heart conditions (such as but not limited to: cardiomegaly, heart failure, myocardial degeneration and myocarditis classified to I50. – or I51.4-I51.7, I51.89, I51.9), are assigned a combination code from category I11 – hypertensive heart disease
CategoryI11, Hypertensive heart disease has two codes to indicate if heart failure is present:
I11.0 Hypertensive heart disease with heart failure
I11.9 Hypertensive heart disease without heart failure
A note under I11.0 states: “Use additional code to identify type of heart failure (I50.-).”
The code for systolic heart failure is I50.2 and the code for diastolic heart failure is I50.3-. Combined systolic and diastolic heart failure is coded with I50.4. Fifth characters in the code further specify whether the heart failure is unspecified, acute, chronic or acute on chronic.
I50.1, Left ventricular failure, unspecified
I50.2, Systolic (congestive) heart failure
I50.3, Diastolic (congestive) heart failure
I50.4, Combined systolic (congestive) and diastolic (congestive) heart failure
Other heart conditions that have an assumed causal connection to hypertensive heart disease:
I50.810, Right heart failure, unspecified
I50.811, Acute right heart failure
I50.812, Chronic right heart failure
I50.813, Acute on chronic right heart failure
I50.814, Right heart failure due to left heart failure
I50.82Biventricular heart failure
I50.83 High output heart failure
I50.84, End-stage heart failure
I50.89, Other heart failure
First, report code I11.0, hypertensive heart disease with heart failure as instructed by the note at category I50, heart failure. Report an additional code from category I50- heart failure to specify the type of heart failure. To assign the most specific code from category I50, the documentation needs to indicate the type of heart failure. For example:
Congestive heart failure due to hypertension: I11.0 + I50.9
Hypertensive heart disease with congestive heart failure: I11.0 + I50.9
A diagnosis of left ventricular, biventricular and end-stage heart failure requires two codes to completely describe the condition: one to identify the left, biventricular or end-stage heart failure, and one to report the type of heart failure.
When the heart condition is unrelated to hypertension: If the provider specifically documents a different cause for the hypertension and the heart condition, the heart condition (I50.-, II51.4-I51.9) and hypertension should be coded separately and the combination code is not used. In such cases, the codes should be sequenced according to the circumstances of the admission/encounter. AAPC provides the following example:
For a patient discharged with a diagnosis of exacerbated chronic diastolic congestive heart failure and a secondary diagnosis of hypertension, the codes to report are:
I11.0 Hypertensive heart disease with heart failure
Code Tobacco Use or Exposure: Code tobacco use if documented. An instructional note provided for categories I11 states to use an additional code to identify exposure to environmental tobacco smoke (Z77.22), history of tobacco use (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17-) or tobacco use (Z72.0). For example:
I11.0 Hypertensive heart disease with heart failure
Ensure Proper Clinical Documentation: Good clinical documentation is essential to code to the highest level of patient specificity. The documentation should include the status of the patient and the type of hypertension being treated and findings to support the diagnosis of hypertension and the current manifestations when applicable. Secondary diagnoses, such as systolic/diastolic heart failure and/or chronic kidney disease should be documented. A valid treatment plan should be documented in the form of: medication, referral, diet, monitoring, and/or ordering a diagnostic exam. Appropriate blood pressure targets must be clearly stated in the treatment plan.
Coding for hypertension requires attention to detail and a proper understanding of the ICD-10 guidelines. Medical billing and coding outsourcing to an experienced provider can ensure accurate coding and compliance for accurate claims submission and appropriate reimbursement.
Cardiac conditions refer to cardiovascular or heart diseases that affect the structures or function of heart. According to the WHO, cardiovascular diseases (CVDs) are the leading cause of death globally, taking an estimated 17.9 million lives each year, and more than four out of five CVD deaths are due to heart attacks and strokes. Proper documentation and coding is essential to streamline the cardiology billing process. Cardiologists and other specialists treating such conditions can choose a professional medical coding company to report the diagnosis and treatments accurately on their medical claims.
Here are some common cardiac conditions and the ICD-10 codes to report them.
Coronary Artery Disease
Coronary artery disease (CAD) occurs when the heart’s blood vessels – the coronary arteries – become narrowed or blocked and fail to supply enough blood to the heart. The condition can lead to angina or a heart attack. For patients with angina in the setting of CAD, coders will choose a combination code in ICD-10-CM that identifies CAD and the presence of angina pectoris as well as its type, if specified.
To report CAD in a transplanted heart, coders can use I25.75- for CAD of the native artery and I25.76- for CAD of a bypass graft.
For patients without angina pectoris, coders can use I25.10.
I25 Chronic ischemic heart disease
I25.1 Atherosclerotic heart disease of native coronary artery
I25.10 …… without angina pectoris
I25.11 Atherosclerotic heart disease of native coronary artery with angina pectoris
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 …… with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
Heart attack or myocardial infarction (MI) occurs when one or more coronary arteries that supply blood to the heart muscles become completely blocked. This blockage of a coronary artery deprives the heart muscle of blood and oxygen, causing injury to the heart muscle. During documentation, myocardial infarction is classified as ST elevation myocardial infarctions (STEMI) or non-ST elevation myocardial infarctions (NSTEMI).
It is also important to document the location of the infarction (Anterior wall, Inferior wall or Other), onset of MI (8 weeks or less, 4 weeks or less) and episode of care (Initial or Subsequent episode of care, Event or Initial and/or Subsequent).
I21 Acute myocardial infarction
I21.0 ST elevation (STEMI) myocardial infarction of anterior wall
I21.1 ST elevation (STEMI) myocardial infarction of inferior wall
I21.2 ST elevation (STEMI) myocardial infarction of other sites
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
Coders should also be able to distinguish cerebral and precerebral arteries because ICD-10-CM codes make this distinction. The codes I60-I62 specify the location or source of a hemorrhage as well as its laterality.
I60 Nontraumatic subarachnoid hemorrhage
I60.0 Nontraumatic subarachnoid hemorrhage from carotid siphon and bifurcation
I60.1 Nontraumatic subarachnoid hemorrhage from middle cerebral artery
I61 Nontraumatic intracerebral hemorrhage
I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical
I61.1 Nontraumatic intracerebral hemorrhage in hemisphere, cortical
I62 Other and unspecified nontraumatic intracranial hemorrhage
I62.0 Nontraumatic subdural hemorrhage
I62.1 Nontraumatic extradural hemorrhage
Code I63 specifies the cause of the ischemic stroke such as thrombosis or unspecified, specific location and laterality of the occlusion.
I63 Cerebral infarction
I63.0 Cerebral infarction due to thrombosis of precerebral arteries
I63.1 Cerebral infarction due to embolism of precerebral arteries
I63.4 Cerebral infarction due to embolism of cerebral arteries
I63.40 Cerebral infarction due to embolism of unspecified cerebral artery
I63.41 Cerebral infarction due to embolism of middle cerebral artery
I63.5 Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery
I63.51 Cerebral infarction due to unspecified occlusion or stenosis of middle cerebral artery
I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I63.8 Other cerebral infarction
I63.81 …… due to occlusion or stenosis of small artery
I63.89 Other cerebral infarction
I63.9 Cerebral infarction, unspecified
For a patient with a history of cerebrovascular disease without any neurologic deficits, use the code Z86.73 and a code for the cerebral infarction without residual deficits (not code I69).
Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Cardiomyopathy is a condition that causes the heart muscle to become enlarged, thick, or rigid. As this disorder progresses, the heart becomes weaker and can lead to heart failure, blood clots or irregular heartbeats called arrhythmias. ICD-10-CM has unique codes for the different types of cardiomyopathy.
I42 – Cardiomyopathy
I42.0 – Dilated cardiomyopathy
I42.1 – Obstructive hypertrophic cardiomyopathy
I42.2 – Other hypertrophic cardiomyopathy
I42.3 – Endomyocardial (eosinophilic) disease
I42.4 – Endocardial fibroelastosis
I42.5 – Other restrictive cardiomyopathy
I42.6 – Alcoholic cardiomyopathy
I42.7 – Cardiomyopathy due to drug and external agent
I42.8 – Other cardiomyopathies
I42.9 – Cardiomyopathy, unspecified
I43 – Cardiomyopathy in diseases classified elsewhere
Atrial fibrillation refers to irregular heartbeat or arrhythmia that can cause a patient to develop blood clots, stroke, heart failure or other conditions. When reporting multiple types of atrial fibrillation in the record, select the most specific type.
I48.9 Unspecified atrial fibrillation and atrial flutter
I48.91 Unspecified atrial fibrillation
Clear documentation is important for accurate and proper medical coding. To report conditions using correct diagnosis and procedure codes and to submit error-free medical claims, practices can rely on experienced cardiology medical billing service providers. Make sure that the coders are familiar with changing coding and billing standards.
Like many other medical specialties, cardiology is also facing coding and reimbursement changes in 2019. While outsourcing cardiology coding to an experienced medical billing and coding company can ensure accurate claim submission and optimal reimbursement, hospitals and surgery centers need to stay up to date on these changes.
For cardiology, ICD-10 generally focuses on increased specificity to describe the patient’s condition. The changes for cardiovascular and cardiothoracic services in 2019 are as follows:
Updates for Cerebral InfarctionAdditions: The following code additions have been made to the Cerebral Infarction category (category I63):
I63.81 – Other cerebral infarction due to occlusion or stenosis of small artery (this code also covers lacunar infarction)
I63.89 – Other cerebral infarction
R29.7 – ICD-10-CM code for the National Institute of Health Stroke Scale (NIHSS) on patients diagnosed with a stroke can be reported in conjunction with acute stroke codes (I63) to identify the patient’s neurological status and the severity of the stroke. The stroke scale codes should be sequenced after the acute stroke diagnosis code(s). At a minimum, the initial score documented should be reported. Multiple stroke scale scores can also be captured if required.
Note: An instructional note under category I63- instructs that an additional code be reported, if applicable, to identify status post administration of tPA (rtPA) in a different facility with the last 24 hours prior to the patient’s admission to the current facility (Z92.82).
Revisions: There are changes to the descriptors for 219 and 239, where the word arteries has been changed to artery:
I63.219 (Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral artery) and
I63.239 (… unspecified carotid artery). In both descriptors, the current word “arteries” has changed to “artery.”
There are also revisions to the descriptors for the following codes with the addition of the word ‘due’:
I63.333 (Cerebral infarction due to thrombosis of bilateral posterior cerebral arteries)
I63.343 (Cerebral infarction due to thrombosis of bilateral cerebellar arteries).
New Subcategory for Category I67Category I67 (Other cerebrovascular disease) now has a new subcategory I67.85 – for hereditary cerebrovascular diseases. This subcategory includes the following news codes:
I67.850 – Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL is also included with this diagnosis)
I67.858 – Other types of hereditary cerebrovascular disease
Under I67.850 i.e. other cerebrovascular diseases there’s a new code which instructs you to report any associated diagnoses. This includes epilepsy and recurrent seizures G40 -; cerebral infarction I63.-; and vascular dementia F01.-.
Note: A new “code also” note under I67.850 (Other cerebrovascular diseases) instructs also reporting any associated diagnoses such as epilepsy and recurrent seizures (G40.-); cerebral infarction (I63.-); and vascular dementia (F01.-).
T81.11XS Post-procedural cardiogenic shock, the sequel
New Guidelines to Code Hypertension with Heart DiseaseMedical coding service providers also need to note the changes in official guidelines on coding hypertension with heart disease and pulmonary hypertension. A report in electronichealthreporter.com explains these new 2019 guidelines as follows:
Coding hypertension with heart disease: In 2018, section I.C.9.a.1 of the official guidelines (Hypertension with Heart Disease) stated that “Hypertension with heart conditions classified to I50.- or I51.4-I51.9 are assigned to a code from category I11, Hypertensive heart disease.”In the 2019, the guidelines change the code listing to “I50.- or I51.4-I51.7, I51.89, I51.9.” Additional code(s) from category I50.- (Heart failure) will continue to be used to identify the heart failure type, when applicable, but in 2019, I51.81 (Takotsubo syndrome) has been removed from the guideline.
There is an additional clarification for the instruction in the Hypertension with Heart Disease subsection about when to code those heart conditions separately from the hypertension. The wording has changed in 2019 as follows:2018: “if the provider has specifically documented a different cause”
2019: “if the provider has documented they are unrelated to the hypertension.”
The wording for the Hypertensive Chronic Kidney Disease subsection also sees a change:2018: “CKD should not be coded as hypertensive if the physician has specifically documented a different cause.”
2019: “CKD should not be coded as hypertensive if the provider indicates the CKD is not related to the hypertension.”
Changes for Pulmonary HypertensionCoders should also become familiar with the redefined sequencing rules for pulmonary hypertension in 2019.2018: For secondary pulmonary hypertension, the guideline stated that you should “code also” associated conditions or adverse effects of drugs or toxins and base the sequencing on the reason for the encounter.
2019: The instruction to base sequencing on the reason for the encounter “except for adverse effects of drugs (section I.C.19.e)” has been revised. The section referenced covers coding for Adverse Effects, Poisoning, Underdosing, and Toxic Effects.
Acute myocardial infarction (AMI) interventionsThe 2019 guidelines expand clarifications on how to code properly for AMI. A new instruction states, “If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type, assign the appropriate codes from category I21 [Acute myocardial infarction] to identify each type. Do not assign a code from I22 [Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction].”The guidelines also clarify that, “Codes from category I22 should only be assigned if both the initial and subsequent myocardial infarctions are type 1 or unspecified.”
The best option for cardiologists to ensure compliance with the new coding guidelines and receive the maximum reimbursement for their services is to outsource coding and billing to an experienced cardiology medical coding company.
Comprehensive medical coding services are available across various specialties and coding complexity increases for patients with multiple health conditions. One medical condition often increases the risk of developing other conditions. A new study has found that preterm birth increases risk of cardiovascular disease (CVD) in mothers. Though previous studies have established the link between premature delivery and CVD later in life, researchers further investigated the link. Latest statistics from the Centers for Disease Control and Prevention (CDC) show that around 1 in 10 babies in the United States are born prematurely.
The team from the Harvard T.H. Chan School of Public Health studied existing data on 70,182 women from the Nurses’ Health Study 2 – one of the largest ongoing investigations into the risk factors for major chronic diseases in women. The researchers found that:
After adjusting for factors such as the mother’s age, education, and lifestyle before the pregnancy, as well as CVD risk factors, women who have a preterm delivery have a 40 percent higher increased risk of CVD later in life.
Women who delivered earlier than 32 weeks had twice the risk of developing CVD.
The risk increased for women who had more than one preterm delivery
Women generally have 33 percent higher risk of dying from CVD and this rises to 36 percent for those who give birth 3 to 7 weeks before term, and to 60 percent for mothers who deliver 8 or more weeks early.
The increased risk remained even if the preterm births were not complicated by hypertension disorders during pregnancy.
The team recommended that adopting a heart-healthy lifestyle could reduce the risk of women developing heart disease later in life. The researchers said that further research is needed to establish the pathways linking premature delivery and CVD. Preterm birth is a concern for babies too as those born too early may not be fully developed.
Under ICD-10-CM, obstetric medical coding has a greater level of specificity than under ICD-9-CM. Most of the codes have a final character identifying the trimester of pregnancy in which the condition occurred. However, this rule does not apply for all conditions since certain obstetric conditions or complications occur during certain trimesters. For example, take preterm labor for which the ICD-10 code is 060. Preterm labor without delivery can take place only in either the second or third trimester. Therefore, we have:
Subcategory O60.0, Preterm labor without delivery, which is further subdivided as
O60.00, Preterm labor without delivery unspecified trimester
O60.02, Preterm labor without delivery, second trimester, and
O60.03, Preterm labor without delivery, third trimester
O60.1 – Preterm labor with preterm delivery
O60.10 – Preterm labor with preterm delivery, unspecified trimester
O60.12 – Preterm labor second trimester with preterm delivery second trimester
O60.13 – Preterm labor second trimester with preterm delivery third trimester
O60.14 – Preterm labor third trimester with preterm delivery third trimester
These obstetric codes also require the use of a seventh character extension – 1 through 9 – to identify the fetus in a multiple gestation that is affected by the condition being coded. The appropriate code from category O30, Multiple gestation, must also be assigned when using a code from this category that has a seventh character of 1 through 9. The ICD-10 code series for supervision of a pregnancy with a history of preterm labor is O09.211 – O09.219.
Revised, expanded, and new ICD-10 obstetric diagnostic codes took effect in October 2016. Established physician coding companies have expert coders who can help ob-gyns tackle the complexities involved in obstetrics and gynecology medical billing and coding to maximize reimbursement.
The Cardiology track of the 6th Annual Specialty Coding extravaganza meet is scheduled for February 13-14 in Orlando. This is a good opportunity to listen to cardiology coding pro Linda Gates-Striby as she is sure to take your cardiology coding knowledge to a higher level. She will focus on the following topics:
Caths and interventions: Get the first-ever opportunity to code along with actual case movies of cardiac catheterizations and interventions from an actual cath lab, so you can see the procedure and code it with her hands-on supervision.
Remote device monitoring: Increased utilization of Internet device checks because of device recalls put your coding for these services under Medicare and private payer microscopes. Learn how your frequencies compare to others, find out how to document your medical necessity for the increased visits, and learn just what is a reasonable frequency for pacemaker checks (which have coding guidelines) and ICD checks (that don’t).
Cardiac CTA: Get tested tips on coding these state-of-the-art multi-slice scans, and find out what payers think are billable indications, as the 128 and 256 slice scanners hit the scene. Also, find out to how to bill/code for CTA outside the heart – if your practice has bought the scanner, your physicians are likely looking for other areas to scan to recoup their costs.
A Fib ablations: Find out the top reasons your atrial fibrillation ablation procedures are getting denied – and what you can do about it. Get tips on how to correctly bill for a transseptal puncture (Hint: Stay away from the diagnostic cardiac cath codes), and how to bill for an ablation with an EP study.
Coming trends: Discover some of what you can anticipate in 2008: T Wave Alternans testing, protime clinics moving to the hospital, the future of Doppler color flow, coverage of the CPT codes for anticoagulant management, reimbursement for nuke and other in-office imaging services, and much more.
If interested in the Interventional Procedure track go to http://www.extrav2008.com/st_int.html Other medical specialties at the extravaganza include, gastroenterology, general surgery , interventional procedures , multi-specialty , ob-gyn , orthopedics , pain management , pediatrics , primary care and urology.
The Cardiology Coding and Reimbursement Conference conducted by the Coding Institute will be held in Denver from April 13-15, 2008. The preconference workshop will be on Sunday April the 13th and will have the following topic.
Peripheral Vascular Boot Camp Prepares You for Your Toughest Claims
Presenter: Nikki M. Vendegna, CPC