Hello.
Today we're going to work on Chapter 28, the diseases of the Circulatory System.
This corresponds to Chapter 9 in the ICD-10-CM code book.
As a reminder, a large section of this chapter has to do with coding procedures.
So ignore this section and when you're working in the exercises, ignore the part of the exercise
that has to do with the procedure and just code the diagnosis.
The Coding Handbook has examples of the arterial system and venous system on pages 382 and 383,
but I also wanted to make sure that you know similar illustrations and additional
illustrations are available to you in the back of the code book.
So I want to look at those.
Mine are pretty wrinkled because I do use them.
The first one is the Peripheral Nervous System, and I even have them labeled here so I can
find them quickly.
The Central Nervous System, you have here the brain, the cranial nerves.
This one is really wrinkled.
The eye, the ear, down at the bottom.
And here's the veins and the arteries.
So you can be sure to look at them.
I find that procedure coding requires the use of these and diagnosis coding like ICD-10-CM
I find that they just help me understand the pathology, but not really help me select
the code as much as in procedure coding.
But even so, it's good for you to know that they're here and that you can use them in
any body system.
The book does not talk about all the abbreviations that are used in the medical record, or in
the code book for that matter.
So I made a couple of slides here that have to do with just abbreviations or acronyms
that you're going to see in the medical record.
You can download these PowerPoints separately from the podcast.
You can then print whichever slide you want to, to have it for your reference.
And I suggest until you know these abbreviations inside and out that you have this in a handy place.
Because you will use it, especially as we move in the course to being able to read
a medical record, read an operative report, read a history and physical.
You're going to find that the doctors typically abbreviate things.
You very rarely are ever going to see many things spelled out just because doctors are
very busy people and they expect those of us who're in the medical records to be able
to interpret it according to what they mean.
There're two slides here.
I'm not going to go through all of them, but I do want you to be aware of them and they
are fair game in any exam.
When we talk about some of the chapters, the importance of relationships cannot be overemphasized.
It's true in this chapter, and it's true in some of the other chapters.
When a causal relationship is stated, and that means due to something or implied, that's
one way you're going to code and another way you're going to code is when a causal relationship
is assumed.
For example, the relationship between chronic kidney disease and hypertension is assumed.
You don't have to look for additional documentation.
You assume there is a relationship between those two things.
But, in other diagnoses, you have to see if something, like a headache or something else
is due to hypertension or due to an infection or due to something else.
Saying "due to" is implying a causal relationship or stating a causal relationship.
There's a difference between looking for that documentation
and then knowing that some relationships
are assumed.
I don't think that this author does a very good job of explaining heart attacks.
So I'm going to spend a few slides to talk more to you about the differences in NSTEMI
and STEMI cardiac wall damage, and the way those are coded.
Here on the left, this is a partial thickness.
This dark area right here is the partial thickness of the heart wall that you're seeing.
That's NSTEMI.
And STEMI is when you see the full thickness.
The entire part of that cardiac wall has been affected.
So STEMI stands for, the S-T is referring to the segment of an electrocardiogram, which
I will show you that in the next slide.
E is elevation.
M is myocardial.
I is infarction.
And a non-STEMI is just referring to the fact that you're not seeing that ST elevation on the ECG.
Here's an example.
You can see this part of the curve there.
That's the ST elevation.
That's the STEMI, what it looks like.
And then when you see the depression, the ST depression, that's the non-STEMI, non-STEMI being
non-elevation of that ST segment.
So that's what the doctors would see on an electrocardiogram.
And then I have here restated again for you that a STEMI is a full thickness injury of
the heart muscle.
The non-STEMI is a partial thickness injury of the heart muscle.
And then I have some terms there about Q-waves and non-Q-waves.
But the next slide is when I went and did a little bit of research to find this slide
to show you that when you see certain terms you're going to know it's a STEMI.
It's pretty obvious here.
Everything is a STEMI except for this subendocardial infarction, a non-Q-wave, and a nontransmural MI.
So most of the time you're going to be coding the STEMIs instead of the non-STEMIs.
But when the patient presents to the emergency room, there's no difference in how they present.
They both come in with chest pain,
nausea, vomiting, sweating, hard time taking a deep breath.
But the NSTEMI turns out to be less severe, a less severe type of heart attack compared
to the STEMI.
So I just wanted to spend a few minutes on that so it's a little more clear what the
code book is referring to.
Let's jump in.
Exercise 28.1 number 7.
There are some of these exercises that lend themselves to the guidelines, to being able to refer
back to guidelines.
And other exercises take you back to the Coding Handbook.
But it is information that is vital for you to understand and because it isn't tied to
a guideline, you don't have an immediate reference to it in any way.
So it's one of those things that you just have to learn.
That's why I've highlighted here in this slide that you might highlight that in your Coding
Handbook to know that heart failure in a patient who has rheumatic heart disease is classified as
rheumatic heart failure. And that's that I09.81 code.
I have here the pathway for you, noting that there's an instructional note under the I09
category code to "use an additional code to identify the type of heart failure", and that's
what is here.
So that first code is the mitral valve with aortic valve, both of them combined.
The second one is the rheumatic heart failure.
And the last one is the congestive heart failure.
I also have a note here: Do not make an assumption that CHF is rheumatic in nature.
Not everyone who has CHF has rheumatic heart disease.
So that's not an assumption you can make.
But if you know someone has rheumatic heart disease, then you're going to code that rheumatic
heart failure in addition to the congestive heart failure.
The next exercise, 28.3 number 1.
The patient felt well until around 10 PM when he began having severe chest pain which increased
in severity.
He was brought to the emergency department by ambulance.
There was no previous history of cardiac disease, but the EKG showed an acute posterolateral myocardial
infarction, and the patient was admitted immediately for further care.
So here's the pathway.
Here's a reminder about the STEMI codes. and here's the posterior lateral, right here in purple.
And here is reference to a guideline.
I didn't type out the entire guideline, but you can.
I think you should go back and read it so you understand how this code ties back to
that guideline.
The next exercise, 28.3 number 3.
A patient was admitted with an acute MI involving the left main coronary artery.
No history of previous infarct or previous care.
A week later he had another acute anterolateral infarction.
So that first one is coded here, for the left main coronary artery.
And then the second one is called a subsequent because it's occurring within that first four
week period.
So here's just a reminder again about the STEMI codes and here's the two guidelines
that are referenced in this exercise.
Exercise 28.3 number 4.
This is kind of a trick question, I think.
The patient was admitted to Community Hospital with severe chest pain identified as an acute
anterolateral wall infarction.
He was then transferred to University two days later for the angioplasty.
Then he was brought back to Community Hospital and he continued his recovery and stayed there
four days.
And then the question is what are the codes?
Each of these encounters has the same code for each of the hospitals.
That first admission to Community Hospital, I21.09.
Patient was transferred to University Hospital. They are also going to code I21.09.
Patient is transferred back to Community Hospital, I21.09.
And this is the coding guideline that references this.
For encounters occurring while the MI is equal to or less than four weeks old, including
transfers to another acute setting or a post-acute setting and the patient requires continued care for
the MI, codes from category I21 may continue to be reported.
So we're in that four week window in this scenario, so we would continue to use that code.
And here's the path for how you got to I21.09.
Exercise 28.3 number 5, the author just took that first, #4 previous side, and changed it
a little bit so now he left Community Hospital.
He's been readmitted to Community Hospital a week later having chest pain and diagnosed
with a new inferior wall MI.
This up here was the anterior lateral wall.
And here is the inferior wall.
So you know it's a new MI.
So we're going to code the subsequent MI as your principal diagnosis, because your care
is directed to that, and then the I21.09 is coded because you're still in that 4 week window.
The patient still is in that four week window.
So you're going to use this one, not an old code, old MI code.
And here is the guideline for the subsequent acute MI.
Exercise 28.4 number 3, impending MI resulting in occlusion of coronary artery.
The guideline that applies in this case is I.B.11, which is not a chapter 9 code.
This is one of those general guidelines in Section B. The others we've been looking at were in
Section C. And this guideline says code any condition described as impending or threatened
as follows.
And it gives you different ways.
If it did occur, code it as confirmed.
If it didn't occur, look in the Alphabetical Index to see if you have any sub-entries that
say impending or threatened.
If those sub-terms are listed that's the code you assign.
If they are not listed, then you're going to code the existing, underlying condition
and not the condition described as impending.
So in this case we would code the occlusion of the artery because there is no impending
MI in the Alphabetical Index.
The next exercise, 28.5 number 2, Hemiplegia on the right, dominant side, due to an old
cerebral thrombosis with infarct.
So I have the pathways here for you.
That sixth character, 1, indicates it's the right, dominant, side.
You find that when you go to the Tabular.
And the guideline we're looking at is category I69, sequela.
These late effects include neurological deficits that persist after initial onset of conditions
classifiable to categories I60-I67.
And what I've added here for you is in this case the cerebral thrombosis would originally
have been coded to I63.60, which is in the range there between the I60 and the I67.
So I know that this coding guideline does apply in this case.
That's what I'm going to do for this podcast Part 1.
And I will continue in Part 2.