Keep in mind these coding tips to improve medical record documentation

ICD-9-CM diagnosis codes, along with Current Procedural Terminology codes reported on claims, must be supported by documentation in a patient’s medical record.

ICD-9-CM is the national standard coding language used to translate a patient’s clinical condition into three- to five-digit codes.

Accurate coding starts with accurate documentation
Clear and concise documentation is essential to providing the best quality of care to patients and ensures health care providers receive their payments in a timely manner. When documentation standards are met and maintained, there shouldn’t be concern about any impending audit or review.

Some of the most challenging conditions to code are diseases of the vascular system. This includes venous thromboembolism and peripheral vascular disease.

Documentation and coding tips for vascular diseases

• Venous thromboembolism is a disease that includes both deep vein thrombosis and pulmonary embolism.
• There are specific ICD-9-CM codes to indicate the vessel involved and specific codes to indicate whether the condition is acute or chronic. Make sure you’re specific when you document and code the blood vessel that’s affected and whether it’s acute or chronic for both venous thromboembolism and pulmonary embolism.
• For deep vein thrombosis, when the documentation does not specify the vessel affected or the status of the condition, then it’s coded as 453.40-DVT NOS (not otherwise specified).
• There’s no specific timeframe that differentiates an acute pulmonary embolism from a chronic pulmonary embolism. The differentiation is determined by the provider’s documentation. In most patients with pulmonary embolism, the emboli dissolve. However, in a small group of patients, the emboli persist and a state of chronic pulmonary embolism develops.
• If the provider documents “history of deep vein thrombosis” or “history of pulmonary embolism,” then the codes are V12.51 and V12.55, respectively. A history of V code means that the condition no longer exists.
• Aortic atherosclerosis and peripheral atherosclerosis are chronic conditions that should be assessed, documented and coded each year.
• If known, document and code the cause of the peripheral artery disease as well as the complication. For example, “lower leg ulcer due to peripheral artery disease.”
• Unspecified peripheral vascular disease, peripheral artery disease or intermittent claudication are coded with 443.9 (Peripheral vascular disease, unspecified). Please note that there are more specific codes to indicate the area and the condition of the atherosclerosis.

Please review the ICD-9-CM coding manual for the fourth- and fifth-digit codes for specifics on code selection.