Coding corner update: Improve medical record documentation for venous thrombosis

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next few issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

ICD-10-CM diagnosis codes, along with Current Procedural Terminology codes reported on claims, must be supported by documentation in a patient’s medical record. Note that ICD-10-PCS will be used for hospital inpatient records only.

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 a 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 superficial and deep vein thrombosis and may result in pulmonary embolism.
• There are specific ICD-10-CM codes to indicate the vessel involved, laterality and to indicate whether the condition is acute or chronic. Make sure you’re specific when you document and code the blood vessel affected, the side of the body and whether it’s acute or chronic for both venous thromboembolism and pulmonary embolism.
• For venous thrombosis, documentation must be provided related to the status of the condition (acute or chronic) even if the vessel affected cannot be specified. Code I82.90 or I82.91 is used in this circumstance: acute/chronic embolism and thrombosis of unspecified vein (respectively).
• 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 venous thrombosis” or “history of pulmonary embolism,” then the codes are Z86.718 and Z86.711, respectively. A “history of” Z code means that the condition no longer exists.
• If known, document and code the cause of the peripheral artery disease as well as the complication. For example, “atherosclerosis of left leg, native arteries, with ulcer of calf , with breakdown of skin” codes to I70.242 and L97.221.
• Unspecified peripheral vascular disease, peripheral artery disease or intermittent claudication are coded with I73.9 (Peripheral vascular disease, unspecified). Please note that there are more specific codes to indicate the area and any comorbid conditions present with the atherosclerosis.

Note: A hyphen (-) is used above to indicate that an additional character is required. Xs are used as part of a valid code in ICD-10-CM.)

Please review the ICD-10-CM coding manual for the fifth and sixth character codes for specifics on code selection.

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.