Coding of CAD

We recently had a coding company audit some of our records.They noted that CAD should be coded as the primary diagnosis even if it is not the focus of care. They are saying that this information was provided by the coding clinic. I cannot find anything to support this in Decision Health. Is anyone aware of this coding rule?


  • It depends on the other diagnoses. I'll copy and paste the decision health Q&A regarding how to code CAD and HTN.....

    Q: Why do I have to code any diagnosis from I20 to I25 before any diagnosis from I10 to I16? Where did this come from?

    A: There is a tabular instruction located at the beginning of the I20-I25 section that says “use additional code to identify presence of hypertension (I10-I16).” The codes listed in a “use additional code” note must be sequenced after the code on which the note is placed, according to coding guidelines. [I.A.13] [I.B.7]

    Based on this instruction, any diagnosis that falls between I10 and I16 must be sequenced after a diagnosis from I20 to I25 regardless of the focus of care.

    Coding experts believed the note was an error and urged coders to take steps such as ensuring documentation supported a choice to ignore the note and for example, code hypertension (I10) before coronary artery disease (CAD) (I25.10) in scenarios in which hypertension is the focus of care. [CPH, 11/17]

    However, the Coding Clinic recently confirmed the validity of the tabular instruction at the I20-I25 section in a note to an individual received on Dec. 7, 2017. [CPH, 1/18, 11/17]

    Q: What if the focus of care is congestive heart failure (CHF) and the patient also has hypertension, an old myocardial infarction (MI) and coronary artery disease (CAD)? How should I sequence these diagnoses?

    A: As it currently stands, coding guidelines and tabular instruction stipulate that the patient’s CAD and the old MI must be coded before hypertension and heart failure.

    So, in compliance with the convention, the scenario should be coded as follows: I25.10 (Atherosclerotic heart disease NOS), I25.2 (Old myocardial infarction), I11.0 (Hypertensive heart disease with heart failure), I50.9 (Heart failure, unspecified).

    Unless another etiology is given or the physician says the hypertension and heart failure are unrelated to each other, the patient’s hypertension and heart failure must be coded as connected with I11.0 immediately followed by I50.9. [I.C.9.a.1]

    And because I11.0 falls between I10 and I16, it must be sequenced after any diagnoses between I20 and I25, including the patient’s CAD (I25.10) and old MI (I25.2).

    However, if the physician stated that the patient’s heart failure was not connected to the hypertension or gave it another cause, I50.9 could be coded as primary followed by I25.10, I25.2 and I10 (Essential (primary) hypertension) because the hypertension and heart failure would have to be coded separately. [I.A.15] [I.C.9.a.1]

    “[The I20-I25 instruction] has been there since the ICD-9 days and has been thought to be an error. So until we get confirmation from the National Center for Health Statistics that we should in fact code the I20-I25 diagnoses prior to hypertension, I wouldn’t change current coding practices,” says Lisa Selman-Holman, HCS-D, principal of Selman-Holman and Associates and the coding service CoDR - Coding Done Right in Denton, Texas.

    Hope this helps!

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