Chapter-9

Disease of circulatory system

Simple questions

1.Mitral Regurgitation-I34.0

2.Mitral valve stenosis with congestive heart failure-I05.0,I50.9

3.Severe mitral stenosis and mild aortic insufficiency-I08.0

4.Aortic and mitral insufficiency-I08.0

5.Persistent atrial fibrillation-I48.19

6.Mitral valve insufficiency with aortic regurgitation-I08.0

7. Acute myocardial infarction, inferolateral wall – I21.19

8. Third –degree atrioventricular block – I44.2

9. Acute myocardial infarction of inferoposterior wall – I21.11

10. Hypertension – I10

11. Quadriplegia due to ruptured berry aneurysm five years ago – I69.065, G82.50

12. Left heart failure with hypertension – I11.0. I50.1

13. Hypertensive cardiomegaly – I11.9

14. Congestive heart failure – I50.9

15. Cardiomegaly – I51.7

16. Cerebral embolism right anterior cerebral artery – I66.11

17. Pulmonary hypertension – I27.20

18. Hypertensive heart disease, myocardial degeneration – I11.9

19. Cerebral embolism right anterior cerebral artery – I66.11

20. Acute coronary insufficiency – I24.8

21. Mitral stenosis and aortic insufficiency – I08.0

22. Atrial fibrillation – I48.91

23. Abdominal aortic aneurysm – I71.4

24.Hypertensive cardiovascular disease essential-I11.9

25. Hemiplegia on right (dominant) side due to old cerebral thrombosis – I69.351

26.Mitral valve Prolapse-I34.1

Rationale:The alphabetic index lists the main term Prolapse and subterm mitral(valve) with
reference to code I34.1.Although in some situations ICD-10-CM assumes a rheumatic origin for heart
valve pathology,it is not always the case.For example,under the main term Disorder and subterm
mitral a cross reference states see endocarditis.The main term endocarditis and subterm mitral
reference to code I05.9 rheumatic mitral valve disease unspecified,assuming rheumatic
origin.However further examination of the subterms in the index reveals a listing of multiple code
options depending on the essential modifiers (additional descriptive terms) in the diagnosis.

27.Type 2 Arterioventricular heart block-I44.1.

Rationale:Conduction disorders are classified by type in ICD-10-CM.The alphabetic index lists the
main term Blocked and subterms atrioventricular and second degree or typesI and II with reference
to code I44.1.The code is confirmed in the tabular lists,which also lists typeI and typeII block as
inclusion terms.

28.Acute on chronic diastolic congestive heart failure-I50.33

Rationale:Similar to ICD-9-CM,category I50,heart failure,in ICD-10-CM classifies heart failure by type

and severity.Note that congestive heart failure,without further specification,is reported with code
I50.9.Heart failure,unspecified.There is no separate designation in ICD-10-CM,however,for
congestive heart failure as there was in ICD-9-CM(428.0).Instead,congestive is a parenthetical term
included in the code description of subcategory codesI50.2- through I50.4.

29.Patient with a history of mild,controlled hypertension present with an acute cerebellar stroke due
to non traumatic hemorrhage-I61.4,I10.

Rationale:The alphabetic index lists the term stroke with a cross reference under the subterm
cerebral hemorrhage.The reference instructs to code to Hemorrhage,intracranial.The main term
Hemorrhage,hemorrhagic lists the subterm intracranial with additional subterms intracerebral and
cerebellum which references code I61.4.Note the instructional notes at the beginning of the code
block

30. 1. stage 3 CKD with CHF due to hypertension.

Answer: I13.0, I50.9,N18.30

Rationale: in ICD-10-CM, a combination code is used to identify those diagnoses that include
hypertensive heart and kidney disease. Under I13.0 tghere is a “Use additional code” note to identify
both the type of heart failure and the stage of chronic kidney disease. The cross-reference under
disease, diseased- see also syndrome did not reveal any additional information. The term “kidney” is
represented under Disease, diseased.

31. This 54-year old patient was being treated for acute non-ST anterior wall MI.she presented to the
ED two weeks later and was diagnosed with an acute inferior wall myocardial infarction. She is still
been monitored following her initial heart attack two weeks earlier and continues to have atrial
fibrillation. She will be transferred to a larger facility for cardiac catheterization and possible further
intervention. What diagnosis codes are assigned?
Answer: I22.1, I21.4,I48.91

Rationale: The official coding guidelines specifically address the sequencing of I22 and I21 and this is
stated as : “ The sequencing of I22 and I21 codes depends on the circumstance of this encounter.”

Moderate questions

32.Chronic aortic and mitral valve insufficiency,rheumatic,with acute congestive heart failure due to
rheumatic heart disease-I08.0,I09.81,I50.9

33.A Patient felt well until around 10.00p.m.when he began having severe chest pain,which
continued to increase 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
infaraction and the patient was admitted immediately for further care-I21.29

34.A Patient with compensated congestive heart failure on lasix began to have extreme difficulty in
breathing and was brought to the emergency department,where he was found to be in congestive
failure. Because it was felt that an impending infarction was possible, a percutaneous transluminal
coronary angioplasty (PTCA) was performed, but the patient went on to have an acute inferolateral
infarction. – I21.19, I50.9

35. A Patient was admitted with acute myocardial infarction involving the left main coronary artery
with no history of previous infarction or previous care for this episode. A week later during the
hospital stay, he also experienced an acute anterolateral infarction. – I21.01 , I22.0

36. A patient was admitted to Community Hospital with severe chest pain, which was identified as an
acute anterolateral wall infarction (no history of earlier care). Patient was transferred to University
Hospital two days later for angioplasty, returned to community Hospital after three days at
University to continue recovery, and stayed for four days. – I21.09

37. The patient in the situation, described as having acute transmural myocardial infarction of
anterior wall, was readmitted to Community Hospital a week later because he was having severe
chest pains and was diagnosed with a new inferior wall MI.-I22.1, I21.09

38. Impending myocardial infarction (crescendo angina) resulting in occlusion of coronary artery –
I24.0

39. Hemopericardium as a complication of acute myocardial infarction of the inferior wall, which
occurred three weeks ago. Patient had been discharged a week before. – I23.0, I21.19

40. Crescendo angina due to coronary arterosclerosis Right and left cardiac catheterization,
percutaneous – I25.110

Complex Questions
41. Occlusion of right internal carotid artery with cerebral infarction with mild hemiplegia resolved
before discharge – I63.231 , G81.90

42. Hemiplegia on right (dominant) side due to old cerebral thrombosis – I69.351

43. Admission for treatment of new cerebral embolism with cerebral infarction and with aphasia
remaining at discharge(Patient suffered cerebral embolism one year ago, with residual apraxia and
dysphagia) – I63.40, R47.01, I69.390, I69.391, R13.10

44. Cerebral infarction due to thrombosis with right hemiparesis (dominant) and aphasia – I63.30,
G81.91, R47.01

45. Cerebral embolism right anterior cerebral artery – I66.11

46. Admission for rehabilitation because of monoplegia of the right arm and right leg, each affecting
dominant side (Paient suffered a nontraumatic extradural hemorrhage one month ago) – I69.231,
I69.241

47. Acute congestive diastolic heart failure due to hypertension – I11.0 , I50.31

48. Bleeding third degree haemorrhoids stasis ulcer, left lower extremity – K64.2, I83.029, L97.929

49. Chronic venous embolism and thrombosis of subclavian veins of long-term Coumadin therapy –
I82.B23, T45.515A, Z79.01

50. Septic embolism pulmonary artery due to staphylococcus Auresus sepsis – A41.01, I26.90

51. A patient was admitted through the emergency department complaining of chest pain with
radiation down the left arm increasing in severity over the past three hours. Initial impression was
impending myocardial infarction, and the patient was taken directly to the surgical suite, where
percutaneous transluminal angioplasty with insertion of coronary stent was carried out on the right
coronary artery. Infarction was aborted, and the diagnosis was listed as acute coronary insufficiency.
– I24.8

52. Atherosclerosis of pervious coronary artery bypass graft with unstable angina. Right greater
saphenous vein graft was used to bring blood from the aorta to the right coronary artery, the left
coronary artery, and the left anterior descending artery. Intraoperative continuous pacing
pacemaker was used during the procedure as well as extracorporeal circulatory assistance.
Pacemaker leads were inserted in left atria and ventricle. – I25.700

53. Occlusion of the right coronary artery. Right and left diagnostic cardiac catheterization – I24.0

54. A patient with known native vessel coronary atherosclerosis and unstable angina underwent
percutaneous balloon angioplasty carried out on three coronary arteries with vessel bifurcation
insertion of two stents, Extracorporeal circulation ( Continuous cardiac output) – I25.110

55. Painful varicose veins, right lower leg, Right greater saphenous ligation and stripping for
varicosities, open – I83.811

56.Renovascular hypertension secondary to fibromuscular hyperplasia,right renal artery-I77.3,I15.0

57.This 81-year-old female is a resident of the nursing facility due to CHF and atrial fibrillation. She fell
from the bed at the nursing facility, and was transferred to the hospital. She was readmitted to the
nursing facility to resume care and to add physical therapy following open reduction and pinning of left
comminuted subcapital femoral neck fracture. Assign the correct diagnostic code(s).

Answer: I50.9      Failure, failed, heart (acute) (senile) (sudden) congestive (compensated)
(decompensated)
I48.91    Fibrillation, atrial or auricular (established
S72.012D   Fracture, traumatic (abduction) (adduction) (separation), femur, femoral, neck, see
Fracture, femur, upper end, subcapital (displaced)
W06.XXXD   Index to External Causes, Fall, falling (accidental) from, off, out of, bed

Rationale: The sixth character 2 for the left hip is obtained from the Tabular. The seventh character D
is used for the subsequent encounter with routine healing. The external cause code is assigned, but
no place of occurrence or activity codes because this is subsequent care. The reason for the
readmission is the CHF and atrial fibrillation.

58. This nursing home resident is admitted following a hospital stay for an acute cerebral
infarction.The resident will receive multiple therapies for the resulting left hemiplegia of the
nondominant side, dysphasia, and facial droop.Other admitting diagnoses include GERD, rheumatoid
arthritis, and early onset Alzheimer's disease with dementia and aggressive behavior.Assign the
correct diagnostic code(s).

Answer:I69.354 Hemiplegia, following, cerebrovascular disease, cerebral infarction, or Sequelae (of),

infarction, cerebral, hemiplegia
I69.321 Dysphasia, following, cerebrovascular disease, cerebral infarction or Sequelae (of), infarction,
cerebral, dysphasia
I69.392 Sequelae (of), infarction, cerebral, facial droop
K21.9 Disease, diseased, gastroesophageal reflux (GERD)
M06.9 Arthritis, arthritic (acute) (chronic) (nonpyogenic) (subacute), rheumatoid
G30.0 Disease, diseased, Alzheimer's, early onset, with behavioral disturbance
F02.81
Rationale: The hemiplegia, dysphasia, and facial droop are considered residual conditions of the
acute cerebral infarction and are the reason that the patient is admitted to the nursing home. Coding
guidelines state that the residual condition is sequenced first, followed by the cause of the sequela. In
this case of cerebrovascular disease, the sequela code has been expanded to include the
manifestation and is an exception to the coding guideline.

59. The patient was seen for treatment of a fine rash that had developed on the patient's trunk and
upper extremities over the last three to four days. The patient was diagnosed with hypertension seven
days ago and started on Ramipril 10 mg daily. The physician determined the rash to be dermatitis due
to the Ramipril. The Ramipril was discontinued and the patient was prescribed a new antihypertensive
medication, Captopril. In addition, the physician prescribed a topical cream for the localized
dermatitis.What diagnosis codes are assigned?

Answer:L27.1,T46.4x5A, I10

Rationale: The reason, after study, for this encounter is the dermatitis which is an adverse effect to
the Ramipril. An instructional note in the Tabular under code L27.1 states quot;Use additional code for
adverse effect, if applicable, to identify drug (136-150 with fifth or sixth character 5).quot; Following
this instruction note, the T46.4X5A is sequenced as a secondary diagnosis code. The seventh
character of A indicates this is the initial encounter for this condition. Documentation states localized
dermatitis, and there is a specific code for that. This documentation does not indicate long-term use of
the drug since it was recently started.

60. This woman is being treated for a severe allergic reaction to chemotherapy due to cancer.
The specific drug is Fluorouracil.

Assign the correct diagnostic code(s).

Answer: T78.40XA    Allergy, allergic (reaction) (to). Review Tabular for complete code assignment.
T45.1X5A   Allergy, allergic (reaction) (to), drug, medicament amp; biological (any) (external)
(internal), correct substance properly administered — see Table of Drugs and Chemicals, by drug,
adverse effect, fluorouracil
C80.1        Cancer, unspecified site (primary) (secondary)

Rationale: Without documentation of the specific adverse effect, the code for the allergic reaction
(T78.40XA) is assigned. The seventh character A is used as the documentation does not indicate that
the patient has received prior treatment for this allergic reaction. The unspecified cancer code is used
as the documentation does not indicate the type of cancer being treated. The Coding Guidelines state
that this code should be used quot;when no determination can be made as to the primary site of a
malignancy.quot;

61.This 54-year old patient was being treated for acute non-ST anterior wall MI. she presented to the
ED two weeks later and was diagnosed with an acute inferior wall myocardial infarction. She is still
been monitored following her initial heart attack two weeks earlier and continues to have atrial
fibrillation. She will be transferred to a larger facility for cardiac catheterization and possible further
intervention. What diagnosis codes are assigned?

Answer: I22.1, I21.4,I48.91

Rationale: The official coding guidelines specifically address the sequencing of I22 and I21 and this is
stated as : “ The sequencing of I22 and I21 codes depends on the circumstance of this encounter.”

62.. This 62-year-old male patient was admitted to the hospital with progressive episodes of chest
pain determined to be crescendo angina, the patient has no previous history of CABG. He had
myocardial infarction five years ago and was diagnosed with coronary artery disease and
progressively has been having more frequent episodes of chest pain. During the hospital stay, he was
given IV nitroglycerin and was subsequently placed on Cardizem for further treatment of his angina.
He was schudled for cardiac catheterization next week.No other complications arose during the
hospitalization. What diagnosis codes are assigned?

Answer: I25.110, I25.2

Rationale:Crescendo angina is included in unstable angina, see the index, angina,crescendo- see
Angina, unstable

63. stage 3 CKD with CHF due to hypertension.

Answer: I13.0, I50.9,N18.3

Rationale: in ICD-10-CM, a combination code is used to identify those diagnoses that include
hypertensive heart and kidney disease. Under I13.0 tghere is a “Use additional code” note to identify
both the type of heart failure and the stage of chronic kidney disease. The cross-reference under
disease, diseased- see also syndrome did not reveal any additional information. The term “kidney” is
represented under Disease, diseased.

64. This 76 year-old man is seen today for treatment of his congestive heart failure. After study, the
final diagnosis was documented as acute on chronic diastolic congestive heart failure. What diagnosis
codes are assigned?

Answer: I50.33
Rationale: An additional code for congestive heart failure is not required as “Congestive” is already
identified in the preceding code.

65.This 62-year-old male patient was admitted to the hospital with progressive episodes of chest pain
determined to be crescendo angina, the patient has no previous history of CABG. He had myocardial
infarction five years ago and was diagnosed with coronary artery disease and progressively has been
having more frequent episodes of chest pain. During the hospital stay, he was given IV nitroglycerin
and was subsequently placed on Cardizem for further treatment of his angina. He was schudled for
cardiac catheterization next week. No other complications arose during the hospitalization. What
diagnosis codes are assigned?

Answer: I25.110, I25.2

Rationale:Crescendo angina is included in unstable angina, see the index, angina,crescendo- see
Angina, unstable.

66. This 54-year old patient was being treated for acute non-ST anterior wall MI. she presented to the
ED two weeks later and was diagnosed with an acute inferior wall myocardial infarction. She is still
been monitored following her initial heart attack two weeks earlier and continues to have atrial
fibrillation. She will be transferred to a larger facility for cardiac catheterization and possible further
intervention. What diagnosis codes are assigned?

Answer: I22.1, I21.4,I48.91

Rationale: The official coding guidelines specifically address the sequencing of I22 and I21 and this is
stated as : “ The sequencing of I22 and I21 codes depends on the circumstance of this encounter.”

67. This nursing home resident is admitted following a hospital stay for an acute cerebral
infarction.The resident will receive multiple therapies for the resulting left hemiplegia of the
nondominant side, dysphasia, and facial droop.Other admitting diagnoses include GERD, rheumatoid
arthritis, and early onset Alzheimer's disease with dementia and aggressive behavior.Assign the
correct diagnostic code(s).

Answer:I69.354 Hemiplegia, following, cerebrovascular disease, cerebral infarction, or Sequelae (of),

infarction, cerebral, hemiplegia
I69.321 Dysphasia, following, cerebrovascular disease, cerebral infarction or Sequelae (of), infarction,
cerebral, dysphasia
I69.392 Sequelae (of), infarction, cerebral, facial droop
K21.9 Disease, diseased, gastroesophageal reflux (GERD)
M06.9 Arthritis, arthritic (acute) (chronic) (nonpyogenic) (subacute), rheumatoid
G30.0 Disease, diseased, Alzheimer's, early onset, with behavioral disturbance
F02.81
Rationale: The hemiplegia, dysphasia, and facial droop are considered residual conditions of the
acute cerebral infarction and are the reason that the patient is admitted to the nursing home. Coding
guidelines state that the residual condition is sequenced first, followed by the cause of the sequela. In
this case of cerebrovascular disease, the sequela code has been expanded to include the
manifestation and is an exception to the coding guideline.

68. The patient is admitted through the emergency room with a complaint of chest pain. The EKG and
laboratory tests completed in the ER are inconclusive, but an acute myocardial infarction is ruled
out. During the hospital stay, the cardiovascular workup did not reveal any coronary artery disease
and the patient did not want to have a cardiac catheterization study performed at this time. The patient
is known to have gastroesophageal reflux disease. Given the conflicting information, the attending
physician concluded the patient had quot;atypical chest pain due to either angina or GERD.quot;
What diagnosis codes are assigned?

Answer: R07.89,  I20.9, K21.9

Rationale: In the instance where a symptom(s) is followed by contrasting/comparative diagnoses, the
symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as
additional codes.

69. This 88-year-old gentleman is receiving home care for his coronary artery disease and the cardiac
pacemaker placed during his hospitalization last week. He continues to gain strength but requires
wound checks, dressing changes, and medication management ongoing. Assign the correct
diagnostic code(s)?

Answer: Z48.812     Aftercare, following surgery (for) (on), circulatory system

Z48.01       Aftercare, following surgery (for) (on), attention to, dressings, surgical
I25.10        Atherosclerosis, coronary artery
Z95.0         Status (post), pacemaker, cardiac

Rationale: The aftercare following surgery on the circulatory system as well as aftercare for the
dressing change are assigned. The code for coronary artery disease without angina is assigned as no
angina is documented.

70. The patient was seen for treatment of a fine rash that had developed on the patient's trunk and
upper extremities over the last three to four days. The patient was diagnosed with hypertension seven
days ago and started on Ramipril 10 mg daily. The physician determined the rash to be dermatitis due
to the Ramipril. The Ramipril was discontinued and the patient was prescribed a new antihypertensive
medication, Captopril. In addition, the physician prescribed a topical cream for the localized dermatitis.
What diagnosis codes are assigned?

Answer:L27.1 Dermatitis, (eczematous) due to drugs and medicaments, (generalized) (internal use)
localized skin eruption

T46.4X5A Table of Drugs and Chemicals, Ramipril, Adverse Effect, initial encounter

I10 Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic)

Rationale: The reason, after study, for this encounter is the dermatitis which is an adverse effect to
the Ramipril. An instructional note in the Tabular under code L27.1 states quot;Use additional code for
adverse effect, if applicable, to identify drug (136-150 with fifth or sixth character 5).quot; Following
this instruction note, the T46.4X5A is sequenced as a secondary diagnosis code. The seventh
character of A indicates this is the initial encounter for this condition. Documentation states localized
dermatitis, and there is a specific code for that. This documentation does not indicate long-term use of
the drug since it was recently started.

71. This 81-year-old female is a resident of the nursing facility due to CHF and atrial fibrillation. She
fell from the bed at the nursing facility, and was transferred to the hospital. She was readmitted to the
nursing facility to resume care and to add physical therapy following open reduction and pinning of left
comminuted subcapital femoral neck fracture. Assign the correct diagnostic code(s).

Answer: I50.9      Failure, failed, heart (acute) (senile) (sudden) congestive (compensated)
(decompensated)
I48.91    Fibrillation, atrial or auricular (established
S72.012D   Fracture, traumatic (abduction) (adduction) (separation), femur, femoral, neck, see
Fracture, femur, upper end, subcapital (displaced)
W06.XXXD   Index to External Causes, Fall, falling (accidental) from, off, out of, bed

Rationale: The sixth character 2 for the left hip is obtained from the Tabular. The seventh character D
is used for the subsequent encounter with routine healing. The external cause code is assigned, but
no place of occurrence or activity codes because this is subsequent care. The reason for the
readmission is the CHF and atrial fibrillation
72. This patient is seen for evaluation of his continuing unstable angina. After significant evaluation,
his symptoms were found to be due to atherosclerosis of his bypassed graft. This is an autologous
arterial graft. Final diagnosis: CAD of bypass graft with unstable angina and hypertensive congestive
heart failure. The patient will be scheduled for surgery. What is the correct diagnosis code(s)?

Answer:I25.720 Atherosclerosis — see also Arteriosclerosis, coronary artery, with angina pectoris, —
see Arteriosclerosis, coronary (artery), bypass graft, autologous artery, with, angina pectoris, unstable

I11.0 Failure, failed, heart (acute) (senile) (sudden), hypertensive — see Hypertension, heart
(disease) (conditions in 151.4-151.9 due to hypertension), with, heart failure (congestive)

I50.9 Failure, failed, heart (acute) (senile) (sudden), congestive (compensated)

Rationale: ICD-10-CM differentiates between the different types of bypassed coronary arteries,
including native arteries, autologous vein, autologous artery, and nonautologous graft material.
Hypertensive congestive heart failure requires two diagnosis codes to correctly identify the condition.
The note at code I11.0 states quote;Use additional code to identify type of heart failure (I50.-).

73. This patient is being treated for a current inferolateral ST elevation myocardial infarction. This
case is complicated by the development of a hemopericardium as a result of the infarction. What is
the correct diagnosis code(s)?

Answer:I21.19, I23.0

Rationale: Infarct, infarction, myocardium, myocardial (acute) (with stated duration of 4 weeks or less),
ST elevation (STEMI), inferior (diaphragmatic) (inferolateral) (inferoposterior) (wall), NEC I23.0
Hemopericardium, following acute myocardial infarction (current complication)/p pstrongRationale:
The ICD-10-CM codes for acute myocardial infarction identify the site. Subcategory I21.1 is used for
ST elevation myocardial infarction of the inferior wall. A code from category 123 must be used in
conjunction with a code from category I21 or category I22. The I23 code should be sequenced after
the I21 or I22 code if the complication of the MI occurs during the encounter for the MI.

74. Assign the correct diagnosis code(s): Acute cerebrovascular infarction—embolism of the left
cerebellar artery with dysphagia and right hemiplegia. Code(s)

Answer:I63.442 Infarct,

Rationale: Infarction, cerebellar – see Infarct, cerebral. (See also Occlusion, artery, cerebral or
precerebral, with infarction.) Occlusion, occluded artery, cerebellar (anterior inferior) (posterior
inferior) (superior) with infarction, due to, embolism. Review the Tabular for complete and correct
code assignment

 R13.10 Dysphagia

 G81.91 Hemiplegia. Review the Tabular for complete code assignment.

 Rationale: ICD-10-CM provides specific codes to identify the involved artery in a cerebrovascular
infarction. Right dominant side (G81.91) was selected based on Coding Guideline I.C.6.a, which
states quot;should the affected side be documented, but not specified as dominant or nondominant,
and the classification system does not indicate a default, code selection is as follows: if the right side
is affected the default is dominant.quote; Codes from category I69 are not used in this scenario as the
dysphagia and hemipeglia are acute deficits from the current CVA.

75. This patient has cardiac defibrillator in situ for ventricular fibrillation and coronary artery disease
who is admitted to the nursing facility for monitoring of the defibrillator. Assign the correct diagnostic
code(s).
Z45.02 Admission (for), adjustment, device NEC, implanted, cardiac, defibrillator, or Encounter, (with
health service) (for) adjustment and management (of), implanted device

I49.01 Fibrillation, ventricular

I25.10 Disease, diseased, coronary (artery) — see Disease, heart (organic), ischemic, atherosclerotic
(of)

Rationale: If indexing Admission (for), adjustment, the Index assists in locating the specific code;
however, when indexing Encounter, the Tabular List must be used to provide the specific code of
Z45.02 for the automatic implantable cardiac defibrillator, rather than the NEC code provided in the
Index..

76. Inpatient admission (episode 1): The reason for this woman’s admission was repair of a
4.7centimeter infrarenal abdominal aortic aneurysm. She also had arterial hypertension. Because of
her strong family history of aneurysms, she wished to have her aneurysm removed on an elective
basis rather than waiting for it to follow its natural course. At surgery, via an open approach, the
aneurysm sac was cut open and a 16-millimeter Dacron graft was placed. The procedure was
successful, and the patient was discharged on the fifth postoperative day. Discharge diagnoses: (1)
Infrarenal abdominal aortic aneurysm, (2) arterial hypertension. Physician office visit (episode 2): The
patient presented for routine follow-up examination of an abdominal aortic aneurysm repair with graft
replacement. She was doing well, with only mild discomfort. The midline incision was well healed.
Femoral and distal pulses were palpable bilaterally. She was to return again in three months.
Diagnosis: Status post aortic aneurysm.

Answers:

I71.4 Abdominal aortic aneurysm, without rupture

I10 Essential (primary) hypertension

Z82.49

Family history of ischemic heart disease and other diseases of the circulatory system

Z09

Encounter for follow-up examination after completed treatment for conditions other than malignant
neoplasm

Z86.79 Personal history of other diseases of circulatory system

Z98.890 Other specified postprocedural states

77. Inpatient admission: The patient was admitted for workup of right carotid artery stenosis. A carotid
duplex performed as an outpatient procedure at another facility showed 80 percent stenosis on the
right side and 40 percent on the left. A nonselective low osmolar carotid arteriography, conducted the
day after admission, showed only a 50 percent stenosis of the right

common carotid artery. The external carotids were found to be small, but there was no significant
internal carotid disease on either side. Therefore, because the patient was asymptomatic, it was felt
that surgery would present a higher risk of stroke than treating her medically. Discharge diagnosis:
Carotid artery disease.

Answers:
I65.23 Occlusion and stenosis of bilateral carotid arteries

78. Inpatient admission: This patient was admitted for repair of a left common carotid stenosis. Two
months earlier, an endarterectomy of a right carotid stenosis had been performed. Six months earlier,
she had suffered a cerebral hemorrhage that resulted in apraxia and oropharyngeal phase dysphagia,
both of which required additional nursing assistance. The open left endarterectomy was successfully
accomplished, and the patient was discharged on the fourth hospital day. Discharge diagnoses: (1)
Left carotid stenosis, (2) residuals of old cerebrovascular accident.

Answers:

I65.23 Occlusion and stenosis of bilateral carotid arteries

I69.390 Apraxia following cerebral infarction

I69.391 Dysphagia following cerebral infarction

R13.12 Dysphagia, oropharyngeal phase

79. Inpatient admission: The patient was admitted with recurrent unstable angina that could not be
controlled with sublingual nitroglycerin. There was no history of bypass or angioplasty in the past. On
left cardiac catheterization with coronary arteriography with contrast, a narrowing in the left anterior
descending coronary artery and a stenotic area in an intermediate branch were identified. A
successful percutaneous transluminal coronary angioplasty (PTCA) of both vessels was carried out.

Discharge diagnosis: (1) Unstable angina secondary to coronary arteriosclerosis, (2) chronic total
occlusion of coronary artery.

Answers:

I25.110

Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

I25.82 Chronic total occlusion of coronary artery

80. Inpatient admission: The patient received his first pacing system 15 years earlier because of
congenital complete heart block and severe bradycardia. At the time of admission, he was
experiencing these conditions again, plus fatigue secondary to pacemaker pulse generator
malfunction. He was admitted for insertion of a new generator. After he was prepped for surgery, the
old pacemaker was removed via an incision into the subcutaneous pocket, and a new dualchamber
pacing device was inserted and connected to the existing leads. The postoperative period was
uncomplicated. Discharge diagnosis: Malfunctioning pacemaker.

Answers:

T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter

Q24.6 Congenital heart block

R00.1 Bradycardia, unspecified

81. A patient was admitted with complaint of a dull ache and occasional acute pain in the right calf.
Examination revealed swelling and redness of the calf as well as a slight fever. The patient gave a
history of having been on Premarin therapy for the past 20 years and stated that she has always
followed the doctor’s instructions for its use. Venous plethysmography revealed the presence of a
thrombus. The estrogen therapy dosage was modified, and the patient was discharged with a
diagnosis of deep vein thrombosis and thrombophlebitis of the right femoral vein due to supplemental
estrogen therapy. She will be seen in the physician’s office in one week and will be followed regularly
over the next several months.

Answers:

I82.411 Acute embolism and thrombosis of right femoral vein

T38.5x5A Adverse effect of other estrogens and progestogens, initial encounter

Z79.818

Long term (current) use of other agents affecting estrogen receptors and estrogen levels.

82. A patient was admitted with systolic heart failure, acute on chronic, congestive heart failure, and
unstable angina. The unstable angina was treated with nitrates, and IV Lasix was administered to
manage the heart failure. Both conditions improved, and the patient was discharged to be followed on
an outpatient basis.

Answers:

I50.23 Acute on chronic systolic (congestive) heart failure

I20.0 Unstable angina.

83. A patient was admitted with occlusion (due to plaque) of the right common carotid artery, and
open carotid endarterectomy was carried out with extracorporeal circulation (continuous cardiac
output) used throughout the procedure.

Answers:

I65.21 Occlusion and stenosis of right carotid artery.

84. A patient was admitted in a coma due to acute cerebrovascular thrombosis with cerebral
infarction; the coma cleared by the fourth hospital day. Aphasia and hemiparesis were also present.
The aphasia had cleared by discharge, but the hemiparesis was still present.

Answers:

I63.30 Cerebral thrombosis with cerebral infarction

R40.20 Coma

R47.01 Aphasia

G81.90 Hemiplegia, unspecified, affecting unspecified side.

85. A patient with type 1 diabetes mellitus with hyperglycemia was admitted for regulation of insulin
dosage. The patient had been in the hospital three weeks earlier for an acute ST elevation
myocardial infarction of the inferolateral wall, and an EKG was performed to check its current status.

Answers:
E10.65 Diabetes mellitus, type 1 with hyperglycemia

I21.19

ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall.

86. A patient who was treated seven weeks ago at Community Hospital for an acute anterolateral
myocardial infarction is now admitted to University Hospital for surgical repair of an atrial septal
defect resulting from the recent infarction. Following thoracotomy, the defect was repaired with a
nonautologous tissue graft; cardiopulmonary bypass (extracorporeal circulation, continuous cardiac
output) was used during the procedure. The patient was discharged in good condition, to be
followed as an outpatient.

Answers:

I51.0 Atrial septal defect, acquired

I25.2 Old myocardial infarction

87. A patient who has had recurrent attacks of angina was seen in his physician’s office because he
felt that the anginal attacks seemed to be occurring more frequently and to be more severe and
more difficult to control. He had not had a thorough evaluation previously, and bypass surgery had
not been recommended in the past. He was admitted to the hospital for diagnostic studies to
determine the underlying cause of this unstable angina. He underwent combined right- and leftheart
catheterization, which revealed significant atherosclerotic heart disease. He was advised that
coronary artery bypass surgery was indicated, but he did not want to make a decision without
further discussion with his family. He was discharged on antianginal medication and will be seen in
the doctor’s office in one week.

Answers:

I25.110

Atherosclerotic heart disease of native coronary artery with unstable angina pectoris.

88. 29. The patient discussed in the preceding case returned to the hospital for bypass surgery. His
angina is under control with the antianginal medications he was prescribed. Reverse right greater
saphenous vein grafts were brought from the aorta to the obtuse marginal and the right coronary
artery; the left internal mammary artery was loosened and brought down to the left anterior
descending artery to bypass this obstruction. The gastroepiploic artery was used as a pedicled graft
to bypass the circumflex. Extracorporeal circulation (continuous cardiac output) and intraoperative
pacemaker were used during the procedure and discontinued afterward.

Answers:

I25.119

Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
89. A patient in acute respiratory failure was brought to the hospital by ambulance with ventilator in
place. In the ambulance, an endotracheal tube was inserted into the patient. He had a long history of
congestive heart failure, and studies confirmed that he was in congestive failure, with pleural
effusion and acute pulmonary edema. The patient was treated with diuretics, and his cardiac
condition was brought back into an acceptable range. He continued on ventilation for four days and
was weaned on the fifth day. The physician was questioned regarding the reason for the admission,
and she indicated that the patient was admitted for the acute respiratory failure.

Answers:

J96.00

Acute respiratory failure, unspecified whether with hypoxia or hypercapnia

I50.1 Left ventricular failure

73. A patient with hypertensive and diabetic end-stage renal disease who is on chronic dialysis is
admitted because of disequilibrium syndrome (electrolyte imbalance) caused by the dialysis.
Answers:

E87.8

Other disorders of electrolyte and fluid balance, not elsewhere classified

I12.0

Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease

N18.6 End-stage renal disease

E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease

Z99.2 Dependence on renal dialysis

Y84.1

Kidney dialysis as the cause of abnormal reaction of the patient, or of later complication, without
mention of misadventure at the time of the procedure.

90. A patient who has had arteriosclerotic disease of the right lower extremity with intermittent
claudication for three years recently progressed to ulceration, and is now admitted with ulceration
and gangrene of the toes of the right foot resulting from the arteriosclerosis. A tarsometatarsal
amputation of the right foot was performed, and the patient left the operating room in good
condition. Answers:

I70.261

Atherosclerosis of native arteries of extremities with gangrene, right leg

L97.519

Non-pressure chronic ulcer of other part of right foot with unspecified severity.
91. A patient with a long history of angina pectoris came to the emergency department complaining
of increasing anginal pain that he could not relieve with nitroglycerin and rest. The pain had
occurred again about an hour ago and has been increasing in severity. Cardiac catheterization done
recently showed some occlusion of the right coronary artery. It was decided to go ahead with a
percutaneous transluminal coronary angioplasty, administering a thrombolytic agent to a coronary
artery, in the hope of averting what appeared to be an impending myocardial infarction. The
procedure was carried out without incident and the infarction was averted, but the patient did have
an occlusion of the coronary artery.

Answers:

I24.0 Acute coronary thrombosis not resulting in myocardial infarction

92. A patient was admitted to the hospital with unstable angina that had been increasing in severity
since the previous day. He was placed on bed rest and telemetry, and IV nitroglycerin was
administered. An EKG showed some paroxysmal tachycardia as well, and so IV heparin was added to
his medication program. His angina returned to its normal status, and the tachycardia was not
shown on repeat studies at the end of one week. The patient was discharged to be seen by a visiting
nurse over the next two weeks to supervise his medication regimen, and an appointment with his
physician was made for two weeks later. Answers:

I20.0 Unstable angina

I47.9 Paroxysmal tachycardia, unspecified.

93. A patient was admitted with a severe stage 3 pressure ulcer on the left buttock, with extensive
necrotic tissue and gangrene. She was taken to the operating room, where the surgeon carefully
excised the necrotic tissue (skin). The ulcer site was

then treated with antibiotic ointment and gauze bandage, and the patient was returned to the
nursing unit, where the wound was monitored carefully and additional antibiotic treatment was
administered. By the fourth day, healing was beginning to close the area, but treatment was
continued until discharge on the seventh day. The family was advised to use an egg crate mattress
and to turn the patient regularly. The patient was scheduled for an outpatient visit in one week.
Answers:

I96 Gangrene, not elsewhere classified

L89.323 Pressure ulcer of left buttock, stage 3.

94. Patient was admitted to the hospital with slurred speech, facial droop, and change in
mental status. Testing revealed an acute embolic cerebral infarction. While hospitalized, the
patient received treatment for hypertension and hyperlipidemia. Due to the patient’s inability
to swallow, a PEG tube was placed. Discharge diagnosis was documented as follows:
Embolic CVA with cognitive deficit, facial droop and oropharyngeal dysphagia;
Hypertension; Hyperlipidemia. Patient is now being admitted to the SNF with orders for PT,
OT, and ST, tube feedings. Med orders include Plavix, Hytrin, and Lipitor. What are the
appropriate codes for the SNF admission?
 I69.318, I69.392, I69.391, R13.12, I10, E78.5, Z43.1, Z79.02,

95. Resident being admitted to the SNF following a hospital stay for acute stroke.
Documentation shows right non-dominant hemiplegia, as well as stroke related vertigo and
seizure disorder. Additional diagnoses include GERD, Rheumatoid Arthritis, Allergic
Rhinitis and multi-infarct dementia. Resident has orders for PT and OT, as well as med
orders for all these diagnoses. What are the appropriate codes?

I69.353, I69.398, R42, G40.909, K21.9, M06.9, F01.50, J30.9,

96. Resident with ESRD on dialysis with hypertension.

I12.0, N18.6, Z99.2

97. Resident has chronic diastolic congestive heart failure with left ventricular failure and
pulmonary edema. Resident did have recent exposure to tuberculosis. Resident also has
diagnoses of ischemic cardiomyopathy, mitral valve regurgitation and aortic valve stenosis.

I50.32, I50.1, I25.5, I08.0. Z20.1,

98. Resident admitted to SNF for therapy services post hospitalization for acute coronary
syndrome which was diagnosed as an acute non-ST elevation myocardial infarction
(NSTEMI MI). Resident had a cardiac catheterization with placement of stents in blocked
vessels due to coronary artery disease. Resident also has HTN, dyslipidemia, glaucoma and
wears a hearing aide in both ears.

I21.4, I25.10, I10, E78.5, H40.9, H91.93, Z95.5