Documentation and Coding: PVD & Atherosclerosis

October 19, 2022

Claims & Coding Medical Policy & Clinical Guidelines

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”

Documentation & Coding Guidance

Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection. Peripheral Vascular Disease (PVD) also referred to as Peripheral Artery Disease (PAD) is a broad term that refers to diseases of the blood vessels outside the heart and brain. Arteriosclerosis and atherosclerosis are used interchangeably for coding and documentation purposes.

Classification:  

System: Arterial or Venous
Vessel type: Native or graft (autologous, nonautologous biologic, nonautologous nonbiologic)
Presence: include if there is ulceration, gangrene
Anatomic location: include site, laterality
Complicating factors: intermittent claudication, rest pain, ulceration, and gangrene

ICD10	Description	Documentation
I73.9	Peripheral vascular disease, unspecified (PVD)	includes Intermittent Claudication and peripheral artery disease, unspecified (PAD)
I70.xxx	Atherosclerosis of native arteries of the extremities	Presence of ulceration or gangrene Intermittent Claudication
L97.xxx	Non-pressure chronic ulcer of lower limb, not elsewhere classified	Important to avoid terms wounds, open wounds or lesion when documenting an ulcer Affected area Severity of ulcer
I77.xxx	Other disorders of arteries and arterioles	Stricture, rupture, necrosis or dissection
I80.xxx	Phlebitis and thrombophlebitis	Affected veins

Aneurysm

ICD10	Description	Documentation
I71.xxx	Aortic aneurysm and dissection	Affected artery site With or without rupture or dissection As of October 1,2022-Category I71-expanded to describe the site of thoracic aorta dissection, as well as the various types of abdominal aortic aneurysms. *Update on 02.20.23-Coding Clinic-2022; Q4: p.24
I72.xxx	Other aneurysm

ICD10

Description

Documentation

I71.xxx

Aortic aneurysm and dissection

Affected artery site
With or without rupture or dissection

As of October 1,2022-Category I71-expanded to describe the site of thoracic aorta dissection, as well as the various types of abdominal aortic aneurysms.
*Update on 02.20.23-Coding Clinic-2022; Q4: p.24

I72.xxx

Other aneurysm

Vascular Disease and Diabetes

ICD10	Description	Documentation
E11.51	Type 2 diabetes mellitus w/diabetic peripheral angiopathy without gangrene	Assumed relationship between Diabetes Mellitus and vascular disease
E11.52	Type 2 diabetes mellitus w/diabetic peripheral angiopathy with gangrene

ICD10

Description

Documentation

E11.51

Type 2 diabetes mellitus w/diabetic peripheral angiopathy without gangrene

Assumed relationship between Diabetes Mellitus and vascular disease

E11.52

Type 2 diabetes mellitus w/diabetic peripheral angiopathy with gangrene

Embolism and Thrombosis: Guidelines for Coding Deep Vein Thrombosis and Pulmonary Embolism

Resources:

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