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) |
|
I70.xxx | Atherosclerosis of native arteries of the extremities |
|
L97.xxx | Non-pressure chronic ulcer of lower limb, not elsewhere classified |
|
I77.xxx | Other disorders of arteries and arterioles |
|
I80.xxx | Phlebitis and thrombophlebitis |
|
Aneurysm
| ICD10 | Description | Documentation |
|---|---|---|
| I71.xxx | Aortic aneurysm and 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 |
|
| 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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