Question

Tuesday

Scenario:

82-year-old Max Millian was admitted with chest pain from the ER today where he was being worked up for an acute myocardial infarction. During admission, his lab reports, EKG, and stress tests were all within normal limits.

Questions:

1. What is the correct diagnosis code assigned for this case?

2. What coding guideline applies to this scenario?

3. Why does this coding guideline apply to this scenario?

Answer 1

1. diagnosis code for chest pain

ICD-10-CM R07.9

2. These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.

3.Angina without coronary atherosclerosis requires documentation regarding specific characteristics such as stable, unstable, or the presence of spasm. In this example, angina pectoris, unspecified is coded as the information in the medical record is insufficient to assign a more specific code. “Other” [forms] is used when the information in the medical record provides detail for which a specific code does not exist. For example, there is no specific code for angina decubitus in ICD-10-CM, as is the case in ICD-9-CM. Angina decubitus is reported with the code for other forms of angina pectoris