Anatomy of the Heart and the. ICD-10 Codes

Anatomy of the Heart and the Diseases ICD-10 Codes Sharon J. Oliver CPC, CPMA, CPC-I All Rights Reserved 1 Anatomy of the Heart Pulmonary Tricuspid (AV) Valve Mitral Aortic Semilunar Valve Chordae Tendineae Papillary Muscles All Rights Reserved 2 1

Rheumatic Heart Disease Rheumatic heart disease is a condition in which permanent damage to heart valves is caused by rheumatic fever. The heart valve is damaged by a disease process that generally begins with a strep throat caused by bacteria called Streptococcus, and may eventually cause rheumatic fever. All Rights Reserved 5 Rheumatic Heart Disease I-10-CM presumes certain Mitral Valve disorders of unspecified etiology are rheumatic in origin. Rheumatoid Heart Disease occurs as a result of an infection I00 I02 Acute rheumatic fever I00: Rheumatic fever without heart involvement I01: Rheumatic fever with heart involvement I02: Rheumatic chorea (neurological manifestation) I05 I09 Chronic rheumatic heart diseases I05: Rheumatic mitral valve diseases I06: Rheumatic aortic valve diseases I07: Rheumatic tricuspid valve diseases I08: Multiple valve diseases (more than 1 condition affecting valves all are classified as rheumatic) I09: Other rheumatic heart diseases All Rights Reserved 6 3

Rheumatic Heart Disease I09.81 Rheumatic heart failure (Use additional code to identify type of heart failure (I50.-) I50 Heart failure (Code first: rheumatic heart failure (I09.81) There is a list of code first diseases: HTN, kidney, etc. I50.1 Left ventricular failure I50.2 Systolic (congestive) heart failure (Code also end stage heart failure, if applicable (I50.84) All Rights Reserved 7 Rheumatic Heart Disease I50.3 Diastolic (congestive) heart failure (Code also end stage heart failure, if applicable (I50.84) I50.4 Combined (systolic diastolic) heart failure (Code also end stage heart failure, if applicable (I50.84) All Rights Reserved 8 4

Hypertensive Heart Disease I10 I15 Hypertensive diseases All Rights Reserved 9 Hypertension Hypertension, also referred to as high blood pressure, is a condition in which the arteries have persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the whole body through the arteries. The pumping through the narrowed vessel consistently increases the systolic and diastolic pressure above normal reference range. All Rights Reserved 10 5

Hypertension Risks: Obesity Alcohol Smoking Family history All Rights Reserved 11 Hypertension I10 Essential Hypertension I11 Hypertensive heart disease with heart failure (identify heart failure I50) I11.9 - Hypertensive heart disease without heart failure I12 Hypertensive chronic kidney disease: stage of kidney disease must be identified: N18.1 N18.6 All Rights Reserved 12 6

Hypertension I13 Hypertensive heart and chronic kidney disease: stage of and type of heart failure must be identified. CKD I15 Secondary Hypertension: code also the underlying disease I16 Hypertensive crisis: code also any identified hypertensive disease (I10-I15) All Rights Reserved 13 Ischemic Heart Disease I20 I25 Ischemic heart diseases All Rights Reserved 14 7

Ischemic Heart Disease Ischemic heart disease is also known as coronary artery disease or "hardening of the arteries. Cholesterol plaque can build up in the arteries of the heart and cause "ischemia," which means the heart is not getting enough blood flow and oxygen. If the plaque blocks an artery, a heart attack can result. Up to 90 percent of heart attacks are due to: smoking, high cholesterol, high blood pressure, diabetes, abdominal obesity ("spare tire", "muffin top ), not eating enough fruits and vegetables, lack of exercise, drinking too much alcohol, and stress. All Rights Reserved 15 Angina Pectoris Commonly known and angina, angina pectoris chest pain is due to ischemia of the heart muscle, generally due to obstruction or spasm of the coronary arteries. The main cause of angina pectoris is coronary artery disease, due to atherosclerosis of the arteries feeding the heart. All Rights Reserved 16 8

Ischemic Heart Disease Use additional code to identify presence of hypertension (I10-I16) Use additional code to identify tobacco exposure/use I20: Angina pectoris TYPE 1 (STEMI) Myocardial Infarction of anterior wall I21: ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction I21.0 Anterior wall: Left main, left anterior descending, other coronary artery I21.1 Inferior wall: Right coronary artery, other coronary artery I21.2 Other sites: Left circumflex, other sites I21.3 Unspecified site I21.4 Non-ST elevation (NSTEMI) All Rights Reserved 17 Myocardial Infarction Quick Reference to Types 1-5 Type 1 MI is spontaneous myocardial necrosis caused by an anatomic blockage of blood flow for a prolonged period of time. Mechanical coronary artery obstruction usually occurs due to plaque rupture or thrombotic occlusion. Type 2 MI is also cell death, but is secondary to ischemia on the basis of supply-demand mismatch, i.e., an imbalance between oxygen demand and supply (e.g., coronary spasm, anemia or hypotension). Type 2 MI is always caused by underlying condition or disease process. Type 3 is MI resulting in sudden cardiac death Type 4a is an MI associated with percutaneous coronary intervention (PCI) Type 4b is MI associated with in-stent thrombosis Type 4c is MI related to restenosis Type 5 is an MI associated with coronary artery bypass graft (CABG) All Rights Reserved 18 9

New Guidelines for 2018 Codes I21.01-I21.4 should only be assigned for Type 1 AMIs in 2018. Notes have been added to specify that STEMI subcategories I21.0-, I21.1-, and I21.2- apply only to Type 1 MIs. Code I21.3, STEMI of unspecified site: Acute MI, unspecified. Code I21.9, Acute myocardial infarction, unspecified, is the default for unspecified acute myocardial infarction or unspecified type. All Rights Reserved 19 New Guidelines for 2018 If only Type 1 STEMI or transmural MI without the site is documented, code I21.3 should be assigned. NSTEMI code I21.4 should be reported for Type 1 non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs. A STEMI code should be reported both when STEMI converts to NSTEMI and when NSTEMI converts to STEMI. This rule applies to Type 1 MIs. If an acute MI is documented as nontransmural or subendocardial, but the site is provided, it should be still coded as a subendocardial acute MI. All Rights Reserved 20 10

New Guidelines for 2018 Subsequent acute MI: The existing rule about using a code from I22.- (Subsequent STEMI and NSTEMI) for AMI within four weeks of another AMI has not changed, but it now applies specifically to Type 1 and unspecified AMI. Coders should continue to use Code I22.- in conjunction with the I21.- code, sequencing them based on the circumstances of the encounter. Do Not assign code I22.- for subsequent myocardial infarctions other than Type 1 or unspecified. Only code I21.A1 should be assigned for subsequent Type 2 AMI. All Rights Reserved 21 New Guidelines for 2018 Only code I21.A9 should be reported for subsequent Type 4 or Type 5 AMI. MI due to demand ischemia or secondary to ischemic (im)balance should be assigned to Type 2 MI and not I24.8, Other forms of acute ischemic heart disease. The Code also and Code first notes should be followed related to complications, and for coding of postprocedural myocardial infarctions during or following cardiac surgery. All Rights Reserved 22 11

Myocardial Infarction Type 2 I21.A Other type of myocardial infarction I21.A1 Myocardial infarction Type 2 Myocardial infarction due to demand ischemia Myocardial infarction secondary to ischemic imbalance Code also the underlying cause, if known and applicable, such as: anemia (D50.0-D64.9) chronic obstructive pulmonary disease (J44.-) heart failure (I50.-) paroxysmal tachycardia (I47.0-I47.9) renal failure (N17.0-N19) shock (R57.0-R57.9) All Rights Reserved 25 Myocardial Infarction Type 3 All Rights Reserved 26 13

Myocardial Infarction Type 5 All Rights Reserved 29 Myocardial Infarction Type 3, 4a, 4b, 4c, 5 I21.A9 Other myocardial infarction type Myocardial infarction associated with revascularization procedure Myocardial infarction Type 3 Myocardial infarction Type 4a Myocardial infarction Type 4b Myocardial infarction Type 4c Myocardial infarction Type 5 All Rights Reserved 30 15

Myocardial Infarction Type 3, 4a, 4b, 4c, 5 Code first, if applicable, postprocedural myocardial infarction following cardiac surgery (I97.190), or postprocedural myocardial infarction during cardiac surgery (I97.790) Code also complication, if known and applicable, such as: (acute) stent occlusion (T82.897 ) (acute) stent stenosis (T82.857 ) (acute) stent thrombosis (T82.867 ) cardiac arrest due to underlying cardiac condition (I46.2) complication of percutaneous coronary intervention (PCI) (I97.89) occlusion of coronary artery bypass graft (T82.218 ) All Rights Reserved 31 Ischemic Heart Disease I22 Subsequent ST elevation (STEMI) and non-st elevation (NSTEMI) myocardial infarction (within the 4 week time frame of the initial MI) I22.0 Anterior wall I22.1 Inferior wall I22.2 non-st elevation I22.8 other sites I22.9 Unspecified site All Rights Reserved 32 16

Ischemic Heart Disease I23 Certain current complication following myocardial infarction (within 28 day period) I23.0 Hemopericardium I23.1 Atrial septal defect I23.2 Ventricular septal defect I23.3 Rupture of cardiac wall with hemopericardium I23.4 Rupture of chordae tendineae I23.5 Rupture of papillary muscle I23.6 Thrombosis of atrium, auricular appendage, and ventricle I23.7 Postinfarction angina I23.8 Other current complications All Rights Reserved 33 Ischemic Heart Disease I24 Other acute ischemic heart disease I24.0 Acute coronary thrombosis not resulting in myocardial infarction I24.1 Dressler s syndrome I24.8 Other forms of acute ischemic heart disease I24.9 Acute ischemic heart disease, unspecified I25 Chronic ischemic heart disease Use additional code for tobacco I25.1 Atherosclerotic heart disease of native coronary artery Use additional code, if applicable to identify: coronary atherosclerosis due to calcified coronary lesion (I25.84) Coronary atherosclerosis due to lipid rich plaque (I25.83) All Rights Reserved 34 17

Ischemic Heart Disease I25.10 of native coronary artery without angina pectoris I25.11 of native coronary artery with angina pectoris I25.110 of native coronary artery with unstable angina pectoris I25.111 of native coronary artery with angina pectoris with documented spasm I25.118 of native coronary artery with other forms of angina pectoris I25.119 of native coronary artery, unspecified All Rights Reserved 35 Ischemic Heart Disease I25.2 Old myocardial infarction I25.3 Aneurysm of heart I25.4 Coronary artery aneurysm and dissection I25.5 Cardiomyopathy I25.6 Silent myocardial ischemia I25.7 Atherosclerosis of coronary artery bypass graft and coronary artery of transplanted heart with angina pectoris I25.8 Others forms of chronic ischemic heart disease I25.9 Chronic ischemic heart disease, unspecified All Rights Reserved 36 18

Other Heart Diseases I26 I28 Pulmonary heart disease and diseases of pulmonary circulation I30 I52 Other forms of heart disease I60 I68 Cerebrovascular diseases I69 Sequelae of cerebrovascular disease I70 I79 Diseases of arteries, arterioles and capillaries I80 I89 Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified I95 I99 Other and unspecified disorders of the circulatory system. All Rights Reserved 37 Exposure to Tobacco I10 I15 Hypertensive diseases I20 I25 Ischemic heart diseases Require: Use additional code to identify: History of tobacco use (Z87.891) History of environmental tobacco smoke (Z77.22) Occupational exposure to environmental tobacco smoke (Z57.31) Tobacco dependence (F17.-) Tobacco use (Z72.0) All Rights Reserved 38 19

Size and Location The human heart is about the size of a fist. It is located in the mediastinum of the thoracic cavity, slightly left of the midline. It s pointed tip, the apex, rests just above the diaphragm. All Rights Reserved 39 Heart Chambers The inside of the heart has four chambers: Right Atria; receives deoxygenated blood from the superior and inferior vena cava that is returning from the body Left Atria; receives oxygenated blood from the lungs via the pulmonary veins Right Ventricle; pushes the deoxygenated blood from the right atria into the pulmonary artery to the lungs for oxygenation Left Ventricle; pushes the oxygenated blood from the left atria into the aorta to distribute nutrients and oxygen to every cell in the body All Rights Reserved 40 20

Heart Valves The heart has four valves; two at the exit of the atria and two at the exit of the ventricles. The valves prevent the blood from flowing backward into the heart chambers. They open and close depending on the pressure of the blood surrounding them. If the blood pressure behind the valves is greater than in front of them they will open. If the blood pressure in front is greater they will close. All Rights Reserved 41 Heart Valves All Rights Reserved 42 21

Mitral and Tricuspid Valves The mitral and tricuspid valves located between the atria and the ventricles have specialized attachments called the papillary muscles and the chordae tendineae. These prevent the valves from opening backward into the atria when ventricular pressure rises. Papillary muscles contract along with the ventricle, pulling taut the chordae tendineae to keep the valve tight shut. All Rights Reserved 43 ICD-10 Codes I34 Nonrheumatic mitral valve disorders I34.0 insufficiency I34.1 prolapse I34.2 stenosis I35 Nonrheumatic aortic valve disorders I35.0 stenosis I35.1 insufficiency I34.2 stenosis with insufficiency I36 Nonrheumatic tricuspid valve disorders I36.0 stenosis I36.1 insufficiency I36.2 stenosis with insufficiency I37 Nonrheumatic pulmonary valve disorders I37.0 stenosis I37.1 insufficiency I37.2 stenosis with insufficiency All Rights Reserved 44 22

Chordae Tendineae and Papillary Muscles Chordae Tendoneae Purkinje Fibers Papillary Muscles All Rights Reserved 45 Complications I51.1 Rupture of chordae tendineae, not elsewhere classified. I51.2 Rupture of papillary muscle, not elsewhere classified All Rights Reserved 46 23

Cardiac Cycle 1. Diastole: At this stage the ventricles are relaxed. In early diastole the mitral and tricuspid valves open and blood that has been building up in the atria during systole rapidly flows into the ventricles. the blood returning to the heart flows from the atria into the ventricles. At the end of this process the ventricles are about 75% full. All Rights Reserved 47 Cardiac Cycle 2. Atrial Systole: The right and left atria contract simultaneously, forcing any remaining blood into the ventricles, which are still relaxed, through the mitral and tricuspid valves. After atrial systole the ventricles are full, yet the contraction of the atria has only contributed to 25% of this volume. Even higher pressure in the contracting atria keeps the mitral and tricuspid valves open. The aortic and pulmonary valves remain closed. All Rights Reserved 48 24

Cardiac Cycle 3. Isovolumic Contraction: This is the first stage of systole, when the muscle of the ventricles starts to contract and increase the pressure on the blood within the ventricle. This increased pressure is enough to close the mitral and tricuspid valves, but not enough to open the aortic and pulmonary valves. During this stage the ventricles contract as a closed system. Increased ventricular pressure means the mitral and tricuspid valves close, yet it is not high enough to open the pulmonary and aortic valves. All Rights Reserved 49 Cardiac Cycle 4. Ejection: Eventually the ventricular contraction causes the pressure of the blood within the ventricles to exceed the pressure of the blood in the aorta and pulmonary arteries. At this point the aortic and pulmonary valves are forced open and blood is powerfully ejected from the ventricles. The papillary muscles prevent the mitral and tricuspid valves from opening. All Rights Reserved 50 25

Cardiac Cycle 5. Isovolumic Relaxation: Isovolumic relaxation is the earliest phase of diastole. The ventricles start to relax and the pressure of blood within the falls to below that of the blood in the aorta and pulmonary artery. The aortic and pulmonary valves both close. The pressure in the ventricles is still too high to allow the mitral and tricuspid valves to open. All Rights Reserved 51 Cardiac Conduction System All Rights Reserved 52 26

Cardiac Conduction System The cardiac conduction system consists of specialized cells that transport electrical impulses through the cardiac muscle in order to trigger its contraction. The impulse for each heartbeat starts in the sinoatrial (SA) node, which is located in the right atrium. It rapidly flows through the atria and causes them to contract (atrial systole).. All Rights Reserved 53 Cardiac Conduction System Electricity cannot pass directly between the atria and ventricles; instead it is channeled into the atrioventricular (AV) node. It is delayed slightly to ensure that the atrial contraction is over before the ventricles start to contract. After leaving the AV node, the electrical impulse rushes through the bundle of His and Purkinje fibers. These are the conducting fibers that run through the ventricle walls, to stimulate contraction of the ventricles. All Rights Reserved 54 27

Blood Supply The heart is the most active muscle in the body. It needs a constant supply of blood to deliver oxygen and nutrients to its cells and remove their waste. Even though the heart is always full of blood, this cannot reach all the cells of its thick walls. So the heart has its own blood vessels, the coronary circulation. All Rights Reserved 55 Coronary System All Rights Reserved 56 28

Coronary Arteries The coronary arteries that supply the heart are forced shut under the pressure of the contracting muscle. Therefore, they can only fill when the heart is relaxed during diastole. The main coronary arteries are: Right coronary artery (PDA PLA) Left circumflex artery (OM) Left anterior descending (Diagonal) Left Main (LM) Ramus Intermedius (RI) All Rights Reserved 57 Diseases of the Heart Signs of Coronary Artery Disease A precursor to a heart attack, coronary artery disease or CAD occurs when sticky plaque builds up inside the coronary arteries. This narrows the arteries, making it more difficult for blood to flow through. Many people don't know they have CAD until a heart attack strikes. But there are warning signs, such as recurring chest pain caused by the restricted arteries: ICD-10-CM: I20.0 I20.9 All Rights Reserved 58 29

Diseases of the Heart Inside a Heart Attack The plaque deposited in your arteries is hard on the outside and soft and mushy on the inside. Sometimes the hard outer shell cracks. When this happens, a blood clot forms around the plaque. If the clot completely blocks the artery, it cuts off the blood supply to a portion of the heart. Without immediate treatment, that part of the heart muscle could be damaged or destroyed. ICD10-CM: I21 I22.9 All Rights Reserved 59 Diseases of the Heart Arrhythmia: Erratic Heart Beat Regular electrical impulses cause your heart to beat. But sometimes those impulses become erratic. The heart may race, slow down, or quiver. Arrhythmias are often harmless variations in rhythm that pass quickly. But some types make your heart less effective at pumping blood, and that can take a serious toll on the body. Let your doctor know if you've noticed your heart beating abnormally. ICD10-CM: I49 I49.9 All Rights Reserved 60 30

Cardiomyopathy Cardiomyopathy Cardiomyopathy is a disease involving changes in the heart muscle. These changes may interfere with the heart's ability to pump effectively, which can lead to a chronic condition called heart failure. Cardiomyopathy is sometimes associated with other chronic conditions, such as high blood pressure or heart valve disease. ICD-10-CM: I42 I43 All Rights Reserved 61 Diseases of the Heart Heart Failure Heart failure doesn't mean your heart stops working. It means the heart can't pump enough blood to meet the body's needs. Over time, the heart gets bigger to hold more blood, it pumps faster to increase the amount of blood moving out of it, and the blood vessels narrow. The heart muscle may also weaken, reducing the blood supply even more. Most cases of heart failure are the result of coronary artery disease and heart attacks. ICD-10-CM: I50 I50.9 All Rights Reserved 62 31

Myocardial Ischemia Myocardial ischemia occurs when blood flow to the heart muscle (myocardium) is obstructed by a partial or complete blockage of a coronary artery by a buildup of plaques (atherosclerosis). If the plaques rupture, you can have a heart attack (myocardial infarction). ICD-10-CM: I25 I25.6 All Rights Reserved 63 Angioplasty Treatment: Angioplasty Angioplasty is used to open a blocked heart artery and improve blood flow to the heart. The doctor inserts a thin catheter with a balloon on the end into the artery. When the balloon reaches the blockage, it is expanded, opening up the artery and improving blood flow. The doctor may also insert a small mesh tube, called a stent, to help keep the artery open after angioplasty. All Rights Reserved 64 32