April 14, 2008

Coding for Peripheral Vascular Disease
For The Record
Vol. 20 No.8 P. 28

Peripheral vascular disease (PVD) is a circulatory condition resulting in reduced blood flow to the extremities, typically occurring in the legs. The most common symptom of PVD is intermittent claudication, which is pain while walking that resolves after a few minutes of rest. The location of the pain will depend on the site of the narrowed or clogged artery.

PVD and intermittent claudication, not otherwise specified, is classified to ICD-9-CM code 443.9. If the PVD is due to diabetes mellitus, codes 250.7 and 443.81 would be assigned. The diabetic code (250.7x) would be sequenced first, and it requires a fifth-digit subclassification to identify if the diabetes is type 1 or 2 and is controlled or uncontrolled.

Another condition patients may have related to PVD is atherosclerosis, or a widespread accumulation of fatty deposits in the arteries. Atherosclerosis of the extremities is classified to code 440.2 and requires a fifth-digit subclassification to differentiate the type as follows:

• 440.20, Atherosclerosis of the extremities, unspecified;

• 440.21, Atherosclerosis of the extremities with intermittent claudication;

• 440.22, Atherosclerosis of the extremities with rest pain;

• 440.23, Atherosclerosis of the extremities with ulceration;

• 440.24, Atherosclerosis of the extremities with gangrene; and

• 440.29, Other.

Codes from subcategory 440.2x are considered a hierarchy. In other words, if the patient has atherosclerotic peripheral vascular disease (ASPVD) with gangrene, it is assumed the patient also has an ulcer. Do not assign codes 440.23 and 440.24 on the same record. If the patient does have an ulcer with the atherosclerosis, according to coding directives, it is appropriate to assign a code for any associated ulceration (707.10-707.9) in addition to the 440.2x code. Since it is considered a hierarchy, if the patient also has gangrene, code 440.24 is assigned, but it is still appropriate to list code 707.1x as a secondary diagnosis to identify the type and site of the skin ulcer.

For coding purposes, the physician must document that the PVD is due to atherosclerosis before a code from 440.2 may be assigned. For example, a patient is admitted to the inpatient setting with PVD and is scheduled to undergo surgery for amputation below the knee. If the physician documents PVD throughout the medical record and the pathology report states atherosclerosis of the leg, the physician should be queried for clarification. Without additional physician documentation, code 443.9 would be assigned. It would not be appropriate to assign a code from 440.2x in this case without the physician documenting ASPVD or PVD due to atherosclerosis. In fact, Coding Clinic advises to query the physician for further specification if the physician documents vague diagnoses as peripheral vascular disease or intermittent claudication (AHA Coding Clinic for ICD-9-CM, 1992, fourth quarter, page 25).

Subcategory 440.2 is used to classify atherosclerosis of the native arteries. If the patient has atherosclerosis of bypass graft of the extremities, a code from subcategory 440.3x is assigned. The fifth-digit subclassification will depend on whether the bypass graft was an autologous vein bypass graft (440.31) or a nonautologous vein bypass graft (440.32).

More recently, physicians are documenting peripheral arterial disease (PAD). Although there is no official coding advice for PAD, it is safe to say that artery is included in the term vascular. Vascular is defined in Stedman’s Medical Dictionary as “related to or containing blood vessels.” An artery is defined as “a relatively thick-walled, muscular, pulsating blood vessel conveying blood away from the heart.” Therefore, assign code 443.9 for a diagnosis of PAD. It appears that PAD is indicating more specifically which blood vessel is involved. It may still be appropriate to query the physician for clarification if it is possible the patient has atherosclerosis.

Signs and Symptoms
Besides intermittent claudication, other common signs and symptoms of PVD include leg numbness or weakness; cold legs or feet; poor wound healing on toes, feet, or legs; color change in the legs; weak or absent pulse; and bruits over the arteries.

Diagnosis
The physician may order the following studies to aid in the diagnosis of PVD: angiography to follow the blood flow through the arteries, and ankle-brachial index to compare the blood pressure in the ankle with the blood pressure in the arm.

Treatment
Medications may be used to treat PVD by helping to prevent blood clots, lower blood pressure, decrease cholesterol, and control pain and other symptoms. In other cases, surgery may be required. Angioplasty is a common procedure used to reopen the artery. Angioplasty of the noncoronary vessel is classified to code 39.50. If a drug-eluting stent is inserted, assign code 00.55. If a non–drug-eluting stent is inserted, assign code 39.90. It is important to remember to assign at least two codes if a stent is inserted—one for the angioplasty and one for the stent insertion. Other codes are also necessary to identify the number of vessels that the procedure was performed on (00.40-00.44) and the number of stents inserted (00.45-00.48).

Coding and sequencing for PVD depend on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.