Ask the Expert

This month’s selection:

On our calcium score reports, many times there is only a score and not an impression. Can we code plaques in the heart arteries based on the score alone?

0 = no calcified plaque detected (risk of coronary artery disease is very low—less than 5%)

1-10 = calcium detected in extremely minimal levels (risk of coronary diseases is still low—less than 10%)

11-100 = mild levels of plaque detected with certainty (minimal narrowing of heart arteries is likely)

101-300 = moderate levels of plaque detected (relatively high risk of a heart attack within three to five years)

300-400 = extensive levels of plaque detected (very high risk of heart attack, high levels of vascular disease are present)

Lorraine Oefinger Lopez, RHIT, CCS

Response:

According to ICD-10-CM Official Guidelines for Coding and Reporting, coders are advised not to interpret laboratory or study results. Specifically, the guidelines state that the coding of a diagnosis must be based on the provider's diagnostic statement that the condition exists. I am unable to locate any specific guidance that would allow a coder to bypass this rule in this scenario. It is crucial that coders rely on the physician's or health care provider's diagnostic statement and do not interpret diagnostic results themselves (ICD-10-CM Official Guidelines for Coding and Reporting, Section I, A, 19, Code Assignment and Clinical Criteria).

I.A.19. Code Assignment and Clinical Criteria: The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.

In light of these guidelines, it is not advised to code coronary artery disease or plaque based solely on coronary artery calcium scores from diagnostic reports. The calcium scores provide a quantitative measure of calcified plaque in the coronary arteries, which can be an indicator of coronary artery disease risk. However, the interpretation of these scores and their clinical significance should be provided by the health care provider.

If a calcium score report indicates the presence of calcified plaque but does not include a clinical interpretation or diagnosis from the health care provider, it would be appropriate to query the provider for clarification. The query should seek to understand the clinical relevance of the calcium score in the context of the patient's overall health condition, including whether the provider considers it indicative of coronary artery disease or another specific condition that should be coded.

In summary, the coding of any condition, including those suggested by calcium scores, should be directly based on the provider's diagnosis. If the provider's interpretation is not explicitly stated in the documentation accompanying the calcium score, a query should be made to the provider to obtain a definitive diagnosis before coding. This approach ensures that coding practices adhere to ICD-10-CM guidelines and accurately reflect the patient's diagnosed conditions.

— Jacob Swartzwelder (he/him/él), CPC, CRC, CPMA, CIC, CEMC, is an AAPC-approved instructor, AAPC National Advisory Board member, and SAFe 5 Agile Practitioner.