21 Mar Off
The last six months of ICD10 implementation has brought about many new challenges and learning opportunities for both providers and coding professionals. One such opportunity is the documentation of peripheral vascular disease (PVD). Documenting PVD without further specificity in ICD-10 codes to I73.9, Peripheral Vascular Disease, Unspecified.
In order to document most specifically for PVD, it’s important to include these components in your documentation:
- Location of vein/artery affected
- Whether the vein/artery is native or a graft (and type of graft if known)
- Complications such as intermittent claudication, ulceration or rest pain
- Laterality (left, right, or bilateral) and specify if one or both sides are affected by complicating conditions of atherosclerosis.
An example of best practice documentation for PVD without complication would be: Patient has atherosclerosis of native artery bilateral lower extremities without ulceration or claudication. This documentation would result in code I70.203, Unspecified atherosclerosis of native arteries of extremities, bilateral legs. This is a more specific code than I73.9, reflecting more specific documentation, which is more clinically relevant.
To document a more complicated case of PVD, one could document: Patient has atherosclerosis of native artery of right lower extremity with rest pain. This documentation would result in code I70.221, which is very specific and includes the complication of rest pain. A briefer method, such as PAD d/t atherosclerosis of native artery RLE with resting pain would also code to I70.221.
Many providers may prefer to continue documenting with the term PAD or even PVD. Our recommendation is to document PAD due to atherosclerosis, because including the term atherosclerosis allows coders to capture the more specific codes, when the condition is caused by the atherosclerotic process, as most arterial disease is.
The increased number of ICD-10 codes for common diagnoses in the elderly population is significant. It will take effort and practice to routinely document laterality, type of vein/artery, type of graft, and whether complicating conditions exist with the condition. However, getting into the habit of adding this documentation will result in more specific codes, which will have long-term benefits. Unspecified codes may eventually be rejected or penalized. So, beginning to document with the most possible specificity is both best practice now and defense against any future repercussions of unspecified codes.