"Assign code 414.01, Coronary atherosclerosis, of native coronary artery, if medical record documentation shows no history of prior coronary artery bypass. If the documentation is unclear concerning prior bypass surgery, query the physician."
Aortic Atherosclerosis coding – Documentation that indicates “aortic atherosclerosis” or “atherosclerosis of the aorta” without further clarification cannot be coded according to
Assign code 438.89, Other late effects of cerebrovascular disease and code 728.87, Muscle weakness, for residual muscle weakness secondary to late effect of cerebrovascular accident.
Therefore, when the physician documents weakness secondary to an old CVA, you cannot code 438.20. Physicians must be educated regarding this rule, so that they can adjust their documentation going forward.
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