Guest Post: Look for underlying cause of coronary artery disease

by Cheryl Ericson, MS, RN, CCDS, CDIP

Coronary artery disease (CAD) develops when the arteries that supply the blood to the heart muscles become hardened and narrowed due to a buildup of cholesterol and other materials, such as plaque, on their inner wall. It’s also called atherosclerosis.

CAD is the most common type of heart disease and occurs in a wide range of patients. This chronic condition is the leading cause of death in the United States for both men and women. Usually, but not always, the complications associated with CAD are what lead to death, rather than the chronic condition itself, says Cheryl Ericson, MS, RN, CCDS, CDIP, CDI Education Director for ezDI, and an ACDIS Advisory Board member.

Atherosclerosis can reduce blood flow, and as a result it can decrease oxygen to the heart muscles. If the heart muscles don’t get enough oxygen for long enough, infarction can result, leading to tissue necrosis or death, Ericson says. If it’s only a brief lack of oxygen, the patient might develop chest pain, more specifically angina, which is a specific type of chest pain associated with CAD. Prolonged oxygen deprivation can lead to tissue death, which is an acute myocardial infarction (AMI). In addition, CAD weakens the heart muscles, thereby contributing to heart failure and different arrhythmias.

The thing that’s tricky from a clinical documentation perspective is that CAD is not something that typically needs to be treated in the inpatient setting, Ericson says. Physicians can usually monitor and treat patients very well in the outpatient setting. As such, CDI specialists need to look for the acute reason for the admission, that is, the new symptom associated with the chronic CAD, which is often the cause of the inpatient admission.

Editor’s Note: This article is an excerpt from Briefings on Coding Compliance Strategies.