In a primary care setting, we sometimes encounter patients who have been diagnosed with angina pectoris and are being followed by the primary care practitioner (PCP). In this blog, we will share some of the most common issues regarding this risk-adjusted condition that causes a great deal of consternation for providers and coders alike.
It’s not uncommon for patients with CAD to experience anginal symptoms (described as squeezing, suffocating or a burning feeling in the middle of chest) but the key, as all clinicians know, is to differentiate between cardiac and noncardiac causes. The medical literature informs that assessing atypical chest pain begins with careful examination of the chest wall by means of an EKG to start, and noting any abnormal heart sounds. Atypical chest pain has its own diagnosis code (R07.89), which should be used during the investigational period.
In outpatient medicine, diagnoses are coded once confirmed and in the scenario above, until an individualized plan of testing is carried out in stages and its results evaluated by the clinician, we code based on we (absolutely) know. In the inpatient setting, providers are permitted by coding guidelines to code “rule out” or differential diagnoses, and PCPs should be mindful of this convention when reviewing inpatient records.
Once a diagnosis of angina is confirmed, the PCP should document the path to the diagnosis and the treatment plan. If the patient is prescribed a nitrate medication, it should be linked to the diagnosis in the provider’s charting. In addition, if the patient undergoes a successful intervention and is no longer experiencing angina or being treated for it despite treatment for coronary artery disease (CAD), the angina portion of the diagnosis should be retired.
One of the biggest errors of “support” we see in auditing charts is a reference that the patient had angina in 2015 and PRN Nitro is on the medication list – no signs or symptoms, no episodes, just a medication that is refilled in perpetuity. This is highly suspect, especially if the patient has had a procedure. In these cases, it’s important for the PCP’s documentation to describe the patient’s anginal symptoms since the last visit and episodes when he or she last took the medication. Absent documented anginal episodes or medication specifically for treating angina and not CAD or hypertension, the condition is not supported.
Chart auditors look for contradictory information, such as a recent cardiologist’s note that disputes the PCP’s diagnosis or a negative stress test. Unless the PCP has charted recent episodes, angina would be queried and flagged for possible removal.
In a nutshell, remember that each note needs to stand alone. At every visit that you assess this condition, be sure to document:
- Any signs and symptoms (s/s) the patient has recently experienced or is experiencing.
- Last time patient had those s/s and/or took angina medication.
- Linkages among all the medications for angina in the assessment or treatment plan.
- How the condition is progressing and how the patient is responding to your treatment plan.
There is sometimes a big difference between the clinical and coding perspectives. Some providers believe that once a patient has angina, this clinical diagnosis never goes away. But in all reality, if there are no current signs of it and there is no documented treatment for this condition right now, just Nitro as needed (and it hasn’t been needed), it’s considered resolved from a coding standpoint.