Providers must confirm the accuracy of their diagnoses to ensure that diagnosis and coding practices comply with ICD-10-CM Official Guidelines for Coding and Reporting and all applicable legal requirements. Failure to address diagnosis inaccuracies can result in administrative sanctions and potential financial penalties. Accurate coding and submission activities allow us to provide the best benefits and resources possible to our customers.
This guide is informational and not meant to replace the clinician’s judgment when caring for the patient.
Content updated April 2023
Pt is a 68 y/o BM, presents today c/o with discomfort and fatigue in legs. History of CAD
Social Hx- divorced, former athlete, social drinker, non-smoker
BP 118/90 Pulse 80 Resp. 18 Ht. 6’2†Wt. 245
BMI: 30.0
Med List- Warfarin 5mg qd; Atorvastatin 40 mg qd
ABI - .90
Plan – schedule Duplex study
Diagnosis: Peripheral angiopathy
Coded as:
I73.9 PAD, unspecified
Pt is a 75 y/o morbidly obese WF, presents today for follow up care PAD, c/o severe constant pain in right forefoot and toes, pain scale 9/10.
Vitals – Temp 98.2, Pulse 84 Resp. 16 Ht. 5-2â€
Wt. 235 BMI: 43 Social Hx: widowed, alcohol 1 drink/day, denies tobacco use
Med Hx: morbid obesity, atherosclerosis of lower extremities, LBKA, COVID-19,
Exam: Alert x3, non-ambulatory, right foot cold, dorsalis pedal and posterior tibial both nonpalpable
CTA Report: Severe stenosis of R anterior tibial, posterior tibial, and peroneal, significant for calcified plaque. Bilateral femoral moderate stenosis
Plan: Referral to vascular surgeon
Diagnosis: PAD w/rest pain, Morbid obesity
I70.221 - Atherosclerosis of native arteries of the right foot with rest pain
Z68.43 – BMI 43
E66.01 – Morbid obesity due to excess calories
Z89.512 – Acquired absence L leg below knee
*The sole purpose of the examples is to demonstrate the application of coding guidelines discussed in the materials. Examples do not represent complete documentation of a condition, nor provide any clinical advice. Each patient and medical record is unique, and assignment of codes depends solely on the distinct documentation within an individual record.
