Chest Pain Coding rules for symptoms when a diagnosis is not confirmed.

Alcoholic Cardiomyopathy Etiology-specific cardiomyopathy documentation.

Dressler’s Syndrome Documenting post-MI pericardial inflammation.

Long QT Syndrome Distinguishing between congenital and acquired causes.

Brugada Syndrome Documentation for genetic arrhythmia syndromes.

Demand Ischemia (Type 2 MI) Rapid AFib leading to elevated Troponin without plaque rupture.

Electrolyte Imbalance Documentation for critical lab values.

Old Myocardial Infarction Status Documenting a past event.

Silent Ischemia Documentation for objective ischemia without symptoms.

Venous Insufficiency Documenting chronic venous conditions and complications.

Hyperlipidemia Specificity Distinguishing lipid disorder types.

PAD Severity Documenting atherosclerosis of the extremities.

Sick Sinus Syndrome (SSS) Superiority over the term "Bradycardia".

Bundle Branch Blocks Documentation for conduction delays.

Myocarditis Specific documentation for heart muscle inflammation.

Aortic Dissection Anatomy and chronicity of the dissection.

Aortic Aneurysm Location Documenting an abdominal aortic aneurysm.

Endocarditis Organism Linking a cultured organism to the site of infection.

CKD Staging Capturing risk adjustment factors for kidney disease.

Nicotine Dependence Documentation for vaping or smoking.

Morbid Obesity Documentation for patients with BMI > 40.

Right Heart Failure Documentation for isolated right-sided failure.

Ventricular Tachycardia (VT) Specify the duration to ensure clinical accuracy.

A hematoma forms at a device pocket site. Appropriate documentation should be:

Pulmonary Hypertension Groups Specify the PH group to determine the risk adjustment score.

Tricuspid Regurgitation Noting severe TR during lead placement.

Takotsubo Syndrome Documenting stress-induced cardiomyopathy.

Atherosclerotic Heart Disease with Angina Use the specific combination for native coronary vessels.

Coronary Artery Dissection Specify if the dissection is traumatic or spontaneous.

Cardiac Tamponade During a procedure, pressures drop due to a perforation.

Pericarditis Specificity After an ablation, the patient develops chest pain.

Syncope Etiology A patient is admitted for Syncope; you find a definitive cause.

Atrial Fibrillation Specificity "Afib" unspecified (I48.91) is a documentation red flag.

Mitral Regurgitation Etiology Distinguish the cause of the valvular leak.

Arterial Embolism Specify the location of the acute clot.

Cardiomyopathy Type "Cardiomyopathy" (I42.9) is unspecified. Better to document:

Acute Pulmonary Edema Documenting "Pulmonary Edema" alone can be non-specific; you must link it to the cause

Unstable Angina A patient has worsening symptoms at rest.

CAD with Angina If the patient has both coronary artery disease and unstable angina, use the combination code.

Acute Blood Loss Anemia A patient drops Hgb after a procedure and gets transfused.

Aortic Stenosis Etiology To code valvular disease accurately, one must specify the origin.

Sick Sinus Syndrome vs. Bradycardia A patient presents with syncope and a heart rate of 35. A pacemaker is planned.

Hypertensive Emergency BP 200/110 with headache or blurry vision requires specific documentation.

Heart Failure Specificity "CHF" is a documentation red flag. You must document:

Myocardial Infarction Type "MI" or "STEMI/NSTEMI" is the baseline, but ICD-10-CM requires the specific type to distinguish pathophysiology.