Coronary Artery Disease Documentation Guide
Atherosclerotic heart disease affecting the coronary arteries.
ICD-10 Codes: I25.10, I25.11, I25.118, I25.119, I25.5
Common Symptoms
- Chest pain
- Shortness of breath
- Fatigue
- Palpitations
Key Documentation Elements
- Cardiac symptom assessment
- Prior cardiac interventions
- Current cardiac medications
- Risk factor status (lipids, diabetes, smoking)
- Functional capacity assessment
Documentation Challenges
- Capturing detailed cardiac history
- Documenting stress test and catheterization results
- Recording medication optimization
- Tracking risk factor modification
Billing Considerations
- HCC code for chronic ischemic heart disease
- Proper specificity for native vs bypass graft disease
- Documentation supporting complexity of care
Frequently Asked Questions
What documentation is needed for CAD?
CAD documentation should include symptom status, prior cardiac events/interventions, current medications, risk factors, and functional assessment. Scribeable captures all of this from your conversation.