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ICD-10 Coding for History of Coronary Artery Bypass Graft (CABG)(Z95.1, I25.700)

Complete ICD-10-CM coding and documentation guide for History of Coronary Artery Bypass Graft (CABG). Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

CABG statusPost-CABGCoronary bypass history

Related ICD-10 Code Ranges

Complete code families applicable to History of Coronary Artery Bypass Graft (CABG)

Z95.1Primary Range

Presence of aortocoronary bypass graft

This code is used to indicate the presence of a coronary artery bypass graft without active complications.

Atherosclerosis of coronary artery bypass graft(s)

This range is used when there is active coronary artery disease affecting the grafts.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
Z95.1Presence of aortocoronary bypass graftUse when documenting a history of CABG without active coronary artery disease affecting the graft.
  • Operative report confirming CABG
  • Absence of current symptoms related to graft
I25.700Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable anginaUse when there is documented atherosclerosis in the graft with unstable angina.
  • Angiography showing graft stenosis
  • Symptoms of unstable angina

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for history of CABG

Essential facts and insights about History of Coronary Artery Bypass Graft (CABG)

The ICD-10 code Z95.1 is used for documenting the presence of aortocoronary bypass graft without active complications.

Primary ICD-10-CM Codes for history of cabg

Presence of aortocoronary bypass graft
Billable Code

Decision Criteria

clinical Criteria

  • Patient has a history of CABG with no current symptoms or complications.

Applicable To

  • History of CABG without active complications

Excludes

  • Complications of CABG (T82.2-)

Clinical Validation Requirements

  • Operative report confirming CABG
  • Absence of current symptoms related to graft

Code-Specific Risks

  • Using Z95.1 alone when active graft disease is present

Coding Notes

  • Ensure documentation specifies the absence of active graft-related disease.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Atherosclerosis of coronary artery bypass graft(s)

I25.7-
Use when there is active disease affecting the graft.

Presence of aortocoronary bypass graft

Z95.1
Use as a secondary code to indicate the presence of the graft.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Atherosclerotic heart disease of native coronary artery without angina pectoris

I25.10
Use for native coronary artery disease without graft involvement.

Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

I25.110
Use for native coronary artery disease with unstable angina.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting History of Coronary Artery Bypass Graft (CABG) to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z95.1.

Impact

Clinical: May lead to inappropriate treatment decisions., Regulatory: Potential for audit issues., Financial: Risk of claim denials.

Mitigation Strategy

Use specific terms like 'graft stenosis' or 'native vessel disease'., Ensure operative reports are available.

Impact

Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate representation of patient condition.

Mitigation Strategy

Use I25.7- for active disease and Z95.1 as a secondary code.

Impact

Failure to specify vessel involvement can lead to coding errors.

Mitigation Strategy

Implement a checklist for documentation review.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for History of Coronary Artery Bypass Graft (CABG), with expert answers to help guide accurate code selection and documentation.

Documentation Templates for History of Coronary Artery Bypass Graft (CABG)

Use these documentation templates to ensure complete and accurate documentation for History of Coronary Artery Bypass Graft (CABG). These templates include all required elements for proper coding and billing.

Asymptomatic history of CABG

Specialty: Primary Care

Required Elements

  • Year of CABG
  • Current symptom status
  • Graft patency

Example Documentation

Patient is status post CABG in 2018, asymptomatic, with patent grafts.

Examples: Poor vs. Good Documentation

Poor Documentation Example
History of heart surgery.
Good Documentation Example
Status post 3-vessel CABG in 2020, asymptomatic, grafts patent.
Explanation
The good example provides specific details about the surgery and current status.

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