AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 3; Ask the Editor

In-Stent Restenosis Not Further Specified

A patient presented with chest pain and underwent cardiac workup, including coronary angiography. The patient has known coronary artery disease, status post stent placement in the left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA) arteries. The provider documented, “in-stent” restenosis in all three previously placed coronary artery stents. In many cases, the health record documentation does not provide the specificity needed to determine the cause of the stenosis. How is “in-stent” restenosis not further specified coded? In this instance, should the coding professional query the provider to determine the cause of the “in-stent” restenosis? ...

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