Coding Coronary Artery Disease (CAD) may seem straightforward but, there is specific information needed before you can accurately assign a CAD code. Carefully review the patient’s chart to determine if CAD is affecting the native arteries or grafted arteries. If the patient has had a CABG in the past, there is a chance that CAD is present in the grafted arteries rather than in the native arteries. If this is the case assign a code from the range 414.02-414.05. Also remember to assign V45.81 CABG Status to show the patient’s surgical history and extent of CAD. If the patient does not have a history of a CABG surgery, then you can assign code 414.01 CAD of native vessels. Always check your documentation before assigning an unspecified CAD code.
