Question: A patient presented with a sudden onset of severe chest pain, which was less uncomfortable when lying down. The nurse who took their vitals documented that they had a temperature of 101.9 degrees Fahrenheit, and the doctor documented that they had shortness of breath and heart palpitations. The doctored ordered an electrocardiogram (EKG), which was performed in-office. After reviewing the patient’s symptoms and EKG results, the doctor documented a diagnosis of acute pericarditis. What is the best ICD-10-CM code to reflect a diagnosis of pericarditis?
Michigan Subscriber
Answer: Pericarditis occurs when the pericardium, the fluid-filled sac around the heart, becomes inflamed. Pericarditis can present as its own condition or a manifestation due to another illness or condition.
When searching for an accurate ICD-10-CM code, you should look to I30- (Acute pericarditis) codes for acute pericarditis. The chronic types of pericarditis fall under the I31- (Other diseases of pericardium) codes. Some other health conditions may involve pericarditis, in which case you’d code that condition before the pericarditis; in those situations, I32 (Pericarditis in diseases classified elsewhere) can be used.
Since your provider documented the patient’s examination and test results, in addition to the diagnosis of acute pericarditis, you can look to ICD-10-CM code I30.9 (Acute pericarditis, unspecified).
Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
