Cardiology Coding Alert
You Be the Coder:
Determine ICD-9 and ICD-10 Codes for Inconclusive Test
Published on Thu Nov 13, 2014
Question: When a patient suspected to have coronary artery disease presents for an echocardiogram because of chest pain, but the results are inconclusive, which ICD-9 and ICD-10 codes apply? Is there an authoritative rule about this that I can show my manager?
Colorado Subscriber
Answer: Rather than reporting the suspected, but not identified, coronary artery disease, you should report the code for the symptom of chest pain that triggered the test.
Under ICD-9, you should report 786.50 (Unspecified chest pain). Under ICD-10, you’ll have a similarly defined code, R07.9 (Chest pain, unspecified).
Support: ICD-9 official guidelines state, “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider” (Section I.B.6). You can download the guidelines from www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.
You’ll find the exact same wording in Section I.B.4 of the ICD-10 2015 official guidelines, available from www.cdc.gov/nchs/icd/icd10cm.htm#icd2015.
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