Radiology Coding Alert

Question: Following an imaging scan, the physician listed the findings as aortic root abscess.

What codes should I assign to report the diagnosis?

Alaska Subscriber

Answer: You’ll need to review multiple factors before assigning the correct codes for an aortic root abscess. The condition is usually the result of an aortic valve infection. The provider should document the underlying infection, but if the provider doesn’t indicate an infection diagnosis, then you could request the provider add documentation to the chart or medical report stating that.

Next, you’ll want to review the documentation to know if the aortic valve is native or a prosthesis. If the valve is native, then you’ll turn to the ICD-10-CM Alphabetic Index and search for Infection > heart — see carditis. If the infection isn’t identified, you’ll report the unspecified code I51.89 (Other ill-defined heart diseases). However, if the provider identifies the underlying infection, you’ll assign a code that represents the degree of specificity.

If the patient has a prosthetic valve, you’ll assign T82.6XXA (Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter). This code features a Use additional code note instructing you to assign the correct code to identify the infection if the infection is known, which will be the code you’d assign for a native aortic root abscess — I51.89.

Excludes2 note: Parent code T82.- (Complications of cardiac and vascular prosthetic devices, implants and grafts) also features an Excludes2 note that instructs you to assign a code from the T86.- (Complications of transplanted organs and tissue) if the patient is also experiencing failure and rejection of organs and tissue after a transplant.