ICD-9 Coding for Chest Pain
Chest pain is a common complaint in the urgent care setting, and is not always related to an acute heart condition. The characteristics of chest pain depend on the cause, and may be described as ischemic, nonischemic, noncardiac gastroesphageal, pulmonary, or musculoskeletal.
Ischemic cardiac diagnoses includes angina, myocardial infarction, aortic stenosis, hypertrophic cardiomyopathy, and coronary vasospasm. Nonischemic cardiac causes of chest pain include pericarditits, aortic dissection, and mitral valve prolapse.
Non-cardiac causes may include gastroesophageal, pulmonary, musculoskeletal, and dermatologic events. Gastroesophageal causes may include reflux esophagitis, esophageal spasm, esophageal perforation, gastritis and peptic ulcer disease, and achalasia. Pulmonary causes may include pneumothorax, pulmonary embolism, pleuritis, neoplasm, and bronchitis. Musculoskeletal causes may include costochondritis, rib fracture, compression fracture. One dermatologic cause is herpes zoster (shingles).
Anxiety or panic attacks often bring on bouts of chest pain, accompanied by intense fear, rapid heartbeat, rapid breathing (hyperventilation), profuse sweating, and shortness of breath.
The official coding guidelines that apply to outpatient coding do not allow coding for an “uncertain” diagnosis. Instead, the patient’s symptoms and signs are acceptable for reporting purposes when the provider has not established (confirmed) a diagnosis.
To index chest pain in ICD-9-CM, start with main term pain, sub-term chest, followed byessential modifiers describing the type of chest pain. Essential modifiers must be documented as indicated to code the specific type of chest pain.
- Chest pain (unspecified) (central) 786.59 (includes chest discomfort, pressure, and tightness)
- Atypical: 786.59 – Atypical chest pain is experienced outside the chest bone and tends to be sudden, sharp, and short-lived. Causes include overexertion, spasms, acid indigestion and headaches
- Precordial: 786.51
- Painful respiration: 786.52 (includes pain in anterior chest wall, pleuritic, pleurodynia)
- Midsternal: 786.51
- Musculoskeletal: 786.50
- Noncardiac: 786.59
- Substernal: 786.51
- Wall: 786.52
The following vignettes illustrate how and when to apply coding rules and regulations to code chest pain properly:
- Chest pain due to angina is considered to be integral to the cardiac condition: Only the angina would be coded.
- A 63-year-old women presents with non-cardiac chest pain that and severe anxiety: Code non-cardiac chest pain (786.59) and anxiety (300.00).
- A 22-year-old male has chest pain due to cocaine intoxication. This is classified as a poisoning (968.5 and 305.60 Non-dependant use of drugs) with 786.50 (Unspecified chest pain).
- The patient has chest pain with a history of gastroesophageal reflux, likely due to gastrointestinal origin. If there is no definitive answer, assign chest pain.
- A driver involved in a collision presents with chest pain. The patient’s chest is tender on palpation where he hit the steering wheel; however the physician did not document injury. Code for chest pain, not the injury. Do not assume an injury if it is not indicated specifically.
- A male patient presents with severe chest pain. Myocardial infarction has been ruled out. The patient is discharged with a diagnosis of gastritis. Code unspecified chest pain (786.50), with 535.50 Unspecified gastritis and gastroduodenitis.
- If chest pain is diagnosed as musculoskeletal, report 786.52 Anterior chest wall pain (bony and cartilaginous structures and pleura).
- The patient presents with chest pain due either to angina or esophageal spasm. Report 786.50 for chest pain. In the outpatient setting, do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” “working diagnosis,” or other similar terms that indicate the cause of the chest pain is unknown.
- A patient is seen in urgent care for chest pain. The EKG is normal. The final diagnosis is chest pain due to suspected gastroesophageal reflux disease (GERD). The primary diagnosis code for the EKG should be chest pain, unspecified (786.50). Although the EKG was normal, a definitive cause for the chest pain was not determined.
Here are additional tips to ensure appropriate coding for chest pain:
- Do code both chest pain and the condition if the chest pain is not integral to the condition.
- Do query the physician if you suspect the condition is associated with the chest pain.
- Do not code chest pain if it is with an associated condition and chest pain is integral to that condition such as chest pain and angina.
- Do not assume chest pain is non-cardiac or cardiac even if other diagnoses are present. Query the documenting physician for clarification.
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