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Question: An established patient with a prosthetic aortic valve sees the cardiologist 10 days after undergoing a dental extraction. The patient reports several days of intermittent fever, chills, and fatigue. On examination, the cardiologist documents a new systolic murmur and writes “Concern for infective endocarditis.” The cardiologist orders blood cultures and a transthoracic echocardiogram (TTE), with a possible transesophageal echocardiogram (TEE) depending on the initial findings. How should I report the diagnosis?

Florida Subscriber

Answer: While the cardiologist documents that they are concerned about infective endocarditis, that assessment is not the same as a definitive diagnosis. According to the outpatient ICD-10-CM guidelines, you should code the signs and symptoms recorded during the visit to the highest degree of certainty.

Therefore, based on this documentation, report the respective symptom codes that led the patient to seek care, including R50.9 (Fever, unspecified), R01.1 (Cardiac murmur, unspecified), and any other evaluated symptoms, such as R53.83 (Other fatigue), when supported. You may also report Z95.2 (Presence of prosthetic heart valve) because the prosthetic valve affects the workup and risk assessment.

At this moment, you should not use I33.0 (Acute and subacute infective endocarditis). If subsequent testing leads the provider to establish infective endocarditis, report the specific endocarditis diagnosis supported by that later documentation.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC