Cardiology Coding Alert

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.