I44.30, Z95.0
Here is the coding clinic 2019 1st quarter pg 33-34:
Sick sinus syndrome controlled with implanted cardiac device
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2019 Pages: 33-34 Effective with discharges: March 20, 2019
Question:
If a physician sees a patient (in any setting) and evaluates the patient's sick sinus syndrome (SSS) or other significant heart rhythm abnormality, is it appropriate to assign a code for the specific condition in addition to the code for the presence of the cardiac device (i.e. pacemaker, automatic cardioverter/ defibrillator (AICD), cardiac resynchronization pacemaker (CRT-P), or bi-ventricular defibrillator (CRT-D)?
Answer:
Yes, it is appropriate to code the specific condition and the presence of the cardiac device. For example, assign codes I49.5, Sick sinus syndrome, and Z95.0, Presence of cardiac pacemaker. The SSS is still present and is a reportable chronic condition. Although the pacemaker is controlling the heart rate, it does not cure SSS and the condition is still being managed/monitored. According to the inpatient, Official Guidelines for Coding and Reporting: For reporting purposes, the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring.
The Official Guidelines for Coding and Reporting for outpatient services IV.I. & J states, "Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment."