Billable ICD 10 Codes and Required Documentation for Cardiac Rehabilotation
A quick reference guide to ICD 10 billing codes for cardiac rehabilitation and required documentation.
| Billable ICD 10 Codes and Required documentation | ||
| Code | Description | Required Document |
| Heart Attacks: Has to be in the Last 12 months | ||
| I21.01 | ST elevation (STEMI) myocardial infarction involving left main coronary artery | Cath report, Discharge Summary, or Positive Stress Test |
| I21.02 | ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery (widow maker) | Cath report, Discharge Summary, or Positive Stress Test |
| I21.09 | ST elevation (STEMI) involving other coronary artery of anterior wall | Cath report, Discharge Summary, or Positive Stress Test |
| I21.11 | ST elevation (STEMI) myocardial infarction involving right coronary artery | Cath report, Discharge Summary, or Positive Stress Test |
| I21.19 | ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall | Cath report, Discharge Summary, or Positive Stress Test |
| I21.21 | ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery | Cath report, Discharge Summary, or Positive Stress Test |
| I21.29 | ST elevation (STEMI) myocardial infarction involving other sites | Cath report, Discharge Summary, or Positive Stress Test |
| I21.3 | ST elevation (STEMI) myocardial infarction of unspecified site | Cath report, Discharge Summary, or Positive Stress Test |
|
I21.4 |
Non-ST elevation (NSTEMI) myocardial infarction |
Troponin Labs with Discharge Summary or Office Note, Cath Report, or Discharge Summary |
| I21.9 | Acute myocardial infarction, unspecified | Cath report, Discharge Summary, or Positive Stress Test |
| Coronary Artery Bypass Surgery (CABG)(Open Heart) | ||
| z95.1 | Presence of aortocoronary bypass graft | Operative Report, Cath Report |
| Current Stable Angina (Chest Pain) | ||
| I20.1 | Angina Pectoralis with documented spasm | Cath Report or Positive Nuclear Stress Test (MPI) |
|
I20.8 |
Other forms of angina |
Office Note, Discharge Summary from Hospital, Positive Stress Test & Continued Documentation from Physician |
| I20.9 | Angina Pectoralis, unspecified | Office Note, Discharge summary, Cath Report |
| Heart Valve Repair or Replacement | ||
| Z95.2 | Presence of prosthetic heart valve | Operative Report for Open Heart Surgery, Cath Report |
| Z95.3 | Presence of xenogenic heart valve | Operative Report for Open Heart Surgery, Cath Report |
| Z95.4 | Presence of other heart-valve replacement | Operative Report for Open Heart Surgery, Cath Report |
| Z98.890 | Other specified postprocedural states | Operative Report for Open Heart Surgery, Cath Report |
| Coronary Artery Angioplasty or Stent (Sometimes referred to as a Percutaneous Coronary Intervention [PCI] or Percutaneous Transluminal Coronary Angioplasty [PTCA]) | ||
| z95.5 | Presence of coronary angioplasty implant or graft | Cath Report |
| z98.61 | Coronary Angioplasty Status | Cath Report |
| Heart or Heart-Lung Transplant | ||
| z94.1 | Heart Transplant Status | Operative Report |
| Z94.3 | Heart and lungs transplant Status | Operative Report |
| Stable Chronic Heart Failure: EF of 35% or less, AND “optimal heart failure therapy for 6 weeks” (aka 6 weeks post hospital discharge) AND no planned major cardiovascular hospitalizations in the next 6 months, AND NYHA class II – IV symptoms | ||
| I50.22 | Chronic Systolic Heart Failure | Echo Report and Discharge summary |
| I50.84 | End Stage Heart Failure | Echo Report and Discharge summary |
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