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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