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ICD-10 Coding for Aneurysm of Ascending Aorta(I71.21, I71.11)

Complete ICD-10-CM coding and documentation guide for Aneurysm of Ascending Aorta. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Ascending Aortic AneurysmThoracic Aortic Aneurysm (Ascending)

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Related ICD-10 Code Ranges

Complete code families applicable to Aneurysm of Ascending Aorta

I71.0-I71.9Primary Range

Aortic aneurysm and dissection

This range includes codes for various types of aortic aneurysms and dissections, with specific codes for ascending aortic aneurysms.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
I71.21Aneurysm of ascending aorta, without ruptureUse when an ascending aortic aneurysm is confirmed without rupture.
  • Imaging confirmation of aneurysm size ≥5 cm
  • Documentation of location as ascending aorta
I71.11Ruptured aneurysm of ascending aortaUse when an ascending aortic aneurysm is confirmed with rupture.
  • Imaging or surgical confirmation of rupture
  • Clinical signs of rupture such as hemodynamic instability

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for ascending aortic aneurysm

Essential facts and insights about Aneurysm of Ascending Aorta

The ICD-10 code for a non-ruptured ascending aortic aneurysm is I71.21, while a ruptured aneurysm is coded as I71.11.

Primary ICD-10-CM Codes for aneurysm of ascending aorta

I71.21
Aneurysm of ascending aorta, without rupture
Billable Code

Decision Criteria

clinical Criteria

  • Aneurysm size ≥5 cm on imaging

documentation Criteria

  • Specific mention of 'ascending aorta' and 'without rupture'

Applicable To

  • Non-ruptured ascending aortic aneurysm

Excludes

  • Ruptured ascending aortic aneurysm (I71.11)

Clinical Validation Requirements

  • Imaging confirmation of aneurysm size ≥5 cm
  • Documentation of location as ascending aorta

Code-Specific Risks

  • Misclassification if rupture status is not documented

Coding Notes

  • Ensure documentation specifies the location and rupture status.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Congenital bicuspid aortic valve

Q23.1
Use if the patient has a congenital bicuspid aortic valve.

Aortic dissection involving ascending aorta

I71.01x
Use if dissection is present with the aneurysm.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Ruptured aneurysm of ascending aorta

I71.11
Use when imaging or clinical evidence confirms rupture.

Aneurysm of ascending aorta, without rupture

I71.21
Use when there is no evidence of rupture.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Aneurysm of Ascending Aorta to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I71.21.

Impact

Clinical: May lead to inappropriate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential loss of reimbursement for MCCs.

Mitigation Strategy

Train staff on importance of rupture status, Use checklists in documentation templates

Impact

Reimbursement: Incorrect coding can lead to improper DRG assignment., Compliance: May result in audit discrepancies., Data Quality: Impacts accuracy of clinical data.

Mitigation Strategy

Ensure documentation specifies 'ascending aorta'.

Impact

Failure to document rupture status can lead to audit discrepancies.

Mitigation Strategy

Implement mandatory fields in EHR for rupture status.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Aneurysm of Ascending Aorta, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Aneurysm of Ascending Aorta

Use these documentation templates to ensure complete and accurate documentation for Aneurysm of Ascending Aorta. These templates include all required elements for proper coding and billing.

Elective Surveillance

Specialty: Cardiology

Required Elements

  • Patient demographics
  • Aneurysm size and location
  • Rupture status
  • Follow-up plan

Example Documentation

45M with bicuspid aortic valve. TTE shows ascending aortic aneurysm measuring 4.6 cm at sinotubular junction. No dissection or rupture. Plan: Beta-blocker therapy, repeat imaging in 6 months.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Aortic aneurysm noted.
Good Documentation Example
Ascending aortic aneurysm measuring 5.1 cm, no rupture.
Explanation
The good example specifies location, size, and rupture status, which are critical for accurate coding.

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