ICD-10 Coding for Dilation of Aorta(I71.21, I71.11)
Complete ICD-10-CM coding and documentation guide for Dilation of Aorta. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dilation of Aorta
I71.0-I71.9Primary Range
Aortic aneurysm and dissection
This range includes codes for various types of aortic aneurysms and dissections, which are critical for documenting dilation of the aorta.
Other disorders of arteries and arterioles
This range includes codes for aortic ectasia, which may be used when the dilation does not meet the criteria for an aneurysm.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I71.21 | Aneurysm of ascending aorta, without rupture | Use when imaging confirms an ascending aortic aneurysm without rupture. |
|
| I71.11 | Ruptured aneurysm of ascending aorta | Use when there is clinical and imaging evidence of rupture. |
|
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 dilation of the aorta
Essential facts and insights about Dilation of Aorta
Primary ICD-10-CM Codes for dilation of aorta
Decision Criteria
clinical Criteria
- Imaging shows an ascending aortic diameter ≥4.5 cm without rupture.
Applicable To
- Ascending aortic aneurysm
Excludes
- Ruptured ascending aortic aneurysm (I71.11)
Clinical Validation Requirements
- CT/MRI showing ≥4.5 cm diameter
- No hemodynamic instability
Code-Specific Risks
- Misclassification if rupture is not ruled out
Coding Notes
- Ensure imaging confirms the absence of rupture.
I71.11 - Ruptured aneurysm of ascending aorta
Use when there is clinical and imaging evidence of rupture.
Applicable To
- Ruptured ascending aortic aneurysm
Excludes
- Non-ruptured ascending aortic aneurysm (I71.21)
Clinical Validation Requirements
- Imaging showing rupture
- Clinical signs of rupture such as hypotension
Coding Notes
Always confirm rupture through imaging and clinical signs.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dilation of 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 decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Always confirm rupture status with imaging., Document clinical signs of rupture.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure imaging and documentation specify the exact site and presence of rupture.
Impact
High risk of audit if unspecified codes are used when specific codes are applicable.
Mitigation Strategy
Ensure detailed documentation and imaging reports are available.
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 Dilation of Aorta, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dilation of Aorta
Use these documentation templates to ensure complete and accurate documentation for Dilation of Aorta. These templates include all required elements for proper coding and billing.
Aortic Surveillance
Specialty: CardiologyRequired Elements
- Subjective symptoms
- Objective findings
- Imaging review
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Dilation of Aorta? Ask your questions below.