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2025 ICD-10-CM code I30.9

Acute pericarditis, unspecified;inflammation of the pericardium without specifying the cause.

Accurate coding requires thorough documentation specifying the clinical presentation and investigation results.If the cause is later identified, a more specific code should be substituted.

Modifiers may be applicable depending on the circumstances of service (e.g., place of service, type of service, etc.).

Medical necessity for coding I30.9 is established by the presence of clinical findings consistent with acute pericarditis, such as chest pain, pericardial friction rub, and echocardiographic evidence of pericardial effusion or thickening. The underlying cause may or may not be identifiable, necessitating further investigation.Treatment decisions are based on symptom severity and the presence of complications.

Diagnosis and management of acute pericarditis, including determining the etiology through history, physical exam, laboratory tests (e.g., blood work, cardiac biomarkers), and imaging studies (e.g., echocardiogram, CT scan).Treatment may involve medication (e.g., NSAIDs, corticosteroids), pericardiocentesis (fluid drainage), or surgery depending on the severity and cause.Ongoing monitoring of cardiac function and potential complications are also necessary.

IMPORTANT:Consider I30.0 (Acute nonspecific idiopathic pericarditis), I30.1 (Infective pericarditis), or I30.8 (Other forms of acute pericarditis) if more specific information is available.If the pericarditis is chronic, consider codes from the I31-I31 range.

In simple words: This code means the patient has sudden inflammation of the sac around their heart, but the doctor doesn't know why. More tests may be needed to find the cause.

I30.9, Acute pericarditis, unspecified, is an ICD-10-CM code that classifies acute inflammation of the pericardium (the sac surrounding the heart) without specifying a particular cause.This code is used when the cause of the pericarditis is unknown or cannot be determined.It encompasses various types of acute pericarditis that don't fit into more specific categories within the I30 code range.Differential diagnoses should consider infectious, autoimmune, or idiopathic etiologies, requiring further investigation for proper clinical management.

Example 1: A 50-year-old male presents with chest pain, shortness of breath, and a pericardial friction rub.Echocardiogram reveals pericardial effusion.I30.9 is assigned pending further investigation to determine the cause., A 72-year-old female with a history of autoimmune disease presents with chest discomfort.Cardiac biomarkers are slightly elevated, and an echocardiogram shows mild pericardial thickening.After extensive evaluation, no specific cause is found, and I30.9 is assigned., A 25-year-old male presents after a motor vehicle accident with chest pain. An echocardiogram reveals pericardial effusion secondary to trauma. I30.9 may be assigned initially, to be replaced with a more specific injury code once more information is gathered.

Complete history and physical examination documenting chest pain characteristics, auscultation findings (pericardial friction rub), and other symptoms.Results of relevant laboratory tests (complete blood count, cardiac enzyme levels, inflammatory markers). Imaging studies (echocardiogram, chest X-ray, CT scan) to visualize the pericardium and assess for effusion or other abnormalities.Documentation of treatment provided, response to treatment, and any complications.

** The specificity of this code underscores the importance of comprehensive documentation to support medical necessity and accurate billing.

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