2025 ICD-10-CM code I31.4
(Active) Effective Date: N/A Diseases of the circulatory system - Other diseases of pericardium 9: Diseases of the circulatory system (I00-I99) Feed
Cardiac tamponade. Code first underlying cause.
Medical necessity for I31.4 is established by documentation supporting the diagnosis of cardiac tamponade and the need for intervention. This may include evidence of circulatory compromise and the severity of symptoms. The medical necessity of any associated procedures, like pericardiocentesis, should be documented separately.
Diagnosis and treatment of cardiac tamponade typically involves specialists like cardiologists or cardiac surgeons. The physician is responsible for identifying the cause, performing necessary procedures (like pericardiocentesis), and managing the patient's condition.
In simple words: Fluid around the heart is creating pressure and preventing the heart from working properly. This is called cardiac tamponade, and it's important to identify the root cause.
Cardiac tamponade. Code first the underlying condition causing the cardiac tamponade.
Example 1: A patient with a history of lung cancer presents with shortness of breath and chest pain. Diagnostic imaging reveals a large pericardial effusion and signs of cardiac tamponade. The primary code would be I31.4 (Cardiac tamponade), followed by the code for the lung cancer (e.g., C34.90 - Malignant neoplasm of unspecified part of unspecified lung)., A patient is undergoing coronary artery bypass surgery. During the procedure, the surgeon accidentally nicks the pericardium, leading to bleeding and cardiac tamponade. In this instance, I31.4 is coded first, followed by the appropriate codes for the surgery and the accidental puncture., A patient with a recent history of acute pericarditis experiences worsening chest pain and shortness of breath. They are diagnosed with cardiac tamponade secondary to the pericarditis. I31.4 would be used, with I30.9 (Acute pericarditis, unspecified) as the secondary code.
Documentation should clearly indicate the presence of cardiac tamponade, along with supporting clinical findings such as low blood pressure, muffled heart sounds, and distended neck veins. Diagnostic tests, like echocardiography, and any procedures performed, like pericardiocentesis, must be documented. It's also essential to document the underlying cause of the tamponade.
- Specialties:Cardiology, Cardiac Surgery, Emergency Medicine, Internal Medicine.
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office