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2025 ICD-10-CM code I01.2

Acute rheumatic myocarditis; a condition involving inflammation of the heart muscle as a complication of acute rheumatic fever.

Appropriate coding requires confirming both acute rheumatic fever and myocarditis.Careful review of the patient's history, physical exam, and imaging studies is crucial to ensure correct coding.Other relevant codes should be used in conjunction with I01.2 if additional conditions are present.

Medical necessity is established by the presence of symptoms and signs consistent with acute rheumatic fever and evidence of myocarditis on investigations (ECG, echocardiogram). Treatment is medically necessary to prevent or mitigate potential complications like heart failure and permanent cardiac damage.

The clinical responsibility involves diagnosing and managing acute rheumatic fever and its complications. This includes taking a thorough medical history, conducting a physical exam, ordering and interpreting relevant investigations (ECG, echocardiogram, cardiac biomarkers), and providing appropriate treatment, which might include medications (e.g., anti-inflammatory drugs, antibiotics), supportive care, and referral to specialists as needed.

IMPORTANT:This code is a subcategory of I01 (Acute rheumatic heart disease).It excludes chronic rheumatic heart conditions (I05-I09) unless there's evidence of active rheumatic fever or reactivation of the rheumatic process.Consider also codes from other chapters if other conditions coexist (e.g., infections, symptoms).

In simple words: This code describes a heart problem caused by rheumatic fever.Rheumatic fever is an inflammation that can follow a strep throat infection.This specific code means the heart muscle itself is inflamed, which is serious and needs medical attention.

I01.2, Acute rheumatic myocarditis, specifies acute inflammation of the heart muscle (myocardium) as a direct consequence of acute rheumatic fever.This is a serious complication that can lead to heart failure and other cardiovascular issues.The diagnosis requires evidence of both acute rheumatic fever and myocarditis, typically confirmed through clinical examination, electrocardiogram (ECG), echocardiography, and possibly cardiac biomarkers.

Example 1: A 10-year-old presents with fever, joint pain (polyarthritis), and chest pain.ECG shows changes suggestive of myocarditis, and echocardiography reveals reduced left ventricular ejection fraction.Throat culture was positive for group A Streptococcus previously.Diagnosis of acute rheumatic fever with myocarditis (I01.2) is made., A 15-year-old with a history of untreated rheumatic fever develops shortness of breath and fatigue.Physical exam reveals a heart murmur.Echocardiogram demonstrates significant valvular damage and myocardial dysfunction.The diagnosis of acute rheumatic myocarditis with valvular involvement is documented using I01.2 along with additional codes describing the valvular complications., A young adult with a history of rheumatic fever experiences recurrent episodes of chest pain and palpitations.Cardiac evaluation reveals evidence of ongoing myocarditis.The physician documents I01.2, along with codes for chronic rheumatic heart disease and other relevant symptoms based on the patient's presentation.

Detailed history of previous streptococcal infection, physical examination findings (including cardiac exam), ECG findings, echocardiogram report (including left ventricular function, valvular status), cardiac biomarker levels (if measured), and documentation of the clinical course and response to treatment.

** The severity of acute rheumatic myocarditis varies.Documentation should reflect the clinical presentation and the impact on cardiac function.This code may be used in conjunction with other ICD-10-CM codes to capture co-morbidities or other associated conditions.

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