Chapter 9.
Diseases of the
Circulatory System (I00–I99)
Chapter-specific Guidelines with
Coding Examples
The chapter-specific guidelines from the ICD-10-CM Official
Guidelines for Coding and Reporting have been provided
below. Along with these guidelines are coding examples,
contained in the shaded boxes, that have been developed to
help illustrate the coding and/or sequencing guidance found
in these guidelines.
a. Hypertension
The classification presumes a causal relationship between
hypertension and heart involvement and between
hypertension and kidney involvement, as the two
conditions are linked by the term “with” in the Alphabetic
Index. These conditions should be coded as related even
in the absence of provider documentation explicitly
linking them, unless the documentation clearly states the
conditions are unrelated.
For hypertension and conditions not specifically linked by
relational terms such as “with,” “associated with” or “due
to” in the classification, provider documentation must link
the conditions in order to code them as related.
1) Hypertension with heart disease
Hypertension with heart conditions classified to I50.- or
I51.4-I51.7, I51.89, I51.9, are assigned to a code from
category I11, Hypertensive heart disease. Use
additional code(s) from category I50, Heart failure, to
identify the type(s) of heart failure in those patients
with heart failure.
The same heart conditions (I50.-, I51.4-I51.7, I51.89,
I51.9) with hypertension are coded separately if the
provider has documented they are unrelated to the
hypertension. Sequence according to the
circumstances of the admission/encounter.
2) Hypertensive chronic kidney disease
Assign codes from category I12, Hypertensive chronic
kidney disease, when both hypertension and a
condition classifiable to category N18, Chronic kidney
disease (CKD), are present. CKD should not be coded
as hypertensive if the provider indicates the CKD is not
related to the hypertension.
The appropriate code from category N18 should be
used as a secondary code with a code from category
I12 to identify the stage of chronic kidney disease.
See Section I.C.14. Chronic kidney disease.
If a patient has hypertensive chronic kidney disease
and acute renal failure, the acute renal failure should
also be coded. Sequence according to the
circumstances of the admission/encounter.
Patient is admitted with stage IV chronic kidney
disease (CKD) due to polycystic kidney disease.
Patient also is on lisinopril for hypertension.
N18.4 Chronic kidney disease, stage 4
(severe)
Q61.3 Polycystic kidney, unspecified
I10 Essential (primary) hypertension
Explanation: A combination code describing a
relationship between hypertension and CKD is not
used because the physician documentation identifies
the polycystic kidney disease as the cause for the
CKD.
3) Hypertensive heart and chronic kidney disease
Assign codes from combination category I13,
Hypertensive heart and chronic kidney disease, when
there is hypertension with both heart and kidney
involvement. If heart failure is present, assign an
additional code from category I50 to identify the type
of heart failure.
The appropriate code from category N18, Chronic
kidney disease, should be used as a secondary code
with a code from category I13 to identify the stage of
chronic kidney disease.
See Section I.C.14. Chronic kidney disease.
The codes in category I13, Hypertensive heart and
chronic kidney disease, are combination codes that
include hypertension, heart disease and chronic kidney
disease. The Includes note at I13 specifies that the
conditions included at I11 and I12 are included
together in I13. If a patient has hypertension, heart
disease and chronic kidney disease, then a code from
I13 should be used, not individual codes for
hypertension, heart disease and chronic kidney
disease, or codes from I11 or I12.
For patients with both acute renal failure and chronic
kidney disease, the acute renal failure should also be
coded. Sequence according to the circumstances of the
admission/encounter.
Hypertensive heart and kidney disease with
congestive heart failure and stage 2 chronic kidney
disease
I13.0 Hypertensive heart and chronic kidney
disease with heart failure and stage 1
through stage 4 chronic kidney
disease, or unspecified chronic kidney
disease
I50.9 Heart failure, unspecified
N18.2 Chronic kidney disease, stage 2 (mild)
Explanation: Combination codes in category I13 are
used to report conditions classifiable to both
categories I11 and I12. Do not report conditions
classifiable to I11 and I12 separately. Use additional
codes to report type of heart failure and stage of
CKD.
4) Hypertensive cerebrovascular disease
For hypertensive cerebrovascular disease, first assign
the appropriate code from categories I60-I69, followed
by the appropriate hypertension code.
Rupture of cerebral aneurysm caused by malignant
hypertension
I60.7 Nontraumatic subarachnoid
hemorrhage from unspecified
introcranial artery
I10 Essential (primary) hypertension
Explanation: Hypertensive cerebrovascular disease
requires two codes: the appropriate I60–I69 code
followed by the appropriate hypertension code.
5) Hypertensive retinopathy
Subcategory H35.0, Background retinopathy and
retinal vascular changes, should be used along with a
code from categories I10-I15, in the Hypertensive
diseases section, to include the systemic
hypertension. The sequencing is based on the reason
for the encounter.
6) Hypertension, secondary
Secondary hypertension is due to an underlying
condition. Two codes are required: one to identify the
underlying etiology and one from category I15 to
identify the hypertension. Sequencing of codes is
determined by the reason for admission/encounter.
Renovascular hypertension due to renal artery
atherosclerosis
I15.0 Renovascular hypertension
I70.1 Atherosclerosis of renal artery
Explanation: Secondary hypertension requires two
codes: a code to identify the etiology and the
appropriate I15 code.
7) Hypertension, transient
Assign code R03.0, Elevated blood pressure reading
without diagnosis of hypertension, unless patient has
an established diagnosis of hypertension. Assign code
O13.-, Gestational [pregnancy-induced] hypertension
without significant proteinuria, or O14.-, Pre-eclampsia,
for transient hypertension of pregnancy.
8) Hypertension, controlled
This diagnostic statement usually refers to an existing
state of hypertension under control by therapy. Assign
the appropriate code from categories I10-I15,
Hypertensive diseases.
9) Hypertension, uncontrolled
Uncontrolled hypertension may refer to untreated
hypertension or hypertension not responding to current
therapeutic regimen. In either case, assign the
appropriate code from categories I10-I15, Hypertensive
diseases.
10)Hypertensive crisis
Assign a code from category I16, Hypertensive crisis,
for documented hypertensive urgency, hypertensive
emergency or unspecified hypertensive crisis. Code
also any identified hypertensive disease (I10-I15). The
sequencing is based on the reason for the encounter.
11)Pulmonary hypertension
Pulmonary hypertension is classified to category I27,
Other pulmonary heart diseases. For secondary
pulmonary hypertension (I27.1, I27.2-), code also any
associated conditions or adverse effects of drugs or
toxins. The sequencing is based on the reason for the
encounter, except for adverse effects of drugs (See
Section I.C.19.e.).
b. Atherosclerotic coronary artery disease and
angina
ICD-10-CM has combination codes for atherosclerotic
heart disease with angina pectoris. The subcategories for
these codes are I25.11, Atherosclerotic heart disease of
native coronary artery with angina pectoris and I25.7,
Atherosclerosis of coronary artery bypass graft(s) and
coronary artery of transplanted heart with angina
pectoris.
When using one of these combination codes it is not
necessary to use an additional code for angina pectoris. A
causal relationship can be assumed in a patient with both
atherosclerosis and angina pectoris, unless the
documentation indicates the angina is due to something
other than the atherosclerosis.
If a patient with coronary artery disease is admitted due
to an acute myocardial infarction (AMI), the AMI should be
sequenced before the coronary artery disease.
See Section I.C.9. Acute myocardial infarction (AMI)
Patient is being seen for spastic angina pectoris. She
also has a documented history of progressive coronary
artery disease of the native vessels.
I25.111 Atherosclerotic heart disease of native
coronary artery with angina pectoris
with documented spasm
Explanation: Report the combination code for
atherosclerotic heart disease (coronary artery disease)
with angina pectoris. A causal relationship is assumed
in a patient with both atherosclerosis and angina
pectoris, unless the documentation indicates the
angina is due to something other than the
atherosclerosis. When using one of these combination
codes, it is not necessary to use an additional code for
angina pectoris.
c. Intraoperative and postprocedural cerebrovascular
accident
Medical record documentation should clearly specify the
cause- and- effect relationship between the medical
intervention and the cerebrovascular accident in order to
assign a code for intraoperative or postprocedural
cerebrovascular accident.
Proper code assignment depends on whether it was an
infarction or hemorrhage and whether it occurred
intraoperatively or postoperatively. If it was a cerebral
hemorrhage, code assignment depends on the type of
procedure performed.
Embolic cerebral infarction of the right middle cerebral
artery that occurred during hip replacement surgery.
The surgeon documented as due to the surgery.
I97.811 Intraoperative cerebrovascular
infarction during other surgery
I63.411 Cerebral infarction due to embolism of
right middle cerebral artery
Explanation: Code assignment for intraoperative or
postprocedural cerebrovascular accident is based on
the provider’s documentation of a cause-and-effect
relationship between the condition and the procedure.
Proper code assignment also depends on whether the
cerebrovascular accident was an infarction or
hemorrhage, occurred intraoperatively or
postoperatively, and the type of procedure performed.
d. Sequelae of cerebrovascular disease
1) Category I69, Sequelae of cerebrovascular
disease
Category I69 is used to indicate conditions classifiable
to categories I60-I67 as the causes of sequela
(neurologic deficits), themselves classified elsewhere.
These “late effects” include neurologic deficits that
persist after initial onset of conditions classifiable to
categories I60-I67. The neurologic deficits caused by
cerebrovascular disease may be present from the onset
or may arise at any time after the onset of the
condition classifiable to categories I60-I67.
Codes from category I69, Sequelae of cerebrovascular
disease, that specify hemiplegia, hemiparesis and
monoplegia identify whether the dominant or
nondominant side is affected. Should the affected side
be documented, but not specified as dominant or
nondominant, and the classification system does not
indicate a default, code selection is as follows:
• For ambidextrous patients, the default should be
dominant.
• If the left side is affected, the default is non-
dominant.
• If the right side is affected, the default is dominant.
2) Codes from category I69 with codes from I60–I67
Codes from category I69 may be assigned on a health
care record with codes from I60-I67, if the patient has a
current cerebrovascular disease and deficits from an
old cerebrovascular disease.
3) Codes from category I69 and personal history of
transient ischemic attack (TIA) and cerebral
infarction (Z86.73)
Codes from category I69 should not be assigned if the
patient does not have neurologic deficits.
See Section I.C.21. 4. History (of) for use of personal
history codes
e. Acute myocardial infarction (AMI)
1) Type 1 ST elevation myocardial infarction
(STEMI) and non-ST elevation myocardial
infarction (NSTEMI)
The ICD-10-CM codes for type 1 acute myocardial
infarction (AMI) identify the site, such as anterolateral
wall or true posterior wall. Subcategories I21.0-I21.2
and code I21.3 are used for type 1 ST elevation
myocardial infarction (STEMI). Code I21.4, Non-ST
elevation (NSTEMI) myocardial infarction, is used for
type 1 non-ST elevation myocardial infarction (NSTEMI)
and nontransmural MIs.
If a type 1 NSTEMI evolves to STEMI, assign the STEMI
code. If a type 1 STEMI converts to NSTEMI due to
thrombolytic therapy, it is still coded as STEMI.
For encounters occurring while the myocardial
infarction is equal to, or less than, four weeks old,
including transfers to another acute setting or a
postacute setting, and the myocardial infarction meets
the definition for “other diagnoses” (see Section III,
Reporting Additional Diagnoses), codes from category
I21 may continue to be reported. For encounters after
the 4-week time frame and the patient is still receiving
care related to the myocardial infarction, the
appropriate aftercare code should be assigned, rather
than a code from category I21. For old or healed
myocardial infarctions not requiring further care, code
I25.2, Old myocardial infarction, may be assigned.
2) Acute myocardial infarction, unspecified
Code I21.9, Acute myocardial infarction, unspecified, is
the default for unspecified acute myocardial infarction
or unspecified type. If only type 1 STEMI or transmural
MI without the site is documented, assign code I21.3,
ST elevation (STEMI) myocardial infarction of
unspecified site.
3) AMI documented as nontransmural or
subendocardial but site provided
If an AMI is documented as nontransmural or
subendocardial, but the site is provided, it is still coded
as a subendocardial AMI.
See Section I.C.21.3 for information on coding status
post administration of tPA in a different facility within
the last 24 hours.
Acute inferior subendocardial myocardial infarction
(NSTEMI)
I21.4 Non-ST elevation (NSTEMI) myocardial
infarction
Explanation: An AMI documented as subendocardial
or nontransmural is coded as such (I21.4, I22.2),
even if the site of infarction is specified.
4) Subsequent acute myocardial infarction
A code from category I22, Subsequent ST elevation
(STEMI) and non-ST elevation (NSTEMI) myocardial
infarction, is to be used when a patient who has
suffered a type 1 or unspecified AMI has a new AMI
within the 4-week time frame of the initial AMI. A code
from category I22 must be used in conjunction with a
code from category I21. The sequencing of the I22 and
I21 codes depends on the circumstances of the
encounter.
Do not assign code I22 for subsequent myocardial
infarctions other than type 1 or unspecified. For
subsequent type 2 AMI assign only code I21.A1. For
subsequent type 4 or type 5 AMI, assign only code
I21.A9.
If a subsequent myocardial infarction of one type
occurs within 4 weeks of a myocardial infarction of a
different type, assign the appropriate codes from
category I21 to identify each type. Do not assign a
code from I22. Codes from category I22 should only be
assigned if both the initial and subsequent myocardial
infarctions are type 1 or unspecified.
Patient suffered an acute NSTEMI 14 days ago and is
now seen for an inferior STEMI.
I22.1 Subsequent ST elevation (STEMI)
myocardial infarction of inferior wall
I21.4 Non-ST elevation (NSTEMI) myocardial
infarction
Explanation: Both MIs were type 1, and the current
MI occurred within the four-week time frame;
therefore a code for the current/subsequent STEMI
(I22.1) is reported as well as a code for the previous
NSTEMI (I21.4).
5) Other Types of Myocardial Infarction
The ICD-10-CM provides codes for different types of
myocardial infarction. Type 1 myocardial infarctions are
assigned to codes I21.0-I21.4.
Type 2 myocardial infarction (myocardial infarction due
to demand ischemia or secondary to ischemic
imbalance) is assigned to code I21.A1, Myocardial
infarction type 2 with the underlying cause coded first.
Do not assign code I24.8, Other forms of acute
ischemic heart disease, for the demand ischemia. If a
type 2 AMI is described as NSTEMI or STEMI, only
assign code I21.A1. Codes I21.01-I21.4 should only be
assigned for type 1 AMIs.
Acute myocardial infarctions type 3, 4a, 4b, 4c and 5
are assigned to code I21.A9, Other myocardial
infarction type.
The “Code also” and “Code first” notes should be
followed related to complications, and for coding of
postprocedural myocardial infarctions during or
following cardiac surgery.