Find comprehensive information on diagnosing Abdominal Aortic Aneurysm (AAA). This resource covers clinical documentation requirements, ICD-10 codes (I71.4, I71.3, I71.9 for unspecified), medical coding guidelines, and diagnostic criteria for AAA. Learn about the importance of accurate history taking, physical exam findings, and imaging studies (ultrasound, CT scan, MRI) in AAA diagnosis. Explore best practices for healthcare professionals involved in the diagnosis and management of abdominal aortic aneurysms.
Also known as
Aneurysm of abdominal aorta
History of aneurysm in the abdominal part of the aorta.
Aortic aneurysm, unspecified
History of an aortic aneurysm, but no specific location provided.
Personal history of other specified diseases
Personal history of an abdominal aortic aneurysm may be coded here if no I71 code fits.
Personal history of aneurysm
Can be used as a supplementary code indicating history of any type of aneurysm.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the abdominal aortic aneurysm currently ruptured?
Yes
Code as I71.3 Ruptured abdominal aortic aneurysm
No
Is the aneurysm symptomatic?
When to use each related code
Description |
---|
Abdominal Aortic Aneurysm |
Thoracic Aortic Aneurysm |
Ruptured AAA |
Using unspecified codes (e.g., I71.9) when more specific documentation like size or location is available, impacting reimbursement and data accuracy.
Incorrectly coding a ruptured AAA (I71.3) as unruptured (I71.4) or vice versa, leading to significant DRG and quality reporting discrepancies.
Failure to accurately document present on admission (POA) status for AAA, affecting hospital-acquired condition reporting and reimbursement.
Patient presents with a history of abdominal aortic aneurysm (AAA). Initial diagnosis of the abdominal aortic aneurysm was made on [Date of initial diagnosis] and confirmed by [Diagnostic method, e.g., abdominal ultrasound, CT angiogram]. The aneurysm's maximum diameter at the time of diagnosis was [Measurement] cm. Current symptoms include [List current symptoms, e.g., abdominal pain, back pain, pulsating abdominal mass, or asymptomatic]. Patient denies [Pertinent negatives, e.g., chest pain, shortness of breath, syncope]. Risk factors for AAA include [List relevant risk factors, e.g., smoking history, hypertension, hyperlipidemia, family history of AAA, male gender, advanced age]. Past medical history is significant for [List relevant medical history]. Surgical repair of the AAA [was/was not] performed on [Date of surgery, if applicable]. Type of repair, if performed, was [Type of repair, e.g., open surgical repair, endovascular aneurysm repair (EVAR)]. Current management includes [List current management strategies, e.g., surveillance with regular imaging, blood pressure control, smoking cessation counseling, medication management]. Patient education provided regarding AAA rupture risk factors, symptoms of rupture, and the importance of follow-up. Plan is for continued surveillance with [Imaging modality] in [Timeframe] to monitor aneurysm size and assess for any changes. Patient understands the risks and benefits of continued surveillance versus surgical intervention. ICD-10 code I71.4, History of abdominal aortic aneurysm, is assigned.