What ICD10 (International Classification of Diseases, 10th Revision) code is used for a CT (Computed Tomography) coronary calcium score for Medicare reimbursement?

ICD-10 Coding for CT Coronary Calcium Score for Medicare

For Medicare reimbursement of CT coronary calcium scoring, use ICD-10 code Z13.6 (Encounter for screening for cardiovascular disorders) or codes from the Z82.4- series (Family history of ischemic heart disease and other diseases of the circulatory system) when family history is the primary indication.

Primary ICD-10 Codes for Medicare Coverage

Screening and Risk Assessment Codes

• Z13.6 is the most appropriate code when performing coronary artery calcium scoring for cardiovascular risk screening in asymptomatic patients aged 40-75 years with intermediate ASCVD risk 1, 2
• Z82.49 (Family history of ischemic heart disease and other diseases of the circulatory system) can be used when family history of premature CAD is the indication for testing 1
• Z82.41 specifically for family history of sudden cardiac death may also support medical necessity 1

Risk Factor Codes to Support Medical Necessity

• E78.5 (Hyperlipidemia, unspecified) or specific dyslipidemia codes when elevated cholesterol is present 1, 2
• I10 (Essential hypertension) for patients with hypertension 1
• E11.9 (Type 2 diabetes mellitus without complications) when diabetes is a risk factor 1
• Z72.0 (Tobacco use) for current smokers 1

Clinical Context for Appropriate Use

Medicare-Appropriate Patient Population

• Adults aged 40-75 years with borderline (5-7.5%) to intermediate (7.5-20%) 10-year ASCVD risk where decisions about preventive interventions are uncertain 1, 2
• Selected low-risk adults with family history of premature CAD 1
• Patients where calcium scoring will guide shared decision-making about statin therapy or other preventive interventions 1, 2

Documentation Requirements

• Document the Framingham Risk Score or pooled cohort equation (PCE) calculation showing intermediate or borderline risk to justify medical necessity 1, 2
• Include specific cardiovascular risk factors present (hypertension, diabetes, dyslipidemia, smoking, family history) 1, 3
• Note that the test result will influence management decisions, particularly regarding statin therapy initiation 1, 3

Important Coding Pitfalls to Avoid

When NOT to Use Calcium Scoring Codes

• Do not code for patients already on statin therapy or with established cardiovascular disease, as calcium scoring is not indicated in these populations 1, 3
• Avoid coding for low-risk patients (10-year ASCVD risk <5%) or very high-risk patients (>20%) where management is already clear 1, 2
• Do not use for men under 40 or women under 50 due to low prevalence of calcification and radiation exposure concerns 2, 3
• Never code for symptomatic patients being evaluated for chest pain or suspected acute coronary syndrome, as this is not a screening indication 1, 3

Additional Considerations

• Medicare typically does not cover coronary calcium scoring as a screening test, so patients should be counseled about potential out-of-pocket costs before ordering 3
• The test should only be ordered if results will change management, particularly regarding initiation of preventive pharmacotherapy 1, 3
• Document that the patient has been counseled about the implications of test results and potential need for downstream testing if significant calcification is found 3