Z95.0 - Presence of cardiac pacemaker

Clinical Definition

Cardiomegaly refers to an enlarged heart, typically identified when the heart appears larger than normal on imaging studies like chest X-rays or echocardiograms. The condition can be either physiological (as in athletes) or pathological (due to underlying heart disease).

Documentation Requirements

• Specify whether:

  • Primary or secondary to another condition

  • Acute or chronic

  • Associated underlying conditions (e.g., hypertension, valve disease)

  • Cardiothoracic ratio on imaging (>0.5 indicates cardiomegaly)

  • Presence of any heart failure symptoms

  • Results of diagnostic tests (X-ray, echo, MRI)

Common Synonyms

• Enlarged heart

• Heart enlargement

• Big heart

• Cardiac enlargement

• Hypertrophic heart

Coding Conflicts

Excludes1:

• Physiologic cardiomegaly in pregnancy (O99.4)

• Athletic heart syndrome (I51.7)

Excludes2:

• Heart failure (I50.-)

• Ventricular hypertrophy (I51.7)

Scribing.io Automation

Scribing.io's AI automatically identifies and captures:

• Measurements from imaging reports (cardiothoracic ratio)

• Descriptions of heart size in radiology reports

• Associated conditions mentioned during exam

• Temporal references for chronicity

• Test results documenting cardiac enlargement

Remember to have the physician specifically document whether the cardiomegaly is physiologic or pathologic, as this affects code assignment.