Cardiology Coding Alert

Flagging Patients as Uninsurable:

Ethical Issues Complicate Coding for Multiple Valve Disorders

Unlike most coding issues cardiology practices face, the confusion with multiple valve disorders does not directly involve reimbursement issues; rather, it is over whether technically correct coding of multiple valve disease should take precedence over the welfare of the patient. In the case of multiple valve disorders, which most commonly involve the mitral and aortic valve, determining which diagnosis code to use can be confusing when considering the decision could potentially result in rendering your patient uninsurable.

Patients Welfare is At Stake

Many consultants maintain that the 396 series of ICD-9 codes (diseases of the mitral and aortal valve; includes involvement of both mitral and aortic valves, whether specified as rheumatic or not) should not be used for multiple valve disorders unless the patient has rheumatic fever, even though, strictly speaking, that code probably best describes the patients symptoms. For example, when mitral and aortic valve problems are indicated, the technically correct diagnosis code would be 396.3 (mitral valve insufficiency and aortic valve insufficiency; mitral and aortic [valve] incompetence, regurgitation).

Unlike the 395 series of codes (diseases of the aortic valve), which ICD-9 explicitly states should exclude that not specified as rheumatic, the 396 codes have no such restriction. So, technically speaking, the 396 is probably the most accurate diagnosis code describing the condition of a patient with multiple valvular disorders, says Ray Cathey, PA, MHA, a cardiology coding and compliance specialist and president of Medical Management Dimensions in Stockton, CA.

But Cathey maintains there is more to this issue than technically correct coding.

If you use the 396 codes, you are labeling the patient with a potential pre-existing condition because you are saying they have a chronic rheumatic heart. And doing that, in many instances, makes them uninsurable, he says.

Because they relate only indirectly to payment, ICD-9 diagnosis codes tend to be overlooked in favor of the cardiology reimbursement-based procedural CPT codes. From the point of view of cardiology practice coders and other reimbursement specialists, ICD-9 codes are of interest primarily because they indicate medical necessity when billing for a procedure.

But incorrect and/or careless use of these codes sometimes may cause more than denials due to lack of medical necessity. Sometimes, careless use of these codes can label a patient for life and render him or her uninsurable.

Take, for example, the case of a young man with high blood pressure who comes into his cardiologists office and says he passed out while playing golf. The cardiologist takes the mans blood pressure and orders a stress-echo cardiogram (93307, echocardiography, transthoracic, real-time with image documentation [2D] with or without M-code recording; complete). The results of the diagnostic tests confirm the patient has mitral regurgitation as well as stenosis in the aortic valve. The diagnosis codes which would be most technically accurate in this case would be the 396 series.

According to Mary Ann Barry, RN, a cardiac nurse at Boston Medical Center, the results may be confirmed by performing a routine cardiac catheterization (93508-93526). Valvular disorders such as these can occur for any number of reasons, which will determine the course of treatment.

The patient may be monitored with a Holter device (93224, electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation), or an event recorder (93268, patient demand single or multiple event recording with presymptom memory patient demand single or multiple event recording with presymptom memory loop, per 30-day period of time; includes transmission, physician review and interpretation). And, depending on the nature and severity of the valvular problem(s), the patient may require surgery, such as an aortic valve replacement (33413, replacement, aortic valve; by translocation of autologous pulmonary valve with homograft replacement of pulmonary valve [Ross procedure]).

In any event, as soon as the cardiologist bills for the examination and/or the diagnostic treatments he or she used to determine the nature of the problem, diagnosis codes must also be provided to indicate medical necessity.

Cathey maintains that many commercial carriers automatically flag patients who receive a 396 diagnosis in this way, regardless of the exact wordage in the ICD-9 manual. Typically, these are young patients with a congenital problem that doesnt reveal itself until the late teens or early twenties. If they receive such a diagnosis, they may not be able to get health insurance for the rest of their working lives, Cathey says. As a physician assistant, I took the Hippocratic Oath, which states First, do no harm. If I code the patients condition that way, I do plenty of harm, he continues.

424 Series

Cathey recommends using ICD-9 codes in the 424 series (other diseases of encardium), specifically 424.0 (mitral valve disorders), 424.1 (aortic valve disorders) and 424.2 (tricuspid valve disorders, specified as nonrheumatic). For example, with disorders involving both the mitral and aortic valve, he uses 424.0 and 424.1.

For older patients in Medicare with multiple valve disorders, I am able to use 396, because in most cases their insurability is not affected, he says.

The Future Looks Better

One clue as to why some commercial carriers label patients with diagnosis codes 396.0-396.3 as being rheumatic even though the ICD-9 descriptor of the 396 series specifically says, whether specified as rheumatic or not may be found in the AMA version of ICD-9 CM 1999. Unlike other versions of the 1999 ICD-9 manual, such as Medicodes, the AMA version includes the phrase caused by rheumatic heart disease in the short descriptors in 396.0-396.3. This directly contradicts whether specified as rheumatic or not found at the beginning of the 396 section. It is easy to understand why carriers with this version of the ICD-9 manual might conclude that a patient with a 396.0-396.3 diagnosis has a rheumatic heart.

Although the World Health Organization, which produces the ICD code listings, has already produced
ICD-10, it is not expected to be in use in the United States for at least two more years. However, advance copies of the manual indicate that the issue has been resolved by entirely separating diagnoses involving rheumatic heart from those that do not.