Cardiology Coding Alert

You can't afford to assume the 'Rheumatic' range applies only to rheumatic cases.

Finding the correct diagnosis code for a patient with a valve disorder isn't always simple, but you can pinpoint the correct ICD-9 code if you know the nature of the problem and whether more than one valve is involved.

Common valve disorders -- often connected to heart murmurs -- include stenosis (a narrowing of the valve that interferes with the valve opening) and insufficiency or regurgitation (when the valve doesn't close).

When coding valve disorders, you should be sure to check the index of your ICD-9 manual first and then read the code descriptions for guidance, including references to other codes. Includes and excludes notes with the codes are also crucial for understanding which diagnoses do and don't fall under the code.

Determine the Role of 'Rheumatic'

The first step in coding a valve disorder is to determine the problem's origin because that will affect your code choice. There are two different code series to consider for noncongenital cases.

Focus on 393-398.x (Chronic rheumatic heart disease) if the defect resulted from rheumatic fever -- an inflammatory disease that begins with a strep infection and can cause several heart complications.

Caution: Remember that this rule has an important and confusing variant. Although the ICD-9 manual describes the 393-398.x series as being for "chronic rheumatic heart disease," not all of the codes in that series are specific to rheumatic cases.

In brief, not all of the 394.x (Diseases of mitral valve) and 397.x (Diseases of other endocardial structures) codes specify "rheumatic" in their definitions, says Christina Neighbors, MA, CPC, CCC, ACS-CA, charge capture reconciliation specialist and coder at St. Joseph Heart & Vascular Center in Tacoma, Wash.

In contrast, all of the 395.x (Diseases of aortic valve) codes are designated as "rheumatic," says Neighbors. The 396.x (Diseases of mitral and aortic valves) codes apply whether the disease is specified as rheumatic or not. This may be because physicians once believed that multiple valve problems were predominantly rheumatic in nature. But in the U.S. today, doctors see multiple valve problems from other causes.

Alternative: If the noncongenital valve disorder case you're coding doesn't fall under 394.x-398.x, you should use the 424.x series (Other diseases of endocardium).

Smart move: Codes 424.0-424.3 all have exclude notes you must heed to support proper coding, says Neighbors.

Count the Valves Involved to Find Range

You also will need to determine which valve is diseased and the nature of the specific defect to choose the proper code.

Remember that if more than one valve is involved, you will not code each valve disorder separately. That means that if the physician diagnoses mitral and aortic valve diseases together, you should report the appropriate 396.x code, Neighbors says. You should not additionally report 424.0 (Mitral valve disorders) or 424.1 (Aortic valve disorders), she explains.

If you can't find information in the patient's chart concerning which valve is involved or on the particular problem with the valve, you should ask the physician for more information before you code the encounter.

Bonus documentation tip: You also want to see specifics on whether there is stenosis, insufficiency, or stenosis with insufficiency. Keep in mind that the physician may document stenosis as obstruction, and he may use the terms incompetence and regurgitation in place of insufficiency.

Example: Suppose a patient presents with chest pain and syncope.The physician does an examination, listens to the heart, performs an echocardiogram, and determines that the patient has aortic stenosis with mitral regurgitation. If you simply look in the numerical section of the ICD-9 manual, you'll find aortic stenosis listed at 424.1. If you read the exclusions there however or look up the diagnosis in the index, the manual will direct you to 396.x for this disorder when combined with a mitral defect. So 396.2 (Mitral valve insufficiency and aortic valve stenosis) is the correct code.

A common mistake in the scenario above is to code only one of the valve problems, but you should always code to the highest specificity -- which means coding both.

Coders sometimes also use two separate codes for the disorder, overlooking 396.x because it is under the "chronic rheumatic heart disease" heading. Remember that both the index and the notes under the headings will direct you to the right code.

Part 2: Check in next month's issue for a table to help you determine the role of "rheumatic" in codes 394.x-394.8 and 424.x.