Cardiology Coding Alert

Reader Question:

Check Out This Advice for Rheumatic Versus Non-Rheumatic Dx Codes

Question: In ICD-10, if a patient has mitral regurgitation without mention of it being non-rheumatic in the report, would we use the rheumatic diagnosis code? We were told the correct way to code is with the rationale that if the documentation does not specify rheumatic nor non-rheumatic, you would assign the unspecified code, which is also the rheumatic code. However, other coders in our office have always been taught to code as non-rheumatic unless stated otherwise. It seems wrong to give a patient a rheumatic condition (if using the default/unspecified code), when there is no mention of them having rheumatic fever (past or present) and no definite finding saying there is a rheumatic condition. It seems backwards, that the unspecified should default to “non-rheumatic” and not “rheumatic.” Since when do we give patients conditions without any backing to it? That presumption would be incorrect for the large majority of the population. As a group in our facility, we had decided long ago to use “non-rheumatic” for valve disease (even with multiple valves), unless it is specifically stated to be “rheumatic.”

Nebraska Subscriber

Answer: You need to refer to the official guidelines.

“I understand your frustration, and I agree with coding non-rheumatic unless stated otherwise,” says Christina Neighbors, MA, CPC, CCC, Coding Quality Auditor for Conifer Health Solutions, Coding Quality & Education Department, and member of AAPC’s Certified Cardiology Coder steering committee. “However, I do not agree or recommend always coding non-rheumatic regardless of the ICD-10-CM coding guidelines. We as coders/auditors must follow the ICD-10-CM coding guidelines as well as AHA coding clinics and CMS guidance.

Here are some rheumatic heart disease rules of thumb to follow, per Neighbors:

  • A singular cardiac valve disorder stated as “unspecific” or “non-rheumatic” is coded with a non-rheumatic code.
  • A singular cardiac valve disorder stated as “rheumatic” is coded with a “rheumatic” code.
  • Multiple cardiac valve disorders involving multiple valves stated as “unspecified” or “rheumatic” are presumed “rheumatic” and coded with a combination rheumatic code.
  • Some multiple cardiac valve disorders of a singular cardiac valve (Example: mitral valve stenosis and mitral valve insufficiency) are presumed “rheumatic” and coded with a combination rheumatic code even though multiple cardiac valve disorders involving multiple valves are not documented.