Pump out the right ICD-9-CM code
Use the 393-398 series if the valve defect resulted from rheumatic fever.
396.x is appropriate when both the mitral and aortic valves are involved.
Use V43.3 when a patient who's had a valve replacement comes in for follow-up.
To find the correct diagnosis code for a patient with a heart murmur you need to know three key facts:
the origin of the valve disorder
the nature of the problem
whether more than one valve is involved.
When coding valve disorders, check the index of your ICD-9-CM manual and read the code descriptions for guidance, including references to other codes, says Bruce Rappoport, an internist at RCH Healthcare Advisors in Fort Lauderdale.
"The subtext under the headings is important in coding valve disease," Rappoport says. "It tells you what is included in and excluded from the code." There are three different code series.
Use the 393-398 series (chronic rheumatic heart disease) if the defect resulted from rheumatic fever, and "make certain the word 'rheumatic' is stated in the documentation," says Marti Geron, reimbursement manager at The University of Texas Southwestern Medical Center at Dallas.
That said, this rule has an important and confusing variant. Although the ICD-9-CM manual describes the 393-398 series as being appropriate for "chronic rheumatic heart disease," it specifies that you should use 396.x (diseases of mitral and aortic valves) when the patient has problems with both the mitral and aortic valves "whether specified as rheumatic or not." This may be because physicians once believed that multiple valve problems were predominantly rheumatic in nature, Rappoport says. But today, we see multiple valve problems from other causes.
The other two code series used most often for valve disorders are more straightforward. Use the 746.x series (other congenital anomalies of heart) if the valve problem is congenital. Use the 424.x series (other diseases of endocardium) for heart valve disorders resulting from other than congenital causesinfection, for instance.
After you select the code series, determine which valve is diseased and what the specific defect is. If more than one valve is involved, don't code each valve disorder separately, Rappoport says.
Here are basic principles for coding valve disorders, by valve:
Mitral valve. For cases originating from rheumatic disease, choose the 394.x series (diseases of mitral valve) when the patient's problem involves the mitral valve only. Use 394.0 (mitral stenosis) when there's stenosis or an obstruction of the mitral valve, typically a result of childhood rheumatic fever. Use 394.1 (rheumatic mitral insufficiency) when there's incompetence or regurgitation of the mitral valve. Sometimes patients have both defects. In that case, use 394.2 (mitral stenosis with insufficiency).
Code 394.9 for other and unspecified mitral defects related to rheumatic disease. Use 746.5 (congenital mitral stenosis) and 746.6 (congenital mitral insufficiency) for defects that date to the patient's birth.
Use 424.0 (mitral valve disorders) for mitral insufficiency, regurgitation, or incompetence not caused by rheumatic fever and not present at birth.
Aortic valve. When a rheumatic patient has aortic valve defects, use 395.0 (rheumatic aortic stenosis) for a narrowing or obstruction; use 395.1 (rheumatic aortic insufficiency) for regurgitation or incompetence; and use 395.2 (rheumatic aortic stenosis with insufficiency) when both diseases are present. Use 395.9 for other and unspecified aortic defects related to rheumatic disease.
Use 746.3 (congenital stenosis of aortic valve) and 746.4 (congenital insufficiency of aortic valve) when the defects date to birth.
Use 424.1 (aortic valve disorders) for aortic stenosis, insufficiency, regurgitation, or incompetence not caused by rheumatic heart disease and not present at birth.
Both mitral and aortic valves. Sometimes a patient will have stenosis or insufficiency in both the aortic and the mitral valves or stenosis in one and insufficiency in the other. Instead of coding the mitral and aortic valve disorders separately, use the 396 series (diseases of mitral and aortic valves) and choose the correct fourth digit to describe the particular problem the patient has.
For example, a patient presents with chest pain and syncope. You listen to the heart, perform an echocardiogram, and determine that the patient has aortic stenosis with mitral regurgitation. If you simply look in the numerical section of the ICD-9-CM manual, you'll find aortic stenosis listed at 424.1. If you read the exclusions there or look up the diagnosis in the index, the manual will direct you to 396 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 that scenario is to code only one of the valve problems, but you should always code to the highest specificity and code both, Rappoport says.
Physicians sometimes use two separate codes for the disorder, overlooking 396 because it falls under the "chronic rheumatic heart disease" heading. Both the index and the subtext under the headings will direct you to the right code.
Other valve disorders. Code tricuspid and pulmonary valve disorders that are rheumatic in origin using the 397 series. Use the 746 series if these valve disorders are congenital, and use the 424 series if they were not present from birth.
One other code sometimes used with valve disease is V43.3 (organ or tissue replaced by other means; heart valve). You'll most often use this as a secondary code when a patient who has had a valve replacement comes in for a follow-up visit.
This information provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit www.codinginstitute.com.
Coding Consult: Make valve coding an open-and-shut case.
Jun. 6, 2003;80:22.