Rheumatic and Non Rheumatic Heart Disease

jillian.bisbejillian.bisbe
in Clinical & Coding
We have a case of an 80+ year old patient who has mitral, aortic, and tricuspid valve disease. Since the default code is rheumatic valve disorders, I have been asked to query the CT surgeon (is this rheumatic heart disease or not). I don't feel like this is a fair question. Thoughts? Thanks!

Comments

  • JSandRNJSandRN
    Did you end up placing the query? I have been asked to do the same, however, I am not sure what clinical indicators will support rheumatic vs non-rheumatic, as the etiology of the valve disorder is not addressed in any notes. Also, how would you ask the question, what are reasonable choices? 
  • jillian.bisbejillian.bisbe

    This is what I sent. 


    Clinical Indicators: 82 y.o. F with Mitral Regurgitation, S/p Mitral Valve Clip repair. Also has "mild-moderate Aortic Valve Insufficiency, and Tricuspid Valve Regurg, at least moderate".  

    Per ICD-10 coding guidelines, combined aortic, mitral, and tricuspid disease are presumed to be of Rheumatic origin unless stated otherwise.

     Please clarify based on the above if the valve disease is:

    ·        NonRheumatic Valve disease

    ·        Presumed to be of rheumatic origin

    ·        Other

    ·        Clinically Unable to Determine


     After discussion and education with the MD, this is how the query was answered: Provider response: other: most likely not of rheumatic origin. Findings consistent with degenerative valve disease

  • JSandRNJSandRN
    Awe, thank you. We did find a template on the AHIMA website, very similar to this one. Our physician answered UTD. 
  • alkannealkanne
    Where on the AHIMA Site did you find a template??
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