Author: Linda Kobayashi, BA, RHIT, CCS
Editor: Andrea Wong, BS, RHIT
Happy New Year Everyone! Let’s get off to a good start with ICD-10. We hope you’re finding it a little easier now that you’ve had some experience tucked under your belt. We have been discussing the Circulatory System and will continue to do so for the next few weeks.
Problem for this week:
A 65-year-old male patient was diagnosed with mitral valve prolapse, specified as rheumatic. He has a history of rheumatic heart disease as a child. He underwent a mitral valve replacement using porcine tissue, open approach.
- I05.8 = Other rheumatic mitral valve diseases
- 02RG08Z = Replacement of mitral valve with zooplastic tissue, open approach
To locate I05.8: Disease Index > Disease > heart > mitral > specified NEC > I05.8
- The solution would not have been coded as I34.1 because the case study indicated that the patient had a mitral valve problem of rheumatic type, and ICD-10-CM classifies I34.1 as non-rheumatic. It is always important to verify your codes in the tabular after searching the code in the alphabetical index.
- When searching for the Rheumatic mitral valve code, under “Disease > heart > mitral,” ICD-10-CM classifies it under the tabular section “ Chronic rheumatic heart disease.” Hence, the condition is coded to I05.8.
- A history code is not coded because history codes are only coded when a patients past medical condition no longer exists and is used when the patient is not receiving any treatment for the condition.
- Recent data have demonstrated a high incidence of mitral valve prolapse in cases of rheumatic heart disease, which suggests that rheumatic fever may be a cause of mitral valve prolapse.
To locate 02RG08Z: PCS Index > Replacement > Valve > Mitral > 02RG > locate table 02R and go across the row to finish building the code after verifying that the 4th character of G is correct:
Replacement of Mitral Valve with Zooplastic Tissue, Open Approach
- Definition of Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part.
- Explanation: The body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the REPLACEMENT procedure. A REMOVAL procedure is coded for taking out the device used in a previous replacement procedure.
- Zooplastic tissue: Surgical transfer of tissue from an animal to a human. Also called zoografting.
- In terms of approach, it is possible for mitral valve repairs to be done transcatheter via a percutaneous approach. However, our particular case study indicated that the procedure was performed using an open approach.