Flagging Patients as Uninsurable:
Ethical Issues Complicate Coding for Multiple Valve Disorders
Published on Wed Sep 01, 1999
Unlike most coding issues cardiology practices face, the confusion with multiple valve disorders does not directly involve reimbursement issues; rather, it is over whether technically correct coding of multiple valve disease should take precedence over the welfare of the patient. In the case of multiple valve disorders, which most commonly involve the mitral and aortic valve, determining which diagnosis code to use can be confusing when considering the decision could potentially result in rendering your patient uninsurable.
Patients Welfare is At Stake
Many consultants maintain that the 396 series of ICD-9 codes (diseases of the mitral and aortal valve; includes involvement of both mitral and aortic valves, whether specified as rheumatic or not) should not be used for multiple valve disorders unless the patient has rheumatic fever, even though, strictly speaking, that code probably best describes the patients symptoms. For example, when mitral and aortic valve problems are indicated, the technically correct diagnosis code would be 396.3 (mitral valve insufficiency and aortic valve insufficiency; mitral and aortic [valve] incompetence, regurgitation).
Unlike the 395 series of codes (diseases of the aortic valve), which ICD-9 explicitly states should exclude that not specified as rheumatic, the 396 codes have no such restriction. So, technically speaking, the 396 is probably the most accurate diagnosis code describing the condition of a patient with multiple valvular disorders, says Ray Cathey, PA, MHA, a cardiology coding and compliance specialist and president of Medical Management Dimensions in Stockton, CA.
But Cathey maintains there is more to this issue than technically correct coding.
If you use the 396 codes, you are labeling the patient with a potential pre-existing condition because you are saying they have a chronic rheumatic heart. And doing that, in many instances, makes them uninsurable, he says.
Because they relate only indirectly to payment, ICD-9 diagnosis codes tend to be overlooked in favor of the cardiology reimbursement-based procedural CPT codes. From the point of view of cardiology practice coders and other reimbursement specialists, ICD-9 codes are of interest primarily because they indicate medical necessity when billing for a procedure.
But incorrect and/or careless use of these codes sometimes may cause more than denials due to lack of medical necessity. Sometimes, careless use of these codes can label a patient for life and render him or her uninsurable.
Take, for example, the case of a young man with high blood pressure who comes into his cardiologists office and says he passed out while playing golf. The cardiologist takes the mans blood pressure and orders a stress-echo cardiogram (93307, echocardiography, transthoracic, real-time with image documentation [2D] with or without M-code recording; complete). The results of the diagnostic tests confirm the patient has mitral regurgitation as well [...]
