ED Coding and Reimbursement Alert

Question: If the patient has a chronic condition, such as mitral valve disorder, should I report that diagnosis even when the physician is not specifically treating it?

Arizona Subscriber

Answer: You would report the mitral valve disorder only if the physician noted that it was relevant to the patient's presentation. For instance, a 69-year-old male with mitral regurgitation presents with a traumatic ankle sprain; in this case, the mitral valve disorder is not relevant to the presentation.

However, if the patient presents with dyspnea and a worsening murmur, the mitral valve disorder is clinically relevant and could be reported.