Ask the Experts: January 15, 2015

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Question: For outpatient records, do you code mild mitral regurgitation, or mild aortic regurgitation interpretations? I see your answer for INPATIENT, but I am not sure if this is the same for OUTPATIENT?

Answer: If it is an incidental finding on a test, no.  If it has clinical significance that the physician notes, then yes.

- Arlene F. Baril, MHA, RHIA, CHC

*Previous Q & A for reference:

Q: If a physician documents "trace," "mild" or "trace to mild" heart valve conditions (e.g., mild mitral insufficiency) as a diagnosis in the medical record, would it be appropriate to code these conditions? In the instance where the physician is just restating the echo findings, would it be appropriate for these conditions to be coded? See the examples below for reference.

Example Number 1: Cardiology: 5/2: "echo pending " 5/3: "...echo LVH, NL LV MILD MR TR " Attending: 5/3: "echo - mild MR & TR, EF 57%, LVH" The discharge summary states "Echo finding are left ventricular hypertrophy with normal ejection fraction of 55%, 1+ Mitral regurgitation and tricuspid regurgitation"

Example Number 2: Patient is admitted for CHF. A TEE is ordered. Trace atrial regurgitation and mild mitral regurgitation is found. The attending writes progress notes and discharge summary shows: PN HD # 1: Worsening SOB. Continue IV Lasix. X-ray shows: Large pleural Effusion. Assessment: Decompensated CHF. PN HD # 2: CHF. Plan: TEE, continue IV Lasix PN HD # 3: SOB is gone. Pleural effusion subsiding. TEE showed trace atrial regurgitation and mild mitral regurgitation. Assessment: CHF compensated. Discharge summary: PDX: 1. CHF Hospital Course: Patient admitted via ER in decompensated CHF. IV lasix given until the SOB and pleural effusion subsided. TEE performed showed Trace atrial regurgitation and mild mitral regurgitation. Discharge patient on po lasix.

Example Number 3: Echo indicates "trace mitral regurg" and attending physician documents in PN "trace mitral regurg on Echo." No treatment is provided and there is no further documentation through hospital stay. Discharge summary includes "trace mitral regurg" as a finding on Echo only.

Example Number 4: Physician documents in the progress note and discharge summary patient has 'exceptionally mild aortic stenosis and mitral insufficiency'. No further evaluation, workup, etc. was done for these conditions.

Example Number 5: A Cardiologist Consultant was asked to see the patient to evaluate the patient's heart for any abnormalities. Consultant documented that patient has "aortic and mitral regurgitation, clinically mild" as a diagnosis in the Impression. No further workup, monitoring, etc. is performed during this admission, and there is no conflicting documentation in the medical record regarding these conditions.

Example 6: Echo states mild mitral insufficiency and trace aortic insufficiency. MD also document in the progress notes: The patient is doing well. Echo finding: Trace aortic insufficiency and mild mitral insufficiency. CHF Trace AI and mild MI Dehydration

Example 7: Progress notes: Echo showed "trace to mild mitral regurgitation" Discharge summary final diagnoses: Pneumonia Dehydration Mild Mitral Regurgitation Tachycardia Example 8: Progress note: Patient doing better. Echo showed trace to mild mitral regurgitation and mild aortic insufficiency. Due to echo findings, place patient on antibiotics once a day. CAD Angina Hypertension

A: This is an excellent question as coders are often times at odds on the merits of coding "trace" or "mild" valvular problems. You have supplied several documentation examples to support your question, which is always helpful.

To put your question into proper perspective, consider the pathophysiology of valvular disorders such as mitral regurgitation, insufficiency, etc. Mitral regurgitation may result from many processes, such as rheumatic disease, mitral valve prolapse, myxomatous degeneration, infective endocarditis and subvalvular degeneration (due to papillary muscle dysfunction, or ruptured chordae tendineae). Mitral regurgitation may occur as a congenital anomaly, or also occurs transiently during periods of transient ischemia involving a papillary muscle or the adjacent myocardium and may accompany episodes of angina. MR may be seen in patients with hypertrophic cardiomyopathy and heart failure.

The issue here is that MR and TR can be associated with numerous clinical etiologies. When the terms "trace" or "mild" MR or TR is documented in the record absent a discussion by the physician of the clinical significance of the finding, the question of the legitimacy of assigning an additional code for the condition comes into play. Ask yourself the question of whether the MR or TR contributed to the patient's admission or can be explained by the other conditions the patient was admitted for or be evaluated for. Without the clinical significance of MR/TR stated in the record, I would not be inclined to assign an additional code for the condition, particularly since MR/TR often times serves as the only "CC" in an inpatient case and may be construed to outside reviewers as attempts to be "fishing" for a CC.

- Glenn Krauss, RHIA, CCS, CCS-P

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