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Q/A: Querying physicians regarding rheumatic heart disease

CDI Strategies, April 3, 2008

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Question: I have a question about congestive heart failure (CHF) and rheumatic heart disease. I understand the coding guideline that refers to documentation of CHF, aortic valve stenosis, and mitral valve requrgitation. The codes should be 398.91 and 396.2. However, coding guidelines also state "unless the physician specifies a different cause." If the patient has acute on chronic systolic CHF and hypertensive heart disease, stage three chronic kidney disease, and aortic stenosis with mitral valve regurgitation, should a CDI specialist or coder query the physician for the cause of the CHF (hypertension or rheumatic)? Or would the principal diagnosis be the rheumatic heart disease (code 398.91)?

The statement "unless the physician specifies a different cause" tells me that just because the patient has aortic stenosis and mitral valve regurgitation does not mean that is the cause of the CHF. Should we code this as 404.91, 428.23, 428.0, 585.3, or 396.2? The pop-up screen in our encoder states that we should report codes 428.0 and 396.2 as 398.91. What is your advice?

Answer: This is a difficult issue. Allow me to discuss this along a number of fronts.

First, the ICD-9-CM table, index, and ICD-9-CM Official Guidelines for Coding and Reporting ("Official Guidelines") are silent on the issue that you discuss. I am not sure why you state that a coding guideline requires us to use 398.91 and 396.2 when heart failure, aortic valve stenosis, and mitral valve regurgitation coexist (unless you mean that Coding Clinic is a guideline, which it is not. Coding Clinic is advice). Indeed, ICD-9-CM requires patients with a combination of aortic and mitral valve disease of any cause (including the nonrheumatic causes) code to 396.x. On the other hand, I cannot find any requirement in ICD-9-CM or in the Official Guidelines whereby heart failure due to or in the presence of bivalvular heart disease that is not explicitly specified as due to rheumatic heart disease should be coded to 398.91.

Specifically, the ICD-9-CM index to diseases is listed as follows:

• Failure, failed
  • Heart (acute) (sudden) 428.9
    • Congestive (compensated) (decompensated) [see also Failure, heart] 428.0
      • With rheumatic fever (conditions classifiable to 390--note that this is not the 396.x codes)
        • Active 391.8
        • Inactive or quiensent (with chorea) 398.91
    • Rheumatic (chronic) (inactive) (with chorea) 398.91
      • Active or acute 391.8

Unfortunately, Coding Clinic, 1st Quarter, 1995, p. 6 appears to be poorly worded as to require that we code 398.91 (a complication/comorbidity, or CC) when patients have aortic valve stenosis and mitral valve insufficiency in the setting of congestive heart failure, even if the physician does not specify that the heart failure is rheumatic. I believe that this is currently in error, given that acute systolic or heart failure that is not specified as rheumatic codes to the 428.xx series (with acute systolic/diastolic heart failure serving as a major CC), that ICD-9-CM does not link 396.2 and 398.91, and that true rheumatic heart disease (and failure) is becoming rarer in the United States.

Coding Clinic, 2nd Quarter, 2000, pp. 16-17, appears to correct this by stipulating that a coder is not to make an assumption that congestive heart failure is rheumatic in nature when a physician documents valvular disease, including one listed in the subchapter 393-398 (397.0--Diseases of the tricuspid valve). Unless ICD-9-CM directs the coder to assign the code for rheumatic congestive heart failure (which is not required under 396.x) or the physician states the condition is rheumatic, it is inappropriate to assign a code for rheumatic congestive heart failure. Furthermore, Coding Clinic, 3rd Quarter, 2006, p. 7 supports this Coding Clinic as well, stating that "unless ICD-9-CM directs the coder to assign the code for "rheumatic", it is inappropriate to assign a code for rheumatic heart failure".

Some coders that I know appear unwilling to contradict the Coding Clinic, 1st Quarter, 1995 advice regarding this issue. Be aware that the newly released Coding Clinic, 1st Quarter, 2008, p. 19 explicitly states: "Whenever new advice (in Coding Clinic) is published, it always (my emphasis) supercedes earlier advice". Coding Clinic, 2nd Quarter, 2000 and 3rd Quarter, 2006 is newer advice than 1st Quarter, 1995, thus I believe they supercede the requirement to automatically code 398.91 when heart failure occurs in the setting of aortic valve stenosis and mitral valve insufficiency (396.2).

Therefore, it is my opinion at this time that a coder or CDI specialist does not have to query the physician for the cause of the heart failure as possibly rheumatic or nonrheumatic in origin. I disagree with the pop-up instruction in your encoder stipulating that codes 428.0 and 396.2 must be coded as 398.91. Should you have other supporting evidence that this is so, I would appreciate hearing from you. Also, you should consult your fiscal intermediary or Medicare Administrative Contractor for definitive guidance.

(James S. Kennedy, MD, CCS, director of FTI Healthcare in Brentwood, TN, answered this question. You can contact him via e-mail at James.Kennedy@FTICambioHealth.com)

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