A: Before assigning a code for a valvular condition, regardless of the documented severity, the coder should determine if the condition meets the definition of an additional diagnosis as outlined the ICD-10-CM Official Guidelines for Coding and Reporting.
Section III of the guidelines states that an “other diagnosis” for an inpatient encounter is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and/or monitoring.
Section IV.J. addresses coding other diagnoses by stating that all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management should be coded.
Look for documentation in the record that the condition was monitored, evaluated, assessed, or treated (MEAT criteria). If documentation is unclear as to whether a condition met this criteria, the provider should be queried.
Q: How do you code for removal of valvular calcifications?
A: The removal of leaflet vegetations or calcifications during valve replacement surgery is integral to the Replacement root operation and not coded separately (Source: Coding Clinic, Second Quarter 2016: Page 25). When the only procedure performed is removal of valvular calcifications, the root operation is Extirpation (Taking or cutting out solid matter from a body part) in table 02C Source: Coding Clinic, Second Quarter 2016: Page 24).
Q: How do you code heart valve surgery using a Da Vinci robot?
A: In addition to the code for the heart valve procedure, assign a code from table 8E0 for other procedures. The fourth character for body region is W, Trunk Region. The approach is the approach to the procedure, and the fifth character for method is C, Robotic Assisted Procedure.
Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-Approved ICD-10-CM/PCS Trainer
Senior Consultant
Kristi also performs DRG and APC audits and is known for her vast knowledge on coding vascular interventional radiology procedures. Kristi has an extensive background in coding education and consulting and is a national speakers on topics related to ICD-10 and CPT coding as well as code-based reimbursement.