Mitral valve stenosis and aortic valve insufficiency

This code signifies a dual valvular heart disease involving both the mitral and aortic valves. Specifically, it describes a narrowing of the mitral valve opening, restricting blood flow from the left atrium to the left ventricle, concurrently with an incompetent aortic valve, allowing blood to leak back into the left ventricle during diastole.

Apply this code when documentation clearly indicates the simultaneous presence of mitral valve stenosis and aortic valve insufficiency. This typically occurs in patients with rheumatic heart disease or other conditions affecting multiple heart valves. Supporting documentation would include echocardiogram reports, physician notes detailing both conditions, and diagnostic findings confirming the severity of each valvular defect.

• Ensure both mitral stenosis and aortic insufficiency are explicitly documented; do not assume one from the other.
• This code represents a combined condition; avoid coding separate codes for mitral stenosis and aortic insufficiency if this combination code is applicable.
• Review documentation for any underlying cause, such as rheumatic fever, which may require additional coding.