Rheumatic mitral valve disease, unspecified

This code signifies a form of heart valve disease affecting the mitral valve, specifically caused by rheumatic fever, where the precise nature or severity of the mitral valve involvement (e.g., stenosis, insufficiency, or both) is not documented. It indicates a history of rheumatic fever has led to damage of the mitral valve apparatus.

Use this code when documentation confirms a diagnosis of rheumatic mitral valve disease but lacks specific details regarding the type or extent of the valve dysfunction. This code is appropriate when the physician states "rheumatic mitral valve disease, unspecified" or similar phrasing without further elaboration on stenosis or insufficiency.

• Avoid using this code if the documentation specifies rheumatic mitral stenosis (I05.0) or rheumatic mitral insufficiency (I05.1).
• Always query the provider for greater specificity if the documentation allows, as more specific codes exist.
• Sequence this code as a primary diagnosis when it is the reason for the encounter, or as a secondary diagnosis when it is a co-morbidity.