Rheumatic aortic stenosis with insufficiency

This code represents a specific type of heart valve disease where the aortic valve is both narrowed (stenosis) and fails to close completely (insufficiency or regurgitation), and the underlying cause is rheumatic fever. This condition impairs blood flow from the left ventricle to the aorta and can lead to heart failure.

Use this code when documentation clearly indicates a diagnosis of combined aortic stenosis and insufficiency, and explicitly states a rheumatic etiology. This typically occurs in patients with a history of rheumatic fever or rheumatic heart disease. Supporting documentation would include echocardiogram reports detailing both stenotic and regurgitant aortic valve findings, and physician notes confirming the rheumatic origin.

• Always confirm the rheumatic origin; if not specified, consider non-rheumatic aortic valve disorders.
• Do not code separately for aortic stenosis and aortic insufficiency if both are present and due to the same rheumatic process, as this code encompasses both.
• Review documentation for any associated heart failure, which would be coded additionally.