Mitral valve insufficiency and aortic valve stenosis

This code represents the simultaneous presence of two distinct valvular heart diseases: mitral valve insufficiency (regurgitation) and aortic valve stenosis. Mitral insufficiency involves the incomplete closure of the mitral valve, leading to blood flowing backward into the left atrium during systole. Aortic stenosis is the narrowing of the aortic valve opening, obstructing blood flow from the left ventricle to the aorta.

Use this code when documentation clearly indicates both mitral regurgitation and aortic stenosis are present in the same patient. This typically occurs in patients with degenerative valvular disease, rheumatic heart disease, or congenital anomalies. Supporting documentation includes echocardiogram reports, cardiac catheterization findings, and physician notes detailing both conditions.

• Do not use this code if only one of the conditions (mitral insufficiency or aortic stenosis) is documented; use the specific code for the single condition.
• Ensure the documentation specifies both conditions are present, not just suspected or ruled out.
• Consider sequencing based on the primary reason for the encounter if one condition is acutely decompensated or being primarily managed.