What ICD-10 code diagnosis would be used for a patient with normal left ventricular systolic function, mitral valve thickening, tricuspid valve thickening, and mild residual regurgitation?

ICD-10 Coding for Post-Valve Repair with Residual Regurgitation

The primary diagnosis code should be I34.0 (Nonrheumatic mitral [valve] insufficiency) for the mild residual mitral regurgitation following repair, with I07.1 (Rheumatic tricuspid insufficiency) or I36.1 (Nonrheumatic tricuspid [valve] insufficiency) as a secondary code depending on the etiology of the tricuspid valve disease.

Primary Coding Considerations

Mitral Valve Status

• Code I34.0 (Nonrheumatic mitral insufficiency) is appropriate for the documented mild residual mitral regurgitation post-repair, assuming the original pathology was degenerative rather than rheumatic 1
• The thickened mitral valve leaflets with intact repair and mean gradient of 3 mmHg indicate successful structural repair but persistent mild regurgitation 1
• If the original pathology was rheumatic, use I05.1 (Rheumatic mitral insufficiency) instead 2

Tricuspid Valve Status

• Code I36.1 (Nonrheumatic tricuspid insufficiency) for the trace tricuspid regurgitation with thickened leaflets and annular ring 2
• The presence of an annular ring suggests prior surgical intervention, and trace regurgitation is a common finding post-repair 3
• If rheumatic etiology is documented, use I07.1 (Rheumatic tricuspid insufficiency) 2

Secondary Coding Requirements

Left Ventricular Function

• Do not code for left ventricular dysfunction since the ejection fraction of 57% represents normal systolic function 1
• The improvement from prior study to normal biventricular function indicates resolved dysfunction, not current disease requiring coding 1

Additional Considerations

• Code Z95.2 (Presence of prosthetic heart valve) if prosthetic material was used in the mitral repair 1
• Code Z95.3 (Presence of xenogenic heart valve) if biological material was used 1
• Consider Z98.89 (Other specified postprocedural states) for status post-cardiac valve repair if documentation supports this 1

Common Coding Pitfalls

Avoid Overcoding Normal Findings

• Do not code for "thickened valve leaflets" alone without associated dysfunction, as this represents post-surgical changes rather than active disease 1
• The mean gradients of 3 mmHg (mitral) and 1 mmHg (tricuspid) are not hemodynamically significant and do not warrant stenosis codes 1

Severity Documentation Matters

• Mild and trace regurgitation represent clinically significant findings that warrant coding, even though they may not require immediate intervention 1, 4
• Both mild mitral regurgitation and trace tricuspid regurgitation are associated with long-term prognostic implications in post-surgical patients 4, 3, 5

Sequencing Priority

• List the mitral valve code first as it represents the more significant pathology (mild vs. trace regurgitation) 1
• Tricuspid regurgitation, even when trace, should be coded as it provides prognostic information and may progress over time 3, 6, 5

Final Code Summary

Primary diagnosis: I34.0 (or I05.1 if rheumatic)
Secondary diagnosis: I36.1 (or I07.1 if rheumatic)
Additional codes: Z95.2 or Z95.3 (if prosthetic/xenogenic material used), Z98.89 (status post-valve repair)