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I35.1
ICD-10-CM
Aortic Regurgitation

Understanding Aortic Regurgitation (AR), also known as Aortic Insufficiency, is crucial for accurate clinical documentation and medical coding. This page provides information on diagnosing, documenting, and coding Aortic Regurgitation, including relevant healthcare terminology and guidelines for medical professionals. Learn about Aortic Insufficiency symptoms, treatment options, and the importance of proper coding for AR for optimized healthcare reimbursement and data analysis.

Also known as

Aortic Insufficiency
AR

Diagnosis Snapshot

Key Facts
  • Definition : Backflow of blood from the aorta into the left ventricle.
  • Clinical Signs : Shortness of breath, chest pain, palpitations, lightheadedness.
  • Common Settings : Primary care, cardiology clinic, emergency room.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC I35.1 Coding
I06.0-I06.9

Rheumatic aortic valve diseases

Rheumatic heart disease affecting the aortic valve, including regurgitation.

I34.0-I34.9

Nonrheumatic aortic valve disorders

Non-rheumatic disorders of the aortic valve, such as regurgitation.

I35.0-I35.9

Nonrheumatic mitral valve disorders

Non-rheumatic mitral valve issues, sometimes occurring with aortic regurgitation.

Q23.0-Q23.9

Congenital malformations of aortic valve

Birth defects affecting the aortic valve, potentially causing regurgitation.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the aortic regurgitation acute?

  • Yes

    Due to infective endocarditis?

  • No

    Is it chronic?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Leaking aortic valve causes backflow into left ventricle.
Narrowing of aortic valve obstructs blood flow from left ventricle.
Combined stenosis and regurgitation of the aortic valve.

Documentation Best Practices

Documentation Checklist
  • Aortic Regurgitation (AR) diagnosis documentation checklist:
  • 1. Severity (mild, moderate, severe) - echo findings
  • 2. Etiology (e.g., bicuspid valve, IE)
  • 3. Symptoms (dyspnea, chest pain, palpitations)
  • 4. NYHA Functional Class if applicable
  • 5. Management plan (medical therapy, surgery)

Coding and Audit Risks

Common Risks
  • Unspecified Etiology

    Coding aortic regurgitation without specifying rheumatic, congenital, or other cause can lead to inaccurate severity and reimbursement.

  • Acute vs. Chronic AR

    Miscoding acute aortic regurgitation as chronic or vice versa impacts clinical documentation integrity and treatment plans.

  • Severity Documentation

    Lack of documentation specifying mild, moderate, or severe aortic regurgitation affects coding accuracy and quality reporting.

Mitigation Tips

Best Practices
  • ICD-10 I35.x, I06.0 CDI: Document severity, etiology, symptoms.
  • CPT 71010-71020, 93303-93321: Echo crucial for AR assessment, include details.
  • Monitor LV function (EF) regularly. Optimize BP control, prevent CHF.
  • Timely cardiology referral, surgical valve intervention when indicated.
  • Patient education: medication adherence, symptom recognition, lifestyle changes.

Clinical Decision Support

Checklist
  • Confirm diastolic murmur present: auscultation documentation
  • Echocardiogram performed: quantify regurgitant fraction
  • Assess LV size and function: impact of AR noted
  • Symptoms documented: dyspnea, chest pain, palpitations
  • Left ventricular hypertrophy assessed on ECG

Reimbursement and Quality Metrics

Impact Summary
  • Aortic Regurgitation (AR) Diagnosis Reimbursement and Quality Metrics Impact Summary
  • Medical Billing Keywords: Aortic Insufficiency, AR, ICD-10 code I35.X, DRG impact, reimbursement rates
  • Coding Accuracy Impact: Precise documentation of etiology and severity crucial for correct coding and optimal reimbursement.
  • Hospital Reporting Impact: AR impacts quality metrics related to heart failure admissions and readmissions.
  • Reimbursement Impact: Severity and associated procedures influence MS-DRG assignment and reimbursement levels.

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Frequently Asked Questions

Common Questions and Answers

Q: What are the key echocardiographic findings for differentiating mild, moderate, and severe aortic regurgitation in adults?

A: Accurate assessment of aortic regurgitation (AR) severity relies heavily on echocardiography. Differentiating mild, moderate, and severe AR involves integrating multiple parameters. Mild AR is typically characterized by a small regurgitant jet width (<25% of the left ventricular outflow tract diameter) and a limited vena contracta width (<3 mm). Moderate AR often shows a larger regurgitant jet width (25-65% of the LVOT diameter) and a vena contracta width of 3-6 mm, with some evidence of left ventricular volume overload. Severe AR presents with a wide regurgitant jet (>65% of the LVOT diameter), a vena contracta width >6 mm, significant diastolic reversal flow in the descending thoracic aorta, and often substantial left ventricular dilatation and dysfunction. Consider implementing a comprehensive echocardiographic protocol incorporating these measurements for accurate AR severity grading. Explore how integrating Doppler and color flow imaging can further enhance assessment accuracy. Learn more about the role of 3D echocardiography in quantifying AR.

Q: How do I manage a patient with asymptomatic severe aortic regurgitation and preserved left ventricular ejection fraction?

A: Managing asymptomatic severe aortic regurgitation (AR) with preserved left ventricular ejection fraction (LVEF) requires careful monitoring and timely intervention. While the patient may be asymptomatic, severe AR places increased stress on the left ventricle, potentially leading to irreversible left ventricular remodeling and heart failure. Current guidelines recommend aortic valve replacement even in asymptomatic patients with severe AR and preserved LVEF when progressive left ventricular enlargement is observed (left ventricular end-systolic dimension >50 mm or left ventricular end-diastolic dimension >70 mm) or if there is evidence of declining LVEF, even if it remains within the normal range. Close clinical and echocardiographic follow-up is crucial. Explore how serial echocardiography can track LVEF, LV dimensions, and other parameters to inform decision-making. Consider implementing a shared decision-making approach with the patient, discussing the risks and benefits of watchful waiting versus early surgical intervention.

Quick Tips

Practical Coding Tips
  • Code I06.1 for AR
  • Document regurgitation severity
  • Specify cause if known
  • Echo findings support I06.1
  • Check for rheumatic link

Documentation Templates

Patient presents with symptoms suggestive of aortic regurgitation (AR), also known as aortic insufficiency.  The patient reports experiencing shortness of breath (dyspnea), particularly with exertion, along with palpitations and occasional chest pain.  Physical examination reveals a widened pulse pressure, a diastolic murmur heard best at the left sternal border, and possible evidence of left ventricular hypertrophy.  These findings raise clinical suspicion for aortic valve disease, specifically aortic regurgitation.  Differential diagnoses include other causes of valvular heart disease such as mitral regurgitation and aortic stenosis, as well as non-valvular heart conditions like cardiomyopathy.  Diagnostic workup will include an echocardiogram to assess the severity of the regurgitation, quantify left ventricular function, and determine the etiology of the valve dysfunction.  Electrocardiography (ECG) will be performed to evaluate for any rhythm disturbances or evidence of left ventricular hypertrophy.  Chest X-ray may be obtained to assess cardiac size and pulmonary vasculature.  Treatment options for aortic regurgitation will depend on the severity of the condition and the patient's symptoms.  Medical management may include medications such as vasodilators and diuretics to control blood pressure and reduce fluid overload.  Surgical intervention, including aortic valve replacement or repair, may be indicated for severe regurgitation or progressive symptoms.  Patient education regarding lifestyle modifications, medication adherence, and follow-up care will be provided.  ICD-10 code I06.1 will be used for billing and coding purposes related to this diagnosis of aortic regurgitation.  Further evaluation and management will be based on the results of the diagnostic studies and the patient's clinical response to therapy.