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I38
ICD-10-CM
Endocarditis of Aortic Valve

Learn about aortic valve endocarditis, including infective endocarditis of the aortic valve, and its clinical documentation and medical coding. This resource provides information on diagnosis, treatment, and healthcare considerations for endocarditis of the aortic valve. Understand relevant medical coding terms for accurate clinical documentation and billing.

Also known as

Aortic Valve Endocarditis
Infective Endocarditis of Aortic Valve

Diagnosis Snapshot

Key Facts
  • Definition : Infection of the aortic valve, often caused by bacteria.
  • Clinical Signs : Fever, heart murmur, shortness of breath, fatigue, chills, night sweats.
  • Common Settings : Hospital-acquired, intravenous drug use, pre-existing heart conditions.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC I38 Coding
I33.0

Acute and subacute infective endocarditis

Inflammation of the aortic valve due to infection.

I38

Endocarditis, valve unspecified

Endocarditis affecting an unspecified heart valve.

I05-I09

Acute rheumatic fever and rheumatic heart disease

Conditions that can sometimes lead to or mimic endocarditis.

Code-Specific Guidance

Decision Tree for

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

Is the endocarditis acute?

  • Yes

    Native or prosthetic valve?

  • No

    Native or prosthetic valve?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Infection of the aortic valve.
Infection of the mitral valve.
Infection affecting the heart's inner lining.

Documentation Best Practices

Documentation Checklist
  • Document positive blood cultures specifying organism.
  • Describe valve vegetations seen on echocardiogram.
  • Document clinical symptoms (e.g., fever, murmur).
  • Note any predisposing factors (e.g., IV drug use).
  • Specify acuity (e.g., acute, subacute) and etiology.

Coding and Audit Risks

Common Risks
  • Unspecified Organism

    Coding requires specifying the causative organism (e.g., bacterial, fungal) for accurate reimbursement and clinical data.

  • Native vs. Prosthetic Valve

    Distinguishing native vs. prosthetic valve endocarditis is crucial for proper code assignment and severity reflection.

  • Acute vs. Subacute

    Documenting the acuity (acute or subacute) impacts code selection and reflects the clinical picture for quality reporting.

Mitigation Tips

Best Practices
  • Document valve affected (aortic) & laterality for accurate ICD-10 coding.
  • Specify organism if known & document blood cultures for optimal CDI.
  • Detail echo findings: vegetations, abscesses, regurgitation for MS-DRG assignment.
  • Thoroughly document antibiotic treatment & duration for compliance audits.
  • Query physician for clarity if documentation is unclear per CDI best practice.

Clinical Decision Support

Checklist
  • 1. Verify two major Duke criteria or one major and three minor criteria documented.
  • 2. Review positive blood cultures for causative organism (e.g., Streptococcus, Staphylococcus).
  • 3. Check echocardiogram report for vegetations or new valvular regurgitation.
  • 4. Document predisposing factors (e.g., IV drug use, prosthetic valve, prior endocarditis).

Reimbursement and Quality Metrics

Impact Summary
  • Impact: Accurate coding (ICD-10-CM I33.0, I38) maximizes reimbursement for endocarditis treatment.
  • Impact: Proper documentation of aortic valve endocarditis impacts quality metrics like severity scores.
  • Impact: Coding errors can lead to claim denials, affecting hospital revenue cycle management.
  • Impact: Precise coding supports data analysis for endocarditis infection control and prevention efforts.

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Frequently Asked Questions

Common Questions and Answers

Q: What are the key echocardiographic findings suggestive of aortic valve endocarditis in a patient with suspected infective endocarditis?

A: Echocardiography plays a crucial role in diagnosing aortic valve endocarditis. Key findings suggestive of this condition include vegetations on the aortic valve, which appear as oscillating masses attached to the valve leaflets. These vegetations may be visualized on transthoracic echocardiography (TTE), but transesophageal echocardiography (TEE) often provides better visualization, especially in cases of smaller vegetations or prosthetic valve endocarditis. Other echocardiographic signs include valve leaflet perforation, abscess formation around the aortic valve annulus, and new or worsening aortic regurgitation. Explore how a multimodality imaging approach, combining TTE and TEE, can improve diagnostic accuracy in challenging cases. Consider implementing a standardized echocardiography protocol for patients with suspected infective endocarditis to ensure consistent and thorough evaluation.

Q: How do I differentiate between native aortic valve endocarditis and prosthetic aortic valve endocarditis based on clinical presentation and diagnostic workup?

A: Differentiating between native aortic valve endocarditis (NAVE) and prosthetic aortic valve endocarditis (PAVE) can be challenging, as both present with overlapping symptoms such as fever, chills, and heart murmurs. However, PAVE often presents earlier after valve surgery (within 1 year) and may have more insidious onset, while NAVE typically occurs in patients with pre-existing valvular abnormalities. Blood cultures are essential in both cases, but negative cultures are more common in PAVE. Echocardiography, especially TEE, is critical for visualizing vegetations and perivalvular complications. In PAVE, periannular abscesses are more common. Learn more about the specific microbiological profiles associated with NAVE and PAVE, as this can inform antibiotic choices. Consider implementing a structured approach to evaluating patients with suspected aortic valve endocarditis that considers both native and prosthetic valve etiologies.

Quick Tips

Practical Coding Tips
  • Code I33.0 for acute aortic valve endocarditis
  • Code I38 for chronic aortic valve endocarditis
  • Document infection organism for specificity
  • Query physician if cause is rheumatic
  • Check documentation for valve involvement

Documentation Templates

Patient presents with clinical features suggestive of aortic valve endocarditis.  Symptoms include fever, chills, night sweats, fatigue, and new onset murmur consistent with aortic regurgitation.  The patient reports a history of intravenous drug use, a significant risk factor for infective endocarditis.  Blood cultures have been drawn and are pending.  Transthoracic echocardiogram (TTE) was performed and revealed vegetations on the aortic valve, further supporting the diagnosis.  Differential diagnosis includes rheumatic heart disease, congenital aortic valve abnormalities, and non-infective thrombotic endocarditis.  The patient is currently being treated empirically with intravenous antibiotics for presumed infective endocarditis of the aortic valve.  Further investigations, including a transesophageal echocardiogram (TEE) and assessment for embolic complications, are planned.  The patient's condition is being closely monitored for signs of heart failure, stroke, and other complications of endocarditis.  ICD-10 code I33.0, acute and subacute infective endocarditis of the aortic valve, is documented. Treatment plan will be adjusted based on culture results and response to antibiotic therapy.  Prognosis and long-term management will be discussed with the patient following completion of the initial treatment course.