In simple words: The mitral valve in your heart is both stiff and leaky due to damage from rheumatic fever, a complication of strep throat.

This code represents a condition where the mitral valve of the heart, which separates the left atrium and left ventricle, is both narrowed (stenosis) and leaky (insufficiency/regurgitation) due to rheumatic heart disease. Rheumatic heart disease is a consequence of rheumatic fever, typically caused by a streptococcal infection.

Example 1: A 55-year-old patient presents with shortness of breath and fatigue. Upon examination, a heart murmur is detected, and an echocardiogram reveals both mitral stenosis and regurgitation. The patient's medical history indicates prior rheumatic fever, confirming the diagnosis of I05.2., A patient with a known history of rheumatic heart disease experiences worsening shortness of breath on exertion. They undergo cardiac catheterization, which reveals significant mitral stenosis and moderate mitral regurgitation, further supporting the I05.2 diagnosis., A patient with I05.2 is admitted to the hospital with symptoms of heart failure. Treatment for heart failure is initiated, and the patient is monitored closely. They may require ongoing medication or surgical intervention to address the valve dysfunction.

Documentation for I05.2 should include evidence of rheumatic fever history (e.g., documented prior diagnosis, evidence of past streptococcal infection), physical exam findings (e.g., heart murmur), and imaging results (e.g., echocardiogram, cardiac catheterization) demonstrating both mitral stenosis and insufficiency. Severity of the stenosis and regurgitation should also be documented.

** This information is current as of November 30, 2024.Coding guidelines and regulations can change, so it is essential to refer to the most up-to-date resources for accurate and compliant medical billing.