AHA Coding Clinic® for ICD-9 - 2007 Issue 1; Ask the Editor

Attempted Percutaneous Mitral Valvuloplasty and Transseptal Atrial Septum Puncture

The patient is a 74-year-old female, who presented with rheumatic heart-related mitral stenosis with mitral regurgitation. The patient was admitted for percutaneous mitral valvuloplasty. During the procedure, under echocardiographic guidance, the tip of the transeptal needle was placed at the intra-atrial septum and passed across the septum into the left atrium with puncture. At this point the patient developed increased pericardial effusion, deteriorated hemodynamically with lower systolic pressures in the left ventricle, and was given Protamine to reverse the heparin effect. She then underwent pericardiocentesis due to rapid pericardial tamponade and the patient’s hemodynamics markedly improved with correction of the pericardial tamponade. A right and left heart catheterization, as well as a left ventriculography, were carried out prior to the mitral valvuloplasty attempt. However, the mitral valuvuloplasty was not performed. Since procedures are supposed to be coded to the extent in which they were performed, what would be the appropriate code assignments? ...

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