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No ICD-9 Left Behind
By Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC

The interest in ICD-10-CM training is at a fever pitch with most coders, which is not going to stop until well after the October 1, 2013, implementation date. We are constantly seeing the drive for education careening to ICD-10-CM; however, it makes me wonder why ICD-9-CM is being left behind.

Coders should be intimate with their coding manuals; outpatient coding is not only about CPT coding, but rather it is about abstracting the entire picture through a combination of CPT and ICD-9-CM codes. ICD-9-CM has a complete listing of guidelines just like the CPT manual. Glossing over ICD-9-CM knowledge inhibits coders from fully understanding why diagnosis codes are used or sequenced in a particular way to produce complete claims. A coder should have a well-rounded knowledge of CPT, HCPCS, and ICD-9-CM. This will ensure fewer denials due to ICD-9-CM mismatches with the CPT codes selected.

The basics of ICD-9-CM should be well known; however, let’s review the important steps coders need to take to properly report the diagnosis for the following example.

A patient was admitted after developing severe diarrhea on day 50 following a living donor kidney transplant. A stool sample revealed a significant number of donor lymphocytes due to acute graft-vs.-host (GVH) disease. The physician diagnosed the patient with acute GVH disease.

First, locate the main entry term; in this case, let’s look at GVH disease. Remember, conditions are expressed in the documentation and the index as nouns, adjectives, and eponyms. Multiple synonyms are also used for some conditions, allowing a coder to find the correct code through various lookup methods.

The next step is to look at the code found in the tabular section of the index to confirm correct code selection. Here, you will find the code 279.50. If you look underneath this code, it states that if this is a complication due to organ transplant not elsewhere classified, see Complications, transplant, organ. Even though this is a complication from a kidney transplant, you will still need to report the GVH disease, so turn to the tabular section for code 279.50, where you will find 279.51, which accurately reports the disease documented at the highest specificity.

Before applying 279.51 to the claim, you need to perform one additional step. Most coders forget to look around the code to see if there is any parenthetical information that may affect the coding. Perhaps an additional code is required to report a manifestation or if the code includes or excludes a condition or disease. It might also have the instruction to code the underlying disease first.

This example requires the use of a code such as 996.81, Complication of transplanted organ, kidney. An additional code also is required to specify any associated manifestations. The documentation states that the patient suffers from diarrhea because of the disease and transplantation, so the coder would report 787.91, Diarrhea.

To properly report these codes on a claim, you need to know the proper sequencing guidelines. You can look at the guidelines at the front of the book, under Section I, subsection A, number 6, Etiology/manifestation convention (“code first,” “use additional code,” and “in diseases classified elsewhere” notes) or under subsection B, number 9, Multiple coding for a single condition. There are additional sequencing guidelines listed in the guidelines for specific code sets and again in Section II.

The sequencing for this example is 996.81, 279.51, and 787.91.

Another common mistake coders make when assigning ICD-9-CM codes is overlooking or not using V codes and E codes when appropriate. To code to the highest specificity, you should apply all codes pertinent to the visit. V codes or supplemental codes deal with encounters for circumstances other than disease or injury. The ICD-9-CM manual has extensive guidelines for V codes. It also has guidelines for the use of E codes called external causes codes. The common misconceptions about these codes are that if you don’t receive payment for reporting them, then why should you bother using them. The answer is to ensure payers receive a detailed description of a patient’s current condition.

In short, read the guidelines and understand the process of looking up codes in the ICD-9-CM manual without relying on a cheat sheet or your memory. I say this because as a coder, I have done this, but at what cost? What knowledge are we losing by not using our ICD-9-CM manual every day?

Have you ever been asked to fill in for another coder in a different specialty and found that you cannot figure out how that person found the codes without using a cheat sheet? Or have you taken a new job in a different specialty only to find out that the coders don’t use a cheat sheet and you take too long to locate a code because you have become dependent on memory and a cheat sheet?

Break the cycle now. Put the cheat sheet or billing sheet away and test your ability to look up the codes in the index, confirm them in the tabular section, and then look at the guidelines to confirm the sequencing and other rules about the codes that you want to use. How long did it take? Did it take longer than you imagined? If the answer is yes, then you need to focus on your ICD-9 coding skills. If the answer is no, you should continue to test yourself to keep your skills at the highest level.

If you are comfortable with ICD-9-CM and are able to look up a diagnosis by figuring out what information should be used in code selection, then the transition to ICD-10-CM should not be as rocky as it would be if you were not proficient in ICD-9-CM coding.

For most coders who are wondering what they can do now to prepare for the transition, the answer is simple: Know your anatomy, pathophysiology, and terminology and really study your ICD-9-CM manual.

— Shelly Cronin, CPC, CPMA, CANPC, CGSC, CGIC, is CEU vendor manager for AAPC.