October 12, 2009

Meet the 2010 ICD-9-CM Codes
By Judy Sturgeon, CCS
For The Record
Vol. 21 No. 19 P. 6

October brings cool weather, crisp leaves, fresh apples—and new ICD-9-CM codes to learn and put to use. While an article listing all of the code additions, modifications, and deletions is as unavoidably dry as sandpaper, it is also as critical as oxygen to those of us in the profession.

The chapter on infectious diseases was ignored for changes in the new fiscal year, but Chapter 2 has new neoplasm choices. Merckel cell carcinoma is a neuroendocrine skin cancer. While relatively rare compared with melanoma, the occurrence is increasing and subsequently has hit the coding radar screen for reporting. In the past, Merckel cell carcinoma could report to the 173 category as skin by site or perhaps get lumped in with carcinoid tumors as a subgroup of the 209 category. Beginning this month, however, this type of cancer has its own designated codes. Primary Merckel cell carcinoma can be found at 209.3x, and secondary neuroendocrine tumors adds a fourth digit under 209.7x.

A nod is given to the metabolic and immune section of Chapter 3: Gouty arthropathy is being assigned fifth digits. This can be further differentiated by the presence of tophi and whether the presenting case is acute or unspecified. Tumor lysis syndrome is assigned its own code as 277.8 (perhaps due to its occurrence with the use of a new, high-risk chemotherapy being added to the procedure section). Another addition in this chapter results from fifth digits being created to separately identify autoimmune proliferative syndrome (279.41).

Only a passing glance was given to Chapter 4, where anemia due to chemotherapy for cancer can now be reported as 285.3. The mental disorders in Chapter 5 were left alone this year. There are a few new codes under nervous system and sense organs: Temporal sclerosis was split from other conditions of brain by 348.81 and 348.89, respectively. Category 359 is adding inclusion body myositis with the fourth and fifth digits .71 and other inflammatory and immune myopathies NEC at 359.79, should they be indescribable elsewhere. Last but not least, acute conjunctivitis can now be specified as due to chemicals by using 372.06 with its new fifth digit.

While the front of the code book has been relatively unscathed, the circulatory system chapter took a significant hit. Deep venous thrombosis (DVT) is being extensively subdivided and redescribed. Be sure to look at category 453. The inferior vena cava is more specifically identified, acute and chronic DVT are distinct, and other specified site is now quite specifiable.

Bird flu and swine flu (H1N1 virus) have become targets not only for headlines but for new codes, too. Confirmed bird flu is designated code 488.0, Influenza due to identified avian influenza virus, and confirmed swine flu becomes 488.1, Influenza due to identified novel H1N1 influenza virus. The only other digestive chapter changes are the creation of fourth and fifth digits under category 569 to report pouchitis and other complications of intestinal pouch as more specific disorders of the intestines.

Genitourinary codes were overlooked with the sole exception of separating 621.34, Benign endometrial hyperplasia, from 621.35, Endometrial intraepithelial. The obstetric chapter garners a higher level of attention this year: Postpartum endometritis has a significant impact on many delivery diagnosis-related groups and is drawing attention commensurate with its financial influence. No longer to be included under category 670, with a default fourth digit of zero for any major puerperal infection, postpartum endometritis, sepsis, and septic thrombophlebitis can now be separately identified from other major puerperal infections.

The code makers were kind to the congenital and perinatal chapters this year. Omphalocele and gastroschisis are uniquely described by new fifth digits. Hypoxic-ischemic encephalopathy can be further reported as mild, moderate, severe, or unspecified. Feeding problems, code 779.3, is being given fifth digits and now distinguishes between feeding problems, bilious and other vomiting, and failure to thrive in neonates.

Chapters 16 (Symptoms) and 17 (Injuries, Poisonings and Adverse Effects) have undergone notable changes for fiscal year 2010. Bilious vomiting is now a critical distinction, as is colic. Emotional symptoms have created enough anxiety to warrant several new codes. Similarly, there is more distinction for abnormal speech symptoms such as dysphonia, hyponasality and hypernasality, and dysarthria. Inconclusive mammogram has its own code. For those coders who have inwardly held their breath every time they had to try and code an apparent life-threatening event diagnosis in an infant, this can now be reported as 799.82.

The E codes for “How did this happen?” previously started in the E800s have been given a complete new section in the front of the chapter. Codes E000.0 thru E030 describe morbidity and mortality caused by war and peace, play and leisure activities, housework, and cooking and gardening. They describe injuries caused by building, construction, playing music, playing or watching sports, and accidents during exercising and caregiving (even animal caregiving). The codes describing direct and indirect war injuries expand their detail on conventional and unconventional warfare, military watercraft and weaponry, explosive technology, and aircraft destruction.

V code changes aren’t earthshaking. Personal history and screening for traumatic brain injuries have made a coding entrance. Other personal history codes include estrogen, steroid, and immunosuppressive therapies. A few family counseling and problem codes have been added, as have codes for fertility preservation, antibody response examinations, and other currently significant encounters (such as adjustment of gastric lap band) with providers.

Diagnosis codes aren’t the only ones affected by the annual overhaul. While procedure codes are not typically affected as widely as those for diseases, a few notable changes have been made in the therapeutic world. There are new third- and fourth-digit miscellaneous procedure codes for implantation of rechargeable cardiac contractility modulation systems or for the systems’ generator only. Codes for laser interstitial thermal therapy by site debut under 17.61 through 17.69, while a new, high-risk intravenous antineoplastic infusion chemotherapy of clofarabine, or Clolar as a brand name, receives code 17.70. (This is a last-resort type of assault on pediatric acute lymphoblastic leukemia when at least two conventional treatments have failed to produce remission.)

Intravascular ultrasound has new technology competition with new codes: 38.24, Intravascular imaging of coronary vessel(s) by optical coherence tomography (OCT), and 38.25, Intravascular imaging of noncoronary vessel(s) by OCT. More fourth digits were created to describe endovascular embolization/occlusion of head and neck vessels via bare or bioactive coils as 39.75 and 39.76, respectively.

And just in case the patient needs to have a colonic stent, endoscopically or otherwise, be aware that 46.8x now has fourth digits 6 and 7 for that purpose.

Current diagnosis and procedure codes that receive new subgroups often have their text revised or the parent code deleted to reflect the new specificity. Remember to avoid assigning codes from memory unless they have been validated against the newest terminology. Some have description changes for clarity: Failure of a device may be changed to broken device, nonessential modifiers may be taken out of parentheses to indicate required terminology, or vice versa. Performance of inappropriate operation has been changed to read Performance of wrong operation (procedure) on correct patient for more detailed reporting of a critical never event. Removal of joint prosthesis codes now specify ‘without replacement’ in order to stay in the 80.0x procedure code range.

Although each year’s ICD-9 changes have their own purpose and origin, the overall direction continues to be predictable. Each change adds specificity as a requirement to assign its code correctly, and each year offers a reduced ability to assign unspecified codes. While ICD-10 may not be speeding toward implementation, neither has its progress been halted. It may continue to be postponed while the involved factions wrestle with issues regarding implementation and expense, but the continuing demand for improved clarity in documentation and increasing detail in ICD-9-CM code descriptions can only help to make any future transition as painless as possible.

— Judy Sturgeon, CCS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.