April 30, 2007

Carpe Codem (Seize the Code)
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 9 P. 6

Last summer, coders across the country scanned the new and revised ICD-9-CM codes in preparation for the annual October updates. What may have escaped notice, however, was a change in both the index and tabular instructions for coding diagnoses relating to seizure disorders. For coders in the habit of manually entering the code from memory instead of using the index, this may cause a significant impact on several levels.

Technical
The code for febrile seizures was further subdivided this year. If the febrile seizure is described as simple, or not specified further, 780.31 remains correct. Further description of complex or atypical febrile seizure moves to new code 780.32. But if the patient is described as being in status epilepticus, the code will still be 345.3—grand mal status, epileptic—even if the underlying cause is a fever.

During the past several years, most descriptions for convulsions or seizures were assigned only to the seizure codes and not designated to the category that included problems described as epilepsy. Convulsions, recurrent or repetitive seizures, and seizure disorder were not coded as epilepsy unless the documentation specifically included a word or terms generally associated with epileptic seizures (akinetic, atonic, cortical, Jacksonian, salaam, uncinate). If the cause or description included acute trauma or cerebrovascular disease, the coder may be directed to the cause itself rather than a standard seizure code.

Now, however, the index and tabular directions are significantly different. If the seizure is described as recurrent or as a seizure disorder, code assignment is moved to the 345 category and reports as 345.90—epilepsy, unspecified, without intractable epilepsy. The ICD-9-CM council also changed the text on the 345 category to read “Epilepsy and recurrent seizures” instead of simply “epilepsy,” but the codes themselves still report as epilepsy along with various additional descriptive terms. A fifth digit of 0 or 1 designates the presence or absence of documented intractable status.

Repetitive seizure, on the other hand, does not move to the 345 codes. Perhaps this is a distinction based on the technicality that a person can have repetitive seizures in a single episode, but they would need to happen again on another date to be considered recurrent and therefore epileptic. You might need to keep an eye on your encoder software index for this subterm—not all of them updated to match this seeming contradiction of the ICD-9-CM codebook. And while recurrent seizures codes to the 345 category, recurrent convulsions stays in the old 780 area.

Confused? It gets worse.

There are other descriptors that move convulsions and/or seizure diagnoses to completely different categories, too. For a complete list, see the index of the ICD-9 codebook. Some significant examples include newborn, apoplectic, hysterical, and eclamptic.

Legal
While the Council on ICD-9-CM did change the 345 category text description to include recurrent seizures, this will be cold comfort to the patients whose medical data will now report as epilepsy to anyone legally entitled to view their protected health information. Disclosure of this term may affect the person’s ability to hold a driver’s license, employment, or, in some circumstances, insurance.

For years, coders have been cautioned against reporting a patient as having epilepsy without supporting documentation due to those very concerns (see AHA Coding Clinics for ICD-9-CM, 1992, fourth quarter, pages 23-24, and 1993, first quarter, page 24, and multiple years of Faye Brown’s Coding Handbook [currently page 128 of the 2007 issue]).

Why the sudden changes? Are epilepsy and recurrent seizures synonymous after all?

Validation
The response from a query to the American Hospital Association’s (AHA) Council on ICD-9-CM is reassuring. There has been unrest on several fronts regarding these changes, but the AHA anticipated these concerns and secured the support of the Epilepsy Foundation, the National Association of Epilepsy Centers, the American Academy of Neurology, and the Child Neurology Society in making the code changes.

Financial
Because code assignments have changed, legal and financial concerns aren’t limited to those of the patient—diagnosis-related groups (DRGs) and related payments are affected by the various codes for seizures as well. When calculating DRGs, all three febrile seizure codes qualify as complications or comorbidities (CCs) affected by secondary conditions.

The code 780.39 can also affect DRGs that need CCs. Some epilepsy-range codes, however, are not considered CCs for DRG assignment. Because seizure disorder and recurrent seizures are now assigned to 345.90, they no longer provide a CC for DRGs, although terms such as intractable and grand mal status can move the DRG to a higher level.

If the seizure disorder itself caused a hospital admission, its cause and the code category to which it assigns will help determine the DRG. Nervous system DRGs and DRGs for various infections, newborns, mental disorders, and obstetrics are possible results for different types of seizure documentation.

This, in turn, can create legal issues for the entity that is billing services to a DRG payer if coding rules are not followed and also cause DRGs to be assigned incorrectly. If the payer is part of the Centers for Medicare & Medicaid Services, the Federal False Claims Act may come into play because the provider is “submitting a false claim to the government.” Included in this scenario are possible abuse—or even fraud—fines and penalties for the providers whose coders do not keep up with new rules—an expected part of their professional competency—or who actively choose to disregard those rules.

Documentation
As with many other issues that involve diagnosis and procedure coding, coders ultimately rely on the physician to appropriately document the patient’s course of care. With the inclusion or absence of a single adjective having such a significant effect on DRG payments and patient issues, it is critical to make sure medical staff are educated on annual code changes and their ramifications. If seizure documentation is conflicting or unclear as to whether the diagnosis consists of a single event, is recurrent, or is due to a cause other than epilepsy, the physician must be asked to clarify the patient’s documentation.

Is it a pain? Of course it is. Is it a significantly lesser pain than allowing the issue to be neglected, considering its financial and legal impact? Absolutely. We can at least avoid the consequences of ignorance if we remain diligent in the educational portion of our profession, for coders are not only students but teachers as well.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.