September 17, 2007

ICD-9 Changes: More Than a Blip on the Screen
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 19 P. 12

Those of us who deal with hospital inpatient coding have been completely caught up in the major overhaul being made to the Centers for Medicare & Medicaid Services (CMS) diagnosis-related groups (DRGs). As if dealing with severity-adjusted DRGs isn’t enough, soon we will have to accommodate another data entry field on nearly every inpatient diagnosis code: The present on admission indicator is scheduled to follow the severity-adjusted DRG changes.

With system interfaces to coordinate, staff to be trained, and antianxiety medications to be ingested in large quantities, it may be easy for the new ICD-9-CM code changes to slip under the radar on October 1.

While we’re scrambling to keep up with all the new conversions, let’s take a few minutes to get back to basics. No matter what the CMS does to DRGs, and no matter what is or isn’t present on admission, we still have to begin at the beginning. First, we have to code the encounter. Inpatient or outpatient, clinic or long-term care, the diagnoses will be assigned in ICD-9, as will procedure codes in some patient settings. Let’s examine the more significant changes for this year.

The infectious disease chapter saw some activity alongside potential DRG changes. Infant botulism moves from a perinatal infection code to 040.41, and wound botulism is consolidated from the 872-894 range to 040.42. Three new codes for roseola infantum have arrived, and human herpesvirus is adding fifth digits for both 054.3 and 054.9. Not wanting to be upstaged by activity in the H-branch of the viral family, Parvovirus B19 grew a new fifth digit for the 078 category.

Lymphomas are making waves in the sea of cancer codes. The 200 and 202 categories are further defining the following: marginal zone, mantle cell, primary central nervous system, anaplastic, large cell, and peripheral T-cell lymphomas. Also look for new fifth digits for carcinoma in situ of female genital organs.

Endocrine and metabolic chapter codes are calm. Add a fifth digit to 255.4 to distinguish glucocorticoid deficiency from mineralocorticoid deficiency; add another to 258.0 to separate types of multiple endocrine neoplasias (MEN). Chapter 4 remains nearly untouched, but there are coders who may be excited to see a new code (288.66) specifically for bandemia. This may be particularly useful in cases where antibiotics are administered for the significant lab finding but no specific diagnosis of infection can be made.

The entire chapter for mental disorders has one new code: 315.34 is a new entry among speech/language developmental delays if the cause is hearing loss.

This leads us to the nervous system and sense organs, which are well represented in the new codes. New fifth digits abound, from a code for idiopathic normal pressure hydrocephalus to mixed hearing loss. Encompassed in the range are all kinds of myotonia and hearing loss codes. There’s even a new fifth digit at 364.8 in case there is a need to code floppy iris syndrome in the coming year.

New circulatory chapter codes won’t break your heart, but they’ll better describe its vascular troubles. Cardiac tamponade was pressured into adopting its own code. Should a physician take the time to document a chronic total occlusion of a coronary artery (414.2) or an extremity artery (440.4), we’re ready with the new codes. Septic pulmonary embolism will be 415.12, but septic arterial embolism will be 449 instead of a code from the infectious disease chapter. The CMS coughed up only one respiratory chapter code for 2007: 488 is the new code for influenza due to identified avian influenza virus.

The few new codes in the digestive chapter range from one end to the other. Dental implant failures have a real bite now that they have new fourth and fifth digits for detail, and there is a new code for an anal sphincter tear. Look for exceptions in the pregnancy chapter if the tear is complicating delivery but not associated with third-degree perineal lacerations.

In keeping with the new MEN codes, there are new vulvar intraepithelial neoplasia codes. 624.0 will split into fifth digits to separate vulvar intraepithelial neoplasias from vulvar dystrophy. With that as the exception, the genitourary chapter remains constant for another year.

Skin and subcutaneous tissue have no new codes, nor do congenital anomalies and the perinatal chapter. 733.45 is the only new code in the musculoskeletal world, and it describes aseptic necrosis of the jaw bone. The next new symptom codes may be hard to swallow. Dysphagia will have six possible codes instead of only 787.2, thanks to the fifth-digit phenomena. Beware of the ascites split in 2007: Malignant ascites has been conjoined to other ascites with 789.51 and 789.59, respectively, and should be on your DRG radar and code alerts. This converts malignant ascites from the neoplasm chapter to Chapter 16 along with general symptoms, so expect it to be excluded from principal diagnosis status in applicable instances.

The lone representative for injury and poisoning codes will be fifth-digit distinction for infections due to central venous catheters vs. other types of infusions and injections. V codes are somewhat affected with noteworthy changes for personal and family histories related to the new codes, procreative management using natural family planning, and examinations or screening for human papillomavirus, MEN, and other diseases.

New procedure codes are somewhat minimal for pharmaceuticals and diagnostic procedures on the brain. Thymus and thorascopic lung surgeries are affected. Liver biopsy can be reported specifically as transjugular or laparoscopic as of October. Female pelvic relaxation surgeries will be more specific, and there are going to be new codes for insertions of biological grafts and synthetic prostheses. Spinal repairs are getting more detailed codes; new codes have been created for fluorescence vascular angiography and electron radiation therapy, if they are done intraoperatively.

As always, new codes are accompanied by deleted or revised former codes. For a detailed list of all 2007 ICD-9-CM code additions, deletions, and revisions, visit here.

For a crosswalk from the new codes to previous versions, visit the National Center for Health Statistics Web site here.

If you feel overwhelmed by the added criteria for Medicare severity-DRGs, remember the basics: The coding rules didn’t change. If we keep up with the annual code changes and we do a thorough job on each patient’s chart, the payer’s and provider’s software will correctly assign the DRG. Symptoms still need diagnoses, and they still need to be as specific as possible—no change there either. Procedures still need to be explained in as much detail as possible—another soothing constant in a profession full of turmoil. Fall back on basics, keep your eye on the new codes, and don’t let them slip under your radar.

— 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.