Vol. 16 •Issue 21 • Page 28
ICD-9-CM changes make a Big Impact
The changes to 2007 ICD-9 begin to pave the way to ICD-10.
Another year of health care change is upon us, only this time we are going to be facing significant changes to ICD-9-CM codes and the inpatient prospective payment system (IPPS) together. This article will provide a highlight of the new ICD-9-CM codes for FY 2007 and identify what the HIM profession should be doing to cope with these latest changes.
The Centers for Medicare and Medicaid Services (CMS) released its 2007 proposed changes for ICD-9-CM on April 25, 2006. The theme of greater specificity by adding a fifth digit was a clear indication we are moving in the direction of ICD-10.
The final rule was published in the Federal Register on Aug. 1, 2006, and it contained the details on all the coding changes, some which were not published in the proposal rule. The department of Health and Human Services (HHS), under CMS has all the code changes listed in files that you can access and download. The Web site is: www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp.
Here’s a quick summary:
Coders should remember that these new codes are effective with encounters and discharges as of Oct. 1, 2006. There is no grace period for use of these codes. Also, within the final rule were the IPPS changes and several charts and graphs about the diagnostic related group (DRG) revisions, additions and deletions, which included Consolidated Severity-Adjusted DRGs.
Chapters 1 and 2
In looking more closely at the new ICD-9-CM codes, we first find new codes for Postvaricella myelitis also including Postchickenpox myelitis with code 052.2. In this chapter of ICD-9-CM, we also have two other new codes; 053.14, Herpes zoster myelitis and 054.74, Herpes simplex myelitis. These new codes were established to better identify the causal infections related to myelitis. These codes were created based upon a proposal by the American Academy of Neurology. When coding these conditions the coder should look in the Alpha section of the ICD-9-CM book under Myelitis, postvaricella or under Myelitis, herpes. This will lead you to the Tabular Chapter 1 for Infectious and Parasitic Diseases (codes 001-139).
Within Chapter 2 are diagnosis codes representing Neoplasms (140-239), and there are several new codes for 2007 to identify specific blood disorders; here is a short list of some of these new codes:
238.71 Essential thrombocythemia
238.72 Low grade myelodysplastic syndrome lesions
238.73 High grade myelodysplastic syndrome lesions
238.74 Myelodysplastic syndrome with 5q deletion
238.75 Myelodysplastic syndrome, un-specified
238.76 Myelofibrosis with myeloid metaplasia
238.79 Other lymphatic and hematopoietic tissues
Chapters 3 and 4
New codes in Chapter 3 representing Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders (240-279) were established; 277.30, Amyloidosis, unspecified, 277.31, Familial Mediterranean fever and code 277.39, Other amyloidosis.
In Chapter 4, Diseases of the Blood and Blood-Forming Organs (280-289), coders will find new codes for: 284.01, Constitutional red blood cell aplasia, 284.09, Other constitutional aplastic anemia, 284.1, Pancytopenia, and code 284.2, Myelophthisis.
Also, the condition of Neutropenia has new codes. Starting with new code, 288.00, Neutropenia, unspecified. Neutropenia is a hematological disorder characterized by an abnormally low number of neutrophil granulocytes (a type of white blood cells). Neutrophils serve as the primary defense against infections by destroying bacteria in the blood. These new codes will be useful for better comparison to differentiate the various blood disorders and to consistently classify them between ICD-9-CM and ICD-10.
Additional new codes for blood disorders were developed in the 288.4, 288.5 and 288.6 categories and new codes 289.53 for Neutropenic splenomegaly. The final new code for this chapter is 289.83 for myelofibrosis. Coders should note the instructional term indicating to code first the underlying disorder. To distinguish myelofibrosis from myeloproliferative disorders and myelodysplastic syndromes, which are recognized as hematological malignancies, a unique code for myelofibrosis was created.
The American Academy of Neurology requested unique codes for capturing encephalitis, encephalomyelitis and myelitis. This will provide better data for tracking patient outcomes. These new codes can be found in Chapter 6, Diseases of the Nervous System and Sense Organs (320-389). Be sure to make note: There were no new ICD-9-CM codes in Chapter 5, Mental Disorders (290-319), for Oct. 1.
There are other new codes in Chapter 6 including the expansion of code 333.7 for Acquired torsion dystonia to better capture athetoid cerebral palsy, code 333.72 for Acute dystonia due to drugs and Other acquired torsion dystonia with ICD-9-CM code 333.79. In addition, codes 333.85, Subacute dyskinesia due to drugs and 333.94, Restless Legs Syndrome (RLS) are new for 2007. A large series of new codes for the classification of “pain” was added, which will be very helpful for those who work in or with pain management services. Clinical documentation may need to be improved to capture these specific conditions in acute and chronic pain.
The American Academy of Ophthal-mology (AAO) requested a unique code in Chapter 6, Diseases of Nervous System and Sense Organs. The code 377.43 Optic nerve hypoplasia is an underdevelopment of the optic nerve (and that’s the nerve that carries signals from the retina to the brain), and coders might see this documented as abbreviation “ONH.”
Also recommended by the AAO are new codes to classify inflammation of post-procedural bleb, which was previously coded to 379.99, Other ill-defined disorders of eye. A new 379.6 subcategory was established for the different stages of inflammation of a postprocedural bleb. It could also be documented as postprocedural blebitis. It is a complication of surgery, but it is not considered as such in ICD-9-CM, so coders should not use a 900 complication code for this. It can lead to very serious eye infections, which causes loss of vision. When eye surgery is performed, they sometimes will leave a drain in and this is usually after glaucoma surgery. If a bacterial organism gets anywhere near this drain, it is easily invaded and can develop an infection or inflammation.
There are four new codes:
379.60 Inflammation (infection) of postprocedural bleb, unspecified
379.61 Inflammation (infection) of postprocedural bleb, stage 1
379.62 Inflammation (infection) of postprocedural bleb, stage 2
379.63 Inflammation (infection) of postprocedural bleb, stage 3
The different stages (1, 2, 3) and unspecified refer to the amount of associated purulence and inflammation, plus the type of treatment necessary to treat the infection. For example, a stage 1 bleb would have minimal inflammation and would easily be treated with topical antibiotics while a stage 3 would be much more severe requiring antibiotic injection into the subconjunctiva.
A single new code in Chapter 7, Diseases of the Circulatory System (390-459), was created to capture a condition called “Takotsubo syndrome” with code 429.83. Takotsubo syndrome could also be listed as broken heart syndrome or stress induced cardiomyopathy or ventricular dysfunction.
On Oct. 1, 2005, this condition, as well as the equivalent term “apical ballooning syndrome” was indexed to code 429.89, Other ill-defined heart diseases. Due to the recent increase in occurrence of this condition, the National Center for Health Statistics (NCHS) recommends creating a unique code for this syndrome. Takotsubo syndrome is a reversible left ventricular dysfunction in patients without coronary disease precipitated by emotional or physiological stress. Stress triggers adrenalin that shocks the heart, which renders it temporarily weakened.
We don’t know if broken hearts occur more in women than men, but this condition is definitely diagnosed more frequently in women than men. Despite the absence of obstructive coronary artery disease, patients commonly present with ST-segment elevation in the precordial leads, chest pain, relatively minor elevation of cardiac enzymes and transient apical systolic left ventricular dysfunction, but no proven ischemia. Patients with this syndrome are usually monitored and treated accordingly.
Chapters 8 and 9
Within Chapter 8, Diseases of Respiratory System (460-519), coders will find an expansion of category 478 with a new fifth digit for code 478.11, Nasal mucositis (ulcerative). There is an instructional note to use an additional E code to identify adverse effects of therapy, such as: Antineoplastic and immunosuppressive drugs (E930.7, E933.1), and Radiation therapy (E879.2). The other new code is 478.19, Other disease of nasal cavity and sinuses, which also includes abscess of nose (septum), necrosis of nose (septum), ulcer of nose (septum), cyst or mucocele of sinus (nasal) and rhinolith. Prior to October 2006, all of these conditions were assigned to 478.1, Other disease of nasal cavity and sinuses.
Three other new codes in this chapter are: 518.7, Transfusion related acute lung injury (TRALI), 519.11, Acute bronchospasm, which includes Bronchospasm NOS, and 519.19, Other diseases of trachea and bronchus, which includes the following: Calcification of bronchus or trachea, Stenosis of bronchus or trachea and Ulcer of bronchus or trachea.
There are several new codes this year in ICD-9-CM Chapter 9, Diseases of the Digestive System (520-579), including a series of new dental codes to identify cracked tooth, acute and chronic gingivitis, aggressive, acute and chronic periodontitis, and unsatisfactory restoration of tooth (range 525.6x).
Several new codes in the 538.0x series starting with code 528.00 for Stomatitis and mucositis, unspecified also includes: Mucositis NOS, Ulcerative mucositis NOS, Ulcerative stomatitis NOS and Vesicular stomatitis NOS. New code 528.01, Mucositis (ulcerative) due to antineoplastic therapy has an instructional note to use an additional E code to identify adverse effects of therapy, such as: antineoplastic and immunosuppressive drugs (E930.7, E933.1) and/or radiation therapy (E879.2). Then new code 528.02, Mucositis (ulcerative) due to other drugs, also has an instructional note to “use additional E code to identify drug” and code 528.09, Other stomatitis and mucositis (ulcerative).
Currently unique codes for mucositis do not exist and were indexed, Mucositis “see inflammation by site,” which does not allow the condition to be readily identified. Loyola University Medical Center requested these new codes to be able to track and measure resource utilization as well as determine the cost effectiveness of treatment.
These conditions are commonly in patients who are undergoing chemo or radiation therapy treatments.
Chapters 10 and 11
Code expansion for the 608.2 series was requested by the American Urological Association (AUA) to better capture specific conditions relating to the testis. Locate these new codes by first going to the Alpha and looking under the word(s): Torsion, appendix, testis; Torsion spermatic cord; or Torsion testicle. This leads you to the Tabular index and Chapter 10, Diseases of Genitourinary System (580-629).
The five new codes are listed below:
608.20 Torsion of testis, unspecified
608.21 Extravaginal torsion of spermatic cord
608.22 Intravaginal torsion of spermatic cord
608.23 Torsion of appendix testis
608.24 Torsion of appendix epididymis
Also within this chapter are other new codes ranging from Mucositis to Other specified disorders of the female genital organs: 616.81, 616.89, 618.84, 629.29, 629.29, 629.81, 629.89.
The American College of Obstetricians and Gynecologists (ACOG) requested several new OB codes to help capture conditions that complicate pregnancy in Chapter 11, Complications of Pregnancy, Childbirth and the Puerperium (630-677). We start with codes relating to tobacco use during pregnancy; code range 649.00-649.04. The next new codes identify obesity complicating pregnancy with code range 649.10-649.14; you would not also code 278.00, but if documented morbid obesity, then add the code 278.01. Also, coders should note the subcategory excludes excessive weight gain in pregnancy (646.1), so this would be coded in addition.
Then new codes to capture patients who’ve had bariatric surgery in the past and are now pregnant have been created, titled Bariatric surgery status complicating pregnancy, childbirth or the puerperium, code range 649.20-649.24. The next new codes are for Coagulation defects complicating pregnancy, childbirth or the puerperium with a code range of 649.30-649.34; then Epilepsy complicating pregnancy, childbirth or the puerperium code range 649.40-649.44; and Spotting complicating pregnancy codes 649.50-649.53.
The final new code in this series is for capturing uterine size date discrepancy with ICD-9-CM codes 649.60-649.64; this code would not be used to indicate fetal size discrepancy.
With no new codes in Chapters 12, Diseases of the Skin and Subcutaneous Tissue (680-709), we move on to Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue (710-739). Here we find some new codes for nontraumatic compartment syndrome, note this is “nontraumatic” 729. Previously, nontraumatic compartment syndrome was classified to one code: 729.9.
Under the previous classification there was no way to distinguish the anatomical site. It has now been moved to the 729.7 category and has been expanded to the fifth digit for anatomic sites of upper extremity, lower extremity, abdomen and “other.”
Compartment syndrome is a painful condition resulting when pressure in a muscle increases to dangerous levels and the muscle fascia does not expand or stretch easily. In addition, the pressure prevents oxygen-rich blood and nutrients from reaching the muscle cells and the nerve and muscle cells can die and cause loss of limb, paralysis or death. This code expansion will allow better data collection regarding anatomic site.
No new codes in Chapter 14, Congenital Anomalies (740-759), this year but there are some interesting ones for Chapter 15, Certain Conditions Originating in the Perinatal Period (760-779). The American Academy of Pediatrics requested these new codes were created to update the language related to encephalopathic problems with newborns and to identify these potentially devastating conditions accurately. These codes were discussed at the March 2006 Coordination and Maintenance Committee meeting and as such, were not included in the “proposed rule” when it was published.
The new codes are:
768.7 *Hypoxic-ischemic encephalopathy (HIE)
770.87 *Respiratory arrest of newborn
770.88 *Hypoxemia of newborn
775.81 *Other acidosis of newborn
775.89 *Other neonatal endocrine and metabolic disturbances
779.85 *Cardiac arrest of newborn
In Chapter 16, Symptoms, Signs and Ill-Defined Conditions (780-799) you will find several new codes: 780.32, 780.96, 780.97, 784.91, 784.99, 788.64, 788.65, 793.91, 793.99, 795.06, 795.81, 795.82, 795.89.
Of the above new codes, I think coders will find code 780.97, Altered mental status a useful code. This code should not be assigned per the excludes note in the tabular: if the patient has an altered level of consciousness see codes 780.01-780.09, or altered mental status due to known condition, you should code to the condition and if stated as delirium, assign code 780.09 NOS.
A new subcategory and new codes were also created for traumatic and unspecified compartment syndrome. With these new codes, from Chapter 17, Injury and Poisoning, traumatic compartment syndrome can now be separated from nontraumatic.
To locate these codes the coder will reference the alpha under the term “syndrome” then “compartment” or enter these terms when keying into the encoder. Remember the physician documentation MUST support the code assignment. From an inpatient coding perspective, this condition falls under MDC 21 when it is assigned as the principal diagnosis, which represents Injury, Poisoning and Toxic Effects of Drugs. As a principal diagnosis they will group to DRG 454/455 Other Injury, Poisoning and Toxic Effect Diagnoses with and without CC (comorbid or complication). When assigned as a secondary diagnosis, these codes will not be c/c conditions.
There are some additional new codes in the 995 series:
995.20 Unspecified adverse effect of unspecified drug, medicinal and biological substance
995.21 Arthus phenomenon
995.22 Unspecified adverse effect of anesthesia
995.23 Unspecified adverse effect of insulin
995.27 Other drug allergy
995.29 Unspecified adverse effect of other drug, medicinal and biological substance
Coders should review the tabular index for the above new codes.
The final set of new codes is in the V codes section, found in the Chapter for Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01-V85).
The new V codes for “encounter” will be helpful in the outpatient and Home Health settings; codes V58.30, V58.31 and V58.32.
Summary and Action
Some key action items that HIM professionals should do prior to and during the first 30-60 days of implementing these new codes include obtaining or providing education to your coding staff and others who use these code. Obtain new ICD-9-CM coding books, update your coding software and review the new codes and determine if there will be documentation issues. I strongly recommend that physicians be made aware of the new codes and the revisions, of which there are several (i.e., Chronic Renal Disease 403 and 404 code series).
I find it also helpful to create some tip sheets for coders and physicians to remind them of specific code changes. Post these tip sheets, which can be in the form of a flyer or poster. One final action to take is read over the American Hospital Association Coding Clinic 4th Quarter publication, as this often has instructional guidelines regarding new code usage and will be very helpful to coders.
A good place for HIM coding professionals to learn about proposed new codes is to attend the Coordination and Maintenance Committee meeting in Baltimore each year. These meetings are free and open to the public and a wealth of clinical and coding information can be obtained.
The final addendum providing complete information on changes to the diagnosis part of ICD-9-CM is posted on Centers for Disease Control and Prevention’s Web site www.cdc.gov/nchs/icd9.htm. Also, visit www.advanceweb.com/him for a complete list of all diagnoses codes and descriptions.
2. CMS IPPS Proposed Rule FY07
3. CMS IPPS Final Rule FY07, ICD-9-CM Coordination & Maintenance Committee Minutes 2003, 2004 and 2005.
Gloryanne Bryant is the corporate director of coding, HIM Compliance, for Catholic Healthcare West, located in San Francisco. She can be reached at [email protected].