ICD-9-CM Update

ION

SEPTEMBER, 2008

Disclaimer

This presentation is an abbreviated seminar for practices. Other codes may apply. Please review a complete list at

Please get a new code book each year to allow for reference.

This presentation is good for the date of the presentation only. Typos may be evidenced herein. It is not coding or legal advice.

All code changes can be found at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/

Oncology ICD-9-CM Introduction (AMA CC) Chapter 2 of the ICD-9-CM contains the code for most benign and all malignant

neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. Malignant is generally the only one paid for chemo.

If malignant, any secondary (metastatic) sites should also be determined.The Neoplasm Table in the Alphabetic Index should be referenced first. If the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column is appropriate. For example, if the documentation indicates Adenoma,refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to see also neoplasm, by site, benign.

The Table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the Table that corresponds to the type listed in the record.

ICD-9-CM for Cancer The Neoplasm Table from AHA(Cont’d)

The tabular should then be referenced to verify that the correct code has been selected and that a more specific site code does not exist.

If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed

toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines:

1. When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy.

2. When the admission/encounter is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by the appropriate code(s) for the malignancy.

3. When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.

4. When the admission/encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy, the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.

Issues in ICD-9-CM History of

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code. (Effective 12/01/05)

ICD-9-CM Issues Admissions/Encounters involving chemotherapy and radiation therapy

When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by chemotherapy or radiation treatment, the neoplasm code should be assigned as principal or first-listed diagnosis.

When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal or first- listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.

If a patient admission/encounter is solely for the administration of chemotherapy or radiation therapy code V58.0, Encounter for radiation therapy, or V58.1, Encounter for chemotherapy, should be the first-listed or principal diagnosis. If a patient receives both chemotherapy and radiation therapy both codes should be listed, in either order of sequence

ICD-9-CM Issues

Rule Out Diagnoses (“Rule Out Lung Cancer”) Never code this as definitive, unless you have clinical evidence. Codes that describe symptoms and signs, as opposed to

diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-defined conditions (codes 780.0 - 799.9) contain many, but not all codes for symptoms.

ICD-9-CM Guidelines NCHS

Coding and sequencing of complications Coding and sequencing of complications associated with the malignancies or with the therapy:1) Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code 285.22, Anemia in neoplastic disease) is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy. Code 285.22 may also be used as a secondary code if the patient suffers from anemia and is being treated for the malignancy. ICD-9-CM Official Guidelines for Coding and Reporting Effective December 1, 2005 Page 18 of 77 2) Anemia associated with chemotherapy, immunotherapy and radiation therapy When the admission/encounter is for management of an anemia associated with chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by code E933.1. The appropriate neoplasm code should be assigned as an additional code. 3) Management of dehydration due to the malignancy When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.

4) Treatment of a complication resulting from a surgical procedure When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the

principal or first-listed diagnosis if treatment is directed at resolving the complication.

ICD-9-CM Guidelines 12/10/05 from NCDVS

Code Sequencing V58.0, Radiotherapy, and codes from subcategory V58.1x,

Encounter for chemotherapy and immunotherapy for neoplastic conditions. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1x may be used together on a record with either one being sequenced first.

V58.1x Here is the scoop from the ICD-9-CM Maintenance Committee.

V58.11 Encounter for antineoplastic chemotherapyV58.12 Encounter for immunotherapy for neoplastic condition

“ Immunotherapy also called immune therapy and biologic therapy is a treatment that stimulates the body’s immune defense system to fight infection and disease. It is not classified as chemotherapy. Unlike traditional cytotoxic chemotherapies that attack cancer cells themselves, immunotherapy is designed to enhance the body’s defenses by mimicking the way natural substances activate the immune system.  These can stimulate the growth and activity of cancer-killing cells, e.g.interleukin used in the treatment of malignant melanoma and renal cell carcinoma.”

ICD-9-CM Changes

What drugs are immunotherapy? This is as follows: "The Food and Drug

Administration has approved several immunotherapies for use against specific cancer, including Bacille Calmette-Guerin (BCG), interferon-alfa (IFN-alfa), interleukin-2 (IL-2), and other monoclonal antibodies."

V58.1x

Monoclonal Antibodies in Cancer Rituxan (Rituximab) Herceptin (Transtuzumab) Mylotarg (Gemtuzumab ozogamicin) Campath (Alemtuzumab) Zevalin (Ibritumomab tiuxetan) Bexxar (Tositumomab) Erbitux (Cetuximab) Avastin (Bevacizumab) Vectibix (Panitumumab)

Non-Hodgkin’s Lymphoma

The main cell found in lymphoid tissue is the lymphocyte, an infection-fighting white blood cell, of which there are two main types, B lymphocytes (B cells) and T lymphocytes (T cells). B cell lymphomas account for 85% of the non-Hodgkin's lymphoma cases in the United States. There is no known cause for non-Hodgkin's lymphoma but there may be a relationship between the condition and bacterial or viral infection

Treatment generally depends on the behavior of the disease (indolent, aggressive, or very aggressive). There are thirty (30) subtypes of Non-Hodgkin's lymphoma.

Source: AHA Coding Clinic

Non-Hodgkin’s Lymphoma Marginal zone lymphomas (200.3) are slow growing B cell tumors that are categorized

based on whether they occur outside the lymph nodes or within the lymph node. Mucosa-associated lymphoid tissue (MALT) lymphomas for example, are extra-nodal marginal zone lymphomas that occur in the gastrointestinal tract, eyes, thyroid, salivary glands, lungs, and skin. Nodal marginal zone B cell lymphomas involve the lymph nodes but are uncommon. Splenic marginal lymphomas involve the spleen, bone marrow and blood. Treatment for marginal zone lymphomas depends on type, location and presentation.

Mantle cell lymphoma (200.4) is an aggressive Non-Hodgkin's B cell lymphoma that accounts for about 6% of all Non-Hodgkin's lymphoma cases in the United States. It is frequently diagnosed as a stage 4 disease found in the gastrointestinal tract, bone marrow, and the lymph nodes above and below the diaphragm. The chemotherapeutic approach using R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) is a common treatment. Mantle cell lymphoma is difficult to treat but combinations of chemotherapy, biological therapies and other regimens show promise in improving survival.

Source: AHA Coding ClinicThird Quarter, 2007

Non-Hodgkin’s Lymphoma Primary central nervous system (CNS) lymphoma (200.5) is found in the brain and spinal

cord. A weakened immune system increases the risk for this aggressive lymphoma. It is common in patients with acquired immunodeficiency syndrome (AIDS), history of kidney transplant and other immunocompromised conditions. Tumors are usually limited to the cranial-spinal axis and to the eye without systemic involvement. Radiation therapy has been the standard treatment due to the diffuse nature of this lymphoma.

Large cell lymphomas (200.7) are the most common type of Non-Hodgkin's lymphoma. They are aggressive and occur in the lymph node and extranodal sites such as the gastrointestinal tract, testes, thyroid, skin, breast, central nervous system and bone. Large cell lymphomas comprise 20% to 25% of childhood lymphomas. High-dose chemotherapy and stem cell/bone marrow transplant have increased survival rates.

Anaplastic large T cell lymphoma (200.6) and peripheral T cell lymphoma (202.7) are common T cell lymphomas. Anaplastic large T cell lymphomas can be cutaneous or systemic. Cutaneous anaplastic large cell lymphomas appear on the skin and grow slowly. They respond well to radiation and surgery. Chemotherapy is used occasionally. Systemic anaplastic large cell lymphoma may appear throughout the body and frequently affect the skin, bone, soft tissue and lung. Although aggressive, these lymphomas respond to chemotherapy. Peripheral T cell lymphomas represent a diverse group of lymphomas that are aggressive. They often require salvage treatment and transplant, yet respond well to treatment.

Cancer ICD-9-CM Codes 10/1/08 199.2 Malignant neoplasm associated with transplant organ 203.02 Multiple myeloma, in relapse 203.12 Plasma cell leukemia, in relapse 203.82 Other immunoproliferative neoplasms, in relapse 204.02 Acute lymphoid leukemia, in relapse 204.12 Chronic lymphoid leukemia, in relapse 204.22 Subacute lymphoid leukemia, in relapse 204.82 Other lymphoid leukemia, in relapse 204.92 Unspecified lymphoid leukemia, in relapse 205.02 Acute myeloid leukemia, in relapse 205.12 Chronic myeloid leukemia, in relapse 205.22 Subacute myeloid leukemia, in relapse 205.32 Myeloid sarcoma, in relapse 205.82 Other myeloid leukemia, in relapse 205.92 Unspecified myeloid leukemia, in relapse 206.02 Acute monocytic leukemia, in relapse 206.12 Chronic monocytic leukemia, in relapse 206.22 Subacute monocytic leukemia, in relapse 206.82 Other monocytic leukemia, in relapse 206.92 Unspecified monocytic leukemia

Cancer ICD-9-CM Codes 10/1/08 207.02 Acute erythremia and erythroleukemia, in relapse 207.12 Chronic erythremia, in relapse 207.22 Megakaryocytic leukemia, in relapse 207.82 Other specified leukemia, in relapse 208.02 Acute leukemia of unspecified cell type, in relapse 208.12 Chronic leukemia of unspecified cell type, in relapse 208.22 Subacute leukemia of unspecified cell type, in relapse 208.82 Other leukemia of unspecified cell type, in relapse

208.92 Unspecified leukemia, in relapse

Cancer ICD-9-CM Codes 10/1/2008 209.00 Malignant carcinoid tumor of the small intestine, unspecified portion 209.01 Malignant carcinoid tumor of the duodenum 209.02 Malignant carcinoid tumor of the jejunum 209.03 Malignant carcinoid tumor of the ileum 209.10 Malignant carcinoid tumor of the large intestine, unspecified portion 209.11 Malignant carcinoid tumor of the appendix 209.12 Malignant carcinoid tumor of the cecum 209.13 Malignant carcinoid tumor of the ascending colon 209.14 Malignant carcinoid tumor of the transverse colon 209.15 Malignant carcinoid tumor of the descending colon 209.16 Malignant carcinoid tumor of the sigmoid colon 209.17 Malignant carcinoid tumor of the rectum 209.20 Malignant carcinoid tumor of unknown primary site 209.21 Malignant carcinoid tumor of the bronchus and lung 209.22 Malignant carcinoid tumor of the thymus 209.23 Malignant carcinoid tumor of the stomach 209.24 Malignant carcinoid tumor of the kidney 209.25 Malignant carcinoid tumor of foregut, not otherwise specified 209.26 Malignant carcinoid tumor of midgut, not otherwise specified 209.27 Malignant carcinoid tumor of hindgut, not otherwise specified 209.29 Malignant carcinoid tumor of other sites

New Cancer ICD-9 Codes 10/1/2008 209.30 Malignant poorly differentiated neuroendocrine carcinoma, any site 238.77 Post-transplant lymphoproliferative disorder (PTLD) 289.84 Heparin-induced thrombocytopenia (HIT) 999.81 Extravasation of vesicant chemotherapy 999.82 Extravasation of other vesicant agent 999.88 Other infusion reaction 999.89 Other transfusion reaction V07.51 Prophylactic use of selective estrogen receptor modulators (SERMs) V07.52 Prophylactic use of aromatase inhibitors

V07.59 Prophylactic use of other agents affecting estrogen receptors and estrogen levels

V13.51 Personal history of pathologic fracture V87.41 Personal history of antineoplastic chemotherapy V87.42 Personal history of monoclonal drug therapy V87.49 Personal history of other drug therapy

And, there may be more…

Other ICD-9-CM Changes

Secondary Diabetes Mellitus (249.xx) New types of headaches (339.xx) A gaggle of new PAP and anal smear codes

(795.xx-796.xx) V87.xx for exposure to toxic (and potentially

carcinogenic) substances

Funniest 2009 ICD-9-CM Codes

339.43 Primary Thunderclap Headache 339.82 Headache Associated With Sexual Activity 339.85 Primary Stabbing Headache 372.74 Pingueculitis 611.81 Ptosis of Breast 796.77 Satisfactory Anal Smear, But Lacking

Transformation Zone

Changed Codes of Note 203.00 Multiple myeloma, without mention of having achieved remission 203.10 Plasma cell leukemia, without mention of having achieved remission 203.80 Other immunoproliferative neoplasms, without mention of having achieved remission 204.00 Acute lymphoid leukemia, without mention of having achieved remission 204.10 Chronic lymphoid leukemia, without mention of having achieved remission 204.20 Subacute lymphoid leukemia, without mention of having achieved remission 204.80 Other lymphoid leukemia, without mention of having achieved remission 204.90 Unspecified lymphoid leukemia, without mention of having achieved remission 205.00 Acute myeloid leukemia, without mention of having achieved remission 205.10 Chronic myeloid leukemia, without mention of having achieved remission 205.20 Subacute myeloid leukemia, without mention of having achieved remission 205.30 Myeloid sarcoma, without mention of having achieved remission 205.80 Other myeloid leukemia, without mention of having achieved remission 205.90 Unspecified myeloid leukemia, without mention of having achieved remission

Changed Codes of Note (2009) 206.00 Acute monocytic leukemia, without mention of having achieved remission 206.10 Chronic monocytic leukemia, without mention of having achieved remission 206.20 Subacute monocytic leukemia, without mention of having achieved remission 206.80 Other monocytic leukemia, without mention of having achieved remission 206.90 Unspecified monocytic leukemia, without mention of having achieved remission 207.00 Acute erythremia and erythroleukemia, without mention of having achieved remission

207.10 Chronic erythremia, without mention of having achieved remission 207.20 Megakaryocytic leukemia, without mention of having achieved remission 207.80 Other specified leukemia, without mention of having achieved remission 207.20 Megakaryocytic leukemia, without mention of having achieved remission 207.80 Other specified leukemia, without mention of having achieved remission \ 208.00 Acute leukemia of unspecified cell type, without mention of having achieved remission 208.10 Chronic leukemia of unspecified cell type, without mention of having achieved remission 208.20 Subacute leukemia of unspecified cell type, without mention of having achieved remission 208.80 Other leukemia of unspecified cell type, without mention of having achieved remission 208.90 Unspecified leukemia, without mention of having achieved remission

V45.71 Acquired absence of breast and nipple

ICD-10-CM The Department of Health and Human Services (HHS) announced a

long-awaited proposed regulation that would replace the ICD-9-CM code sets now used to report health care diagnoses and procedures with greatly expanded ICD-10 code sets, effective October 1, 2011. In a separate proposed regulation, HHS has proposed adopting the updated X12 standard, Version 5010, and the National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions, such as health care claims. Version 5010 is essential to use of the ICD-10 codes.

In 2000, under authority provided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the ICD-9-CM code sets were adopted for use in the administrative transactions by both the public and private sectors to report diagnoses and inpatient hospital procedures. Covered entities required to use the ICD-9-CM code sets include health plans, health care clearinghouses, and health care providers who transmit any electronic health information in connection with a transaction for which a standard has been adopted by HHS.

Overview of ICD-10

International Classification of Diseases and Related Health Problems, the 10th Edition

Maintained by the World Health Organization Classifies the causes of disease morbidity and

mortality Contains diseases, symptoms, etiologies, and

injuries Official Site:

http://www.who.int/whosis/icd10/

History of ICD

Origin (1893) International List of Causes of Death International Statistical Institute (ISI)

WHO (1946) Morbidity and mortality

Revised every 10 years ICD-10 (1994)

ICD Revisions

Revision Implementation in US

1st 1900-1909

2nd 1910-1920

3rd 1921-1929

4th 1930-1938

5th 1939-1948

6th 1949-1957

7th 1958-1967

8th 1968-1978

9th 1979-1998

10th 1999-present

WHO

ISI

MortalityMorbidity

Mortality

Purpose of ICD-10

WHO: Statistically oriented classification system for

health census and statistics To permit the systematic analysis, interpretation

and comparison of mortality and morbidity data collected in different countries or areas, at different times

Updates of ICD-10

Must through a local Collaborating Centre E.g, US: National Center for Health Statistics (NCHS) Submit to WHO 3 to 6 months before Heads of Centres

annual meeting Present in Heads of Centres meeting in October

Updates: Publish no later than 15 months after each Centre Heads

meeting Latest update available: 1999 (

http://www.who.int/whosis/icd10/corr-eng.htm)

Content of ICD-10 Volume 1:

Tabular List Cause-of-death titles and codes Classification at 3- and 4-character levels

Volume 2: Instruction Manual Description, guidelines, and coding rules

Volume 3: Alphabetical Index to diseases and nature of injury, external

causes of injury Table of drugs and chemicals

ICD-10: The Code

Core code: 3 character (1 letter + 2 digits) A00 Up to 2,600 categories Mandatory for reporting at the international level

Extended code: the 4th digit following a decimal point A00.0 Up to 26,000 categories Recommended not required by WHO

ICD-10: The Classification

Two types of classification: Main classification

diagnoses and health status E11 = Non-insulin dependent diabetes mellitus

Supplementary classification generally outside the formal diagnoses but related

to health care Z83.3 = Family history of diabetes mellitus

ICD-10 Hierarchy for Classification

9,275 codes used in US ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10/

3 level hierarchy Level 1: the 21 chapters

21 categories Level 2: the 1st – 3rd characters (A00)

1643 categories Level 3: the 1st – 4th characters (A00.0)

7611 categories Site for browsing the hierarchy and searching diseases:

http://www.med-ia.ch/bolinosmed/codifications/icd10/

Most Important Coding Rules of ICD-10

1— Highest Level of Specificity

2— Daggers (†) and asterisks (*) are coded

together, daggers first

3— Principal disease: one disease of major

medical cost

1. Highest Level of Specificity

As specific as possible Patient:

Type 2 diabetes mellitus with renal complications Code:

E11.2 = Type 2 diabetes mellitus with renal complications

Not E11 = Type 2 diabetes mellitus

2. Dagger and Asterisk

For a disease encoded by two codes Dagger represents etiological aspects. Asterisk refers to anatomical location

Example: For Renal tuberculosis:

A18.1† urogenital tuberculosis

N29.1* infectious disease of kidney and

ureter classified elsewhere

. .

Differences between ICD-9 &

ICD-10 : Breast Cancer (Partial List) 174 malig neo female breast 1740 malig neo nipple 1741 mal neo breast-central 1742 mal neo breast up-inner 1743 mal neo breast low-inner 1744 mal neo breast up-outer 1745 mal neo breast low-outer 1746 mal neo breast-axillary 1748 malign neopl breast nec 1749 malign neopl breast nos 175 malig neo male breast 1750 mal neo male nipple 1759 mal neo male breast nec

C50011 Malignant neoplasm of nipple and areola, right female breast

C50012 Malignant neoplasm of nipple and areola, left female breast

C50019 Malignant neoplasm of nipple and areola, unspecified female breast

C50021 Malignant neoplasm of nipple and areola, right male breast

C50022 Malignant neoplasm of nipple and areola, left male breast

C50029 Malignant neoplasm of nipple and areola, unspecified male breast

C50111 Malignant neoplasm of central portion of right female breast

C50112 Malignant neoplasm of central portion of left female breast

C50119 Malignant neoplasm of central portion of unspecified female breast

C50121 Malignant neoplasm of central portion of right male breast

C50122 Malignant neoplasm of central portion of left male breast

C50129 Malignant neoplasm of central portion of unspecified male breast

C50211 Malignant neoplasm of upper-inner quadrant of right female breast

C50212 Malignant neoplasm of upper-inner quadrant of left female breast

C50219 Malignant neoplasm of upper-inner quadrant of unspecified female breast

C50221 Malignant neoplasm of upper-inner quadrant of right male breast

C50222 Malignant neoplasm of upper-inner quadrant of left male breast

C50229 Malignant neoplasm of upper-inner quadrant of unspecified male breast

C50311 Malignant neoplasm of lower-inner quadrant of right female breast

C50312 Malignant neoplasm of lower-inner quadrant of left female breast

C50319 Malignant neoplasm of lower-inner quadrant of unspecified female breast

C50321 Malignant neoplasm of lower-inner quadrant of right male breast

C50322 Malignant neoplasm of lower-inner quadrant of left male breast

C50329 Malignant neoplasm of lower-inner quadrant of unspecified male breast

C50411 Malignant neoplasm of upper-outer quadrant of right female breast

C50412 Malignant neoplasm of upper-outer quadrant of left female breast

C50419 Malignant neoplasm of upper-outer quadrant of unspecified female breast

C50421 Malignant neoplasm of upper-outer quadrant of right male breast

C50422 Malignant neoplasm of upper-outer quadrant of left male breast

C50429 Malignant neoplasm of upper-outer quadrant of unspecified male breast

C50511 Malignant neoplasm of lower-outer quadrant of right female breast

C50512 Malignant neoplasm of lower-outer quadrant of left female breast

References

World Health Organization (WHO) http://www.who.int

WHO statistical information http://www.who.int/whosis/icd10/

Centers for Disease Control (CDC) National Center for Health Statistics (NCHS)

http://www.cdc.gov/nchs http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

Get Ready for October 1

Check codes against the full list of codes that you use and make sure that nurses and doctors are updated on the coding possibilities.

Spot check your PM system to make sure additions and changes are in your billing and EMR systems.

Update Superbill or EMR Problem List as necessary.

Educate billers and coders.