Anesthesia Coding Alert

Your practice will dictate how they affect you

The newest edition of ICD-9 (effective Oct. 1) includes new and revised codes for chronic renal failure, prosthetic joint repair, and dehydration/volume depletion that help justify medical necessity for anesthesia.

Much of the new codes- merit depends on the types of cases your anesthesiologists see, so you should be prepared for anything that might cross your desk.

Prepare for New, More Specific Diagnoses

Your job as a coder is to report diagnoses and procedures as precisely as possible to ensure accurate claims and appropriate reimbursement. Most of the ICD-9 changes taking effect in October will make that easier by adding new diagnosis categories or expanding existing ones.

Positive change: Most coders would agree that having more specific diagnoses is a positive change. Some, including Leslie Johnson, CCS-P, CPC, coding supervisor for River Oaks Imaging and Diagnostics in Houston, think the increased details are a sign of what's to come with future editions.

-Coders need to get used to choosing codes that spell out the entire condition from beginning to end instead of relying on faulty and/or misleading nonspecific codes,- Johnson says. You should be ready to treat the case -from a more three-dimensional- perspective to determine the correct codes, she says--as opposed to settling for whatever the technician, CRNA or anesthesiologist decides to write.

Report Dehydration, Volume Depletion Separately

Previous versions of ICD-9 had a single, catchall code for volume depletion (276.5, Volume depletion) that included a range of conditions. The new edition divides this condition into three specific codes:

- 276.50--Volume depletion

- 276.51--Dehydration

- 276.52--Hypovolemia.

The new breakdown can help your coding from both an anesthesia and pain management standpoint. Having codes that distinguish depletion, dehydration and hypovolemia from each other lets you be much more precise with the diagnosis.

Dehydration changes: Severe dehydration can interfere with a patient's metabolism and heart rate. This presents a major risk to the patient's life, which elevates the patient's physical status indicator (P1-P5). Note: Although most carriers don't reimburse extra units for higher physical status modifiers, using them does help document the seriousness of the case and the physician's risk in caring for the patient.

Fortunately, the physician can easily treat dehydration and should correct the situation before the procedure in all but the most extreme emergencies. The dehydration code might not help justify anesthesia procedures but could be a factor the physician considers when he assesses a patient for chronic pain management.

Volume depletion key: Volume depletion is a threat to the patient's life and can cause low blood pressure and high heart rate. Both dehydration and volume depletion can play a vital role when you-re coding for pain management. The patient's condition is extremely important in how the physician treats the patient for short- or long-term pain control, especially for chronic pain due to severe systemic diseases such as AIDS, ESRD or end-stage cancers.

-Our physicians use the volume depletion code a lot to support medical necessity for TEE (transesophageal echocardiography),- says Terry Celestino, CPC, of Tejas Anesthesia in San Antonio. -We-ll be using 276.50 with our cardiac cases.-

Be Less Judgmental With -Overweight- Option

Existing codes related to obesity are 278.00 (Obesity, unspecified) and 278.01 (Morbid obesity). Now you can also choose 278.02 (Overweight) when the patient's weight is a factor to consider. 

Some coders are glad to see this new breakdown because of some anesthesiologists- tendencies to go overboard when determining if a patient's excess weight is a risk factor. Just because a patient is 10 or 20 pounds overweight doesn't mean she should be labeled as obese, Johnson says.
 
-Having a diagnosis breakdown of -overweight- versus -obesity- versus -morbidly obese,- we have more latitude to include this kind of information in the patient's record as some kind of risk without feeling we-re overstating (or understating) the patient's actual condition,- Johnson says.

Key factor: Morbid obesity always raises a patient's physical status to at least P3 (Patient with severe systemic disease) because it is a threat to life. An -overweight- diagnosis could help a carrier understand why a procedure took longer than it usually does.

Another example: The diagnosis can also combine with smoking to elevate the patient's status from P2 (Patient with mild systemic disease) to P3 because an overweight smoker with lung disease is more at-risk during a procedure than a normal-weight person in the same situation.

New ESRD Code Broadens Your Options

A welcome addition to the renal diagnosis choices is in the 585 series (Chronic renal failure). The new ICD-9 expands your choices in this group, plus adds 585.6 (End-stage renal disease).

Coders will rely on this new option because some kidney disease can be chronic, but not all kidney disease is end-stage renal disease (ESRD). Expanding the code series gives you more options for accurately reporting the condition. Now you won't need to worry about -giving-the patient something he doesn't have, such as chronic renal failure versus chronic kidney disease, because the diagnoses lack specificity.

Document Device Replacement With 996 Series

 If you-re reporting a prosthetic joint repair, don't submit the codes you used for the original procedure. ICD-9 expands your options from one code (996.4, Mechanical complication of internal orthopedic device, implant and graft) to nine:

- 996.40--Unspecified mechanical complication of internal orthopedic device, implant, and graft

- 996.41--Mechanical loosening of prosthetic joint

- 996.42--Dislocation of prosthetic joint

- 996.43--Prosthetic joint implant failure

- 996.44--Peri-prosthetic fracture around prosthetic joint

- 996.45--Peri-prosthetic osteolysis

- 996.46--Articular bearing surface wear of prosthetic joint

- 996.47--Other mechanical complication of prosthetic joint implant

- 996.49--Other mechanical complication of other internal orthopedic device, implant, and graft.

The most important thing to remember with these codes is that they represent -redos- or failures, not the original joint replacement procedures.

Example: A patient has hip replacement surgery due to arthritic pain and deterioration. Several months later she falls from her wheelchair and dislodges the prosthetic joint, and she has surgery to correct the problem. When you code the procedure, don't rely on the arthritis and pain diagnoses that justified the original surgery. Instead, report the appropriate code from 996.4x because the problem is mechanical in nature rather than due to her arthritic condition. (In this case, submit 996.42.)

-Mechanical complications can be more than dislodging a prosthesis,- Johnson says. -With the new codes, there is little guesswork involved in determining the correct coding for these scenarios. I can see how much easier it will be to be more specific in our coding for these mechanical complications.-

Revisions Make Renal Coding Easier

Most ICD-9 code revisions of interest to anesthesia providers address hypertensive renal disease (403.xx, Hypertensive renal disease; and 404.xx, Hypertensive heart and renal disease).

Previous editions only included divisions according to malignant, benign or unspecified disease; you reported a fifth digit to indicate whether there was mention of heart or renal failure. The new codes are basically the same but make coding easier by including the fifth-digit information in the base descriptors.

-This combination of two diseases in the descriptor helps when there's a long list of conditions to code,- Johnson says. -We can be more specific and still have room to code those other conditions we might consider to be very important to the case.-