ED Coding and Reimbursement Alert

The ICD-9 2009 manual will bring a few changes to the pleural effusion and pneumonia categories. ED coders should be sure to note these changes before the new codes take effect Oct. 1.

The new code in the pleural effusion set is 511.81 (Malignant pleural effusion).

Use this diagnosis code when the pleural fluid is cancerous, confirms Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

"A malignant pleural effusion is caused by a cancerous invasion of the pleura. This could be due to cancer within the lung or metastatic disease from any other organ (such as the colon or kidney)," says Alan Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. When reporting 511.81, be sure to code for the source of the primary tumor as well, he reminds.

Old way: ICD-9 currently refers coders to 197.2 (Secondary malignant neoplasm of respiratory and digestive systems; pleura) for a malignant pleural effusion, Plummer explains.

On Oct. 1, replace 197.2 with 511.81 for your malignant effusion patients.

Example: The ED physician visits with a patient with malignant cancer of the main bronchus who is suffering from a probable malignant pleural effusion. The physician performs a thoracentesis with insertion of tube.

Beginning Oct. 1, report the following for this encounter:

- 32422 (Thoracentesis with insertion of tube, includes water seal [eg, for pneumothorax], when performed [separate procedure]) for the thoracentesis

- 511.81 to represent the malignant effusion (Caution: Wait for the final diagnosis from cytology on the pleural fluid.)

- 162.2 (Malignant neoplasm of trachea, bronchus and lung; main bronchus) to represent the underlying cancerous condition.

To make room for 511.81, ICD-9 moved 511.8 (Other specified forms of effusion except tuberculosis) to 511.89. "The -catch-all- descriptor for 511.89 remains the same as it was for 511.8," explains Plummer.

Effective Oct. 1, you will need to remember to apply the fifth digit (511.89) when the patient suffers a pleural effusion that does not include cancer or tuberculosis. If you continue to use 511.8, your claims will be denied for an "invalid diagnosis" code.

Coders will also get another pneumonia diagnosis code to add to their arsenals in October. ICD-9 2009 will mark the premiere of 997.31 (Ventilator-associated pneumonia). Use this code when a patient on a respirator develops pneumonia, according to Berman.

Example: A nursing home patient who is chronically vent dependent is brought to the ED for evaluation and found to have pneumonia.

Old way: Coders would have to use the generic 997.3 (Respiratory complications) for this type of pneumonia before 997.31. The new pneumonia code can better describe the source of the patient's pneumonia.

The new ICD-9 coding also deletes 997.3 and replaces it with 997.39 (Other respiratory complications). This vague diagnosis is for use only as a last resort, if you cannot find a more appropriate diagnosis code, Berman explains.

You might find yourself using 997.39 for patients who develop pneumonia after a procedure or Mendelson's syndrome following surgery, other than for labor and delivery (668.0X).