ED Coding and Reimbursement Alert

You'll soon need to jump through more diagnosis coding hoops for patients with thrombosis, as ICD-9 2010 sports a host of new codes to more accurately represent the condition.

Arm yourself: Use this expert input on the new code subsets and you'll have no trouble picking the correct thrombosis diagnosis when ICD-9 2010 becomes effective on Oct. 1.

Patients who report to the ED with thrombosis helped spark an expansion of the 453.xx code set. Most of the new additions will require five digits beginning with ICD-9 2010, confirms Jill Young, CPC, CEDC, CIMC, president of Young Medical Consulting in East Lansing, Mich.

The new codes of most interest to ED providers are:

• 453.50 (Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity), 453.51 (Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity), and 453.52 (Chronic venous embolism and thrombosis of deep vessels of distal lower extremity) for deep vessel thrombosis

• 453.71 (Chronic venous embolism and thrombosis of superficial veins of upper extremity) through 453.79 (Chronic venous embolism and thrombosis of other specified veins); this subset breaks chronic venous embolism into more specific body areas

• 453.81 (Acute venous embolism and thrombosis of superficial veins of upper extremity) through 453.89 (Acute venous embolism and thrombosis of other specified veins); this subset breaks acute embolisms into more specific body areas.

The new code series "will allow the coder to apply a very specific code describing site and type [of thrombosis]," says Sarah Todt, RN, CPC, CEDC, associate director for QA and compliance at MRSI Inc. in Woburn, Mass. "In turn, this will better support the risk assignment for medical decision making and help support diagnostic tests/and procedures."

ED impact: "This [code change] will help in the emergent setting especially, because the acute embolism code would better support an extensive service to the patient," explains Denae M. Merrill, CPC, CEMC, HCC coding specialist at The Coding Source and owner of Merrill Medical Management.

In a nutshell: If someone has a new embolism, use the acute embolism codes, Young says.

These acute codes suggest severe presentations and high-complexity clinical decision making by the provider, so be on the lookout for opportunities to report these diagnoses. When a patient reports to the ED with history of a previous embolism, use a chronic embolism code instead of an acute one.

Example: A patient presents to the ED with pain and swelling in his left arm; he also reports vague shoulder and neck pain. The exam reveals low-grade fever, mild cyanosis of the left arm, and elevated jugular venous distention.

The ED physician diagnoses an acute venous embolism in the left shoulder, and orders catheter-directed anticoagulant therapy. Notes reveal a level-four E/M service.

Beginning on Oct. 1, the proper diagnosis for this claim is 453.81; be sure to append it to 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...).

While the more specific codes might be helpful for EDs, using them will require greater physician specificity, says Jim Strafford, CEDC, MCS-P, vice president of client services with Omega Healthcare. New thrombosis codes will challenge ED docs to be very specific in terms of the condition and location, and getting physician buy-in is crucial to using the new codes correctly.

Best bet: Take steps to make sure your physicians are aware of the changes to thrombosis diagnoses. Consider the following encounter note, which provides the coder enough information to choose the proper ICD-9 code:

• "Male patient, 69, complains of chronic swelling and pain in left leg. Comprehensive history and exam performed.

• Ordered CBC, Chem panel, D-dimer and Doppler US of leg ... Ultrasound is consistent with significant chronic venous thrombosis.

• Discussed case with vasc. surgeon ... surgeon req. initiation of Heparin therapy to prevent worsening and hospital admission.

• Px had distal thrombosis, same leg, Aug. 2008." In this scenario, the physician gives the coder enough information to choose 453.52 as a diagnosis for the E/M service.