ED Coding and Reimbursement Alert

The new ICD-9 codes for 2003 came out a few months ago, and they bring good news to ED coders.

The new codes "bring definitive diagnosis options to the physicians," says Melanie Witt, RN, CPC, MA, an independent coding consultant and educator based in Fredericksburg, Va.

Although the "bread-and-butter codes" of the ED haven't changed, there are some "new enhancements," says Robert Polglase, MD, JD, CEO of Stratagem Group Inc. in Augusta, Ga. (See "New ICD-9 Codes You Should Note for the ED" on page 21 for a list of new codes [not including revised or deleted codes] that Polglase highlights for the ED. Note the key near the box: Polglase highlighted some of the codes because you probably shouldn't or wouldn't use them.)                          

 Below are explanations for a few of them:

Infectious Disease Codes. For some new infectious diseases, you now have to use an additional code to identify the organism. For example, with 040.82 (Toxic shock syndrome), the ED staff probably can't isolate the organism. However, you should still be able to code toxic shock syndrome without any difficulty, Polglase says. But you probably won't be able to use the new diagnosis code for West Nile fever (066.4) because laboratory results for West Nile take a long time, Polglase says. Use symptom codes for patients with potential but not yet confirmed West Nile virus.

Endocrine and Metabolic Section. Be on the lookout for the new code for cystic fibrosis (CF) with pulmonary manifestations, 277.02. Many CF patients develop severe pneumonia, and ED physicians will work up their case fairly aggressively, Polglase says. So, if the CF is included in the history of the diagnosis, you will have a higher level of risk and decision-making, Polglase says, and this will boost your E/M levels.

Obstetric and Gynecology Section. The new codes for abnormal pregnancies (633.00- 633.91) further breakdown ectopic pregnancies by anatomic site. In addition, the big news here is that you can now report an ectopic pregnancy with or without an intrauterine pregnancy, Polglase says. An applicable scenario in the ED would be a woman who presents with abdominal pain and tests positive for pregnancy. The physician does an ultrasound, and the findings are ectopic pregnancy. Now, if you have specific documentation that indicates a tubal pregnancy, you should report a code from the 633.1x series. But if your diagnosis is just an ectopic pregnancy (unspecified), you can report a code from the 633.0x series.

Signs and Symptoms. Pay attention to 780.91 (Fussy infant [baby]) and 780.92 (Excessive crying of infant [baby]). Both of these codes will bring reimbursement for cases previously denied. Consider the ED on the night shift when mothers present their fussing and excessively crying infants. Your ED physician does an exam, obtains a good history and physical, maybe runs some tests, and if no pathology is found, he is left with a final diagnosis of "normal exam." Then you're stuck reporting V20.2 (Routine infant or child health check). And you might get denied for it. Georgia Medicaid will reject the "normal exam" based on site of service 23, Polglase says. "Medicaid says there's no such thing as a normal incident exam in the ER." Well, now you can report one of these two new codes. You may want to educate your physicians, as Polglase does, about these codes and encourage them to write "fussy" or "excessive crying" as the chief complaint.

Postoperative Complications. There's now a different code for internal and external wound dehiscence, so pay attention. Suppose a patient presents with an abdominal wound, and the wound has ruptured or opened through the subcutaneous layer and the muscular layers. You would now use 998.31 (Disruption of internal operation wound). You should use 998.32 (Disruption of external operation wound) for a more superficial rupture through the skin and external tissues. If the physician doesn't specify, then the diagnosis is a disruption of operation wound NOS, 998.32.