Gastroenterology Coding Alert

Gastroenterology coders, rejoice. You've got dozens of new carcinoid tumor, anal Pap smear, dysplasia, and hepatitis codes you can apply to claims as of Oct. 1, thanks to the largest addition of ICD-9 codes in years.

Note: Now these codes appear in a "proposed" rule. CMS may announce more changes, so look to Gastroenterology Coding Alert for more details.

Heads up: "Keep a close watch on fifth digits, the includes/excludes notes, and the NEC (Not elsewhere classifiable) and NOS (Not otherwise specified) codes -- you want to avoid NEC and NOS codes if possible," says Dianne Wilkinson, RHIT, compliance auditor with West Tennessee Healthcare in Jackson.

First, you should explore the numerous malignant and benign carcinoid tumor codes ICD-9 2009 adds to the 209.xx category. ICD-9 creates this new category to distinguish malignant (209.00-209.29, Malignant carcinoid tumor ...) and benign neuroendocrine tumors (209.40-209.69, Benign carcinoid tumor ...) from the biologically different adenocarcinomas and other benign tumors.

Rationale: Carcinoid tumors occur most often in the bronchi, stomach, small intestine, appendix and rectum. Physicians classify these tumors according to the presumed origin, such as the "foregut" (bronchi and stomach), the "midgut" (small intestine and appendix), and the "hindgut" (colon and rectum).

These tumors produce amine and peptides that can cause characteristic hormonal syndromes, which means that these systemic syndromes (as well as the differences of locations) account for diverse clinical presentation, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

Keep in mind: The differentiation between "benign" and "malignant" is not possible during a colonoscopy procedure. You would apply a specific location code like these after surgery possibly as a reason for a follow-up procedure.

For instance, you would use 209.20 (Malignant carcinoid tumor of unknown primary site) as a code for colonoscopy or EGD to look for the primary site when the patient has a metastatic carcinoid identified by other means, Weinstein says.

Example: A 60-year-old man presents as a referral from his oncologist after recent diagnosis of a metastatic malignant carcinoid tumor. He has not had any localizing intestinal symptoms, but a CT scan of the abdomen suggests a possible right colon lesion. You should use 209.20 as the diagnosis code for both the initial E/M visit and the subsequent colonoscopy.

If your gastroenterologist performs a smear of the anus, you will need to learn numerous new codes.

Rationale: The risk of HPV-associated dysplasia and carcinoma is the same for the anus as it is for the cervix for patients who engage in anal intercourse. Physicians can take anal cytologic smears. The cervix and the anus both have transformation zones where mucosa can become squamous. As of Oct. 1, you now have a new set of codes for abnormal cytologies of the anus:

Describe Anal Dysplasia With This New Code

Dysplasia of anus receives a new code in ICD-9 2009: 569.44 (Dysplasia of anus).

Tip: Starting this fall, use 569.44 when your gastroenterologist notes, "Anal intraepithelial neoplasia I and II (AIN I and II) (histologically confirmed)," "dysplasia of anus NOS," or "mild and moderate dysplasia of anus (histologically confirmed)."

Exclusions: Code 569.44 will exclude abnormal results from anal cytologic examination without histologic confirmation (796.70-796.79), anal intraepithelial neoplasia III (230.5, 230.6), carcinoma in-situ of anus (230.5, 230.6), HGSIL of anus (796.74), and severe dysplasia of anus (230.5, 230.6).

You have a new code for autoimmune hepatitis (571.42). A physician can make this diagnosis with a combination of lab tests and liver biopsy, Weinstein says. A patient who has autoimmune hepatitis has continuous hepatocellular inflammation and necrosis, which tends to progress into cirrhosis.

Current method: Until Oct. 1, you should report autoimmune hepatitis with the non-specific code (571.49, Other chronic hepatitis).

In addition, you've got two other areas of new codes:

Wound disruption: Your new code is 998.30 (Disruption of wound, unspecified). This potentially serious complication (also known as "wound dehiscence") means the patient has a physical separation of a surgical wound. Under current ICD-9 guidelines, your gastroenterologist has to specify "external" or "internal" wound dehiscence.

Tissue disorders: Although patients who suffer from a large traumatic hematoma may develop a seroma (a small collection of fluid), nontraumatic hematomas also exist. Therefore, ICD-9 2009 creates 729.90 (Disorders of soft tissue, unspecified), 729.91 (Post-traumatic seroma), 729.92 (Nontraumatic hematoma of soft tissue), and 729.99 (Other disorders of soft tissue).

Revision: Code 998.31 will state, "Disruption of internal operation (surgical) wound" as of Oct. 1.

Note: For a full list of new ICD-9 codes affecting gastroenterology, e-mail editor Suzanne Leder at suzannel@eliresearch.com with "Gastro ICD-9 Update" in the subject line.