Home Health ICD-9/ICD-10 Alert

Hint: Not all behavioral disturbances are aggressive.

Now that you've looked over the lists of new and changed ICD-9 codes you'll contend with come Oct. 1, it's time to roll up your sleeves and see how to put these codes to work. Look for instructional notes following the new pseudobulbar affect and wandering codes to guide your way.

When coding late effects, the general rule is to list two codes, sequencing the code for the condition or nature of the late effect first, and following this with a code for the late effect. But an instruction following a new code in the 310.8 (Other specified nonpsychotic mental disorders following organic brain damage) subcategory might seem to contradict this.

Following new code 310.81 (Pseudobulbar affect) and in the tabular list, you'll see the instruction:

Code first underlying cause, if known, such as:

• amyotrophic lateral sclerosis (335.20)
• late effect of cerebrovascular accident (438.89)
• late effect of traumatic brain injury (907.0)
• multiple sclerosis (340)

In other words, the tabular instruction indicates that you should list the late effect of intercranial injury first and follow it with the 310.81 code. This is the opposite of the traditional late effect sequence.

Loop hole: The Official ICD-9 Guidelines for Coding and Reporting states up front: "These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. The instructions and conventions of the classification take precedence  over guidelines." So the guidelines are just that and notunbreakable law.

In the case of the sequencing instructions at 310.81, the sequencing difference is because Pseudobulbar affect (PBA) is a manifestation of the patient's neurologic disease or injury, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Definition: PBA is a neurologic condition caused by underlying structural damage in the brain which triggers involuntary, frequent and disruptive outbursts of crying or laughing. PBA occurs secondary to neurologic disease or injury and has been reported to occur in patients with amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), patients who suffered a stroke a year ago, and  after a traumatic brain injury, according the the ICD-9 Coordination and Maintenance Committee agenda from September 2010, when the code addition was proposed.

The new code for PBA was added to assist in recognition and diagnosis and to improve the epidemiologic tracking of this distinct neurologic condition.

Suppose you're caring for an Alzheimer's patient who doesn't display combative, aggressive behavior but stillneeds supervision to prevent wandering off. Can you list the new V code for wandering V40.31 with 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance) or new code 294.20 (Dementia, unspecified, without behavioral disturbance)?

No, says Selman-Holman. Wandering was initially included as one of the behaviors listed under 294.11 (Dementia in conditions classified elsewhere with behavioral disturbance). But with the 2012 ICD-9 update, wandering has been removed from this list and added in the note "Use additional code, where applicable, to identify: wandering in conditions classified elsewhere (V40.31)."

When the 294.1x subcategory was initially expanded in 2000 to capture behavioral disturbances associated with dementia in diseases classified elsewhere, wandering was a condition considered to be a behavioral disturbance. ICD-9 code 294.11 was not only used for combative, aggressive behavior associated with dementia.

Now, new code V40.31 will allow you to capture wandering with other conditions besides dementia. To keep data collection consistent, the "use additional code" for V40.31 is listed only with note at the 294.11 and new code 294.21 (Dementia, unspecified, with behavioral disturbance).

The new wandering code was created to capture information about patients, with any ICD-9 diagnosis who wander, the Centers for Disease Control and Prevention (CDC) says on its website. "Wandering was deleted as a subcode under the Alzheimer's and dementia code and added as a condition to be noted in association with disorders classified elsewhere," the CDC says. Adding V40.31 provides a way to document, understand, and improve the situation for patients "who are at risk of injury or death due to dangerous wandering."

Tip: Only list V40.31 when wandering is documented in the medical record by the provider (i.e., physician), the CDC says.

But don't list V40.31 on its own. The new wandering code isn't linked to any one specific diagnosis, but should be used in conjunction with other diagnostic and symptom or procedure codes to classify the behavior or risk factor of wandering, the CDC says.

Take note: There are no "code first," or "code underlying condition" notes for the new 294.2x (Dementia, unspecified) codes, so they aren't considered manifestation codes like the 294.1x (Dementia in conditions classified elsewhere) codes, Selman-Holman says. This means the 294.2x should be a valid code to list when you don't know the disease causing the dementia, but you have the dementia diagnosis.