Home Health ICD-9/ICD-10 Alert

Some skin cancers will no longer earn NRS points.

It's that time of year again -- are you ready for the new and revised 2010 ICD-9 codes? Make sure you know which changes are most likely to impact your agency.

The changes, announced by the Centers for Medicare & Medicaid Services (CMS) are effective Oct. 1 with no grace period. The good news: You'll have fewer changes to master this year than you did last year, said Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C. during a recent Eli-sponsored audioconference. This reduction in changes may be a trend we'll continue to see as we ramp up for ICD-10, she says.

Look for six new codes for Merkel cell carcinoma at 209.3x (Malignant poorly differentiated neuroendocrine tumors). These additions expand on the 209.3x subcategory that was added last year, along with the 209.xx (Neuroendocrine tumor) category. These neoplasm case mix category welcomes the six new codes:

• 209.31 -- Merkel cell carcinoma of the face

• 209.32 -- Merkel cell carcinoma of the scalp and neck

• 209.33 -- Merkel cell carcinoma of the upper limb

• 209.34 -- Merkel cell carcinoma of the lower limb

• 209.35 -- Merkel cell carcinoma of the trunk

• 209.36 -- Merkel cell carcinoma of other sites.

The Merkel cell carcinomas are aggressive skin cancers and are actually more prevalent and more aggressive than melanomas. Until Oct. 1, you would code these skin cancers in the 173 category along with other skin cancers, such as basal cell carcinomas. These new codes help differentiate Merkel cell carcinomas from other skin cancers to better track treatment and prevalence.

Additions for secondary neuroendocrine tumors at 209.7x provide seven new case mix codes:

• 209.70 -- Secondary neuroendocrine tumor, unspecified site

• 209.71 -- Secondary neuroendocrine tumor of distant lymph nodes

• 209.72 -- Secondary neuroendocrine tumor of liver

• 209.73 -- Secondary neuroendocrine tumor of bone

• 209.74 -- Secondary neuroendocrine tumor of peritoneum

• 209.75 -- Secondary Merkel cell carcinoma

• 209.79 -- Secondary neuroendocrine tumor of other sites.

Disappointing: The new skin cancer codes don't earn non-routine supply points, says Trish Twombly, RN, BSN, HCS-D, CHCE, director of coding with Foundation Management Services in Denton, Texas. Up until Oct. 1 the codes for this type cancer earned NRS supply points. After Oct. 1, the new codes ill be more specific but they aren't on the NRS list, she says.

However, both the 209.3x codes and the 209.7x codes are case mix so they add points to the home health resource group calculation, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principle of Selman-Holman & Associates in Denton, Texas.

Four new codes for gouty arthropathy will come in handy when providing pain and medication management for patients with this condition, Adams says. New levels of detail allow you to indicate whether the patient has tophi -- crystallized deposits of uric acid in the soft tissue under his skin. Codes include:

• 274.00 -- Gouty arthropathy, unspecified

• 274.01 -- Acute gouty arthropathy

• 274.02 -- Chronic gouty arthropathy without mention of tophus [tophi]

• 274.03 -- Chronic gouty arthropathy with tophus [tophi]

Speech-language pathologists will welcome two new Neuro 3 case mix codes for late effects of cerebrovascular disease: 438.13 (Late effects of cerebrovascular disease, dysarthria) and 438.14 (Late effects of cerebrovascular disease, fluency disorder).

You'll also see changes to other speech disorder codes:

• 784.42 -- Dysphonia, a disorder of voice production

• 784.51 -- Dysarthria, weakness in musculature of mouth and throat caused by brain lesions

• 784.59 -- Other speech disorder

• V57.3 -- Speech therapy.

Venous embolism and thrombosis is the category to see the largest increase in codes, Adams says.

Now you can indicate whether the condition is acute or chronic and deep vein or superficial. You should not code chronic embolism or thrombosis unless the physician specifies that the condition is chronic, Selman-Holman says. The acute condition lasts anywhere from one to three months and as many as six months after the onset of the condition.

Most patients will not progress to the chronic stage, Selman-Holman says. Once the acute phase has ended, most patients may be maintained on anti-coagulants for prophylactic purposes. If that's the case for your patient, consider the personal history code, V12.51 (Venous thrombosis and embolism). The new codes include:

• 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

• 453.52 -- Chronic venous embolism and thrombosis of deep vessels of distal lower extremity

• 453.6 -- Venous embolism and thrombosis of superficial vessels of lower extremity

• 453.71 -- Chronic venous embolism and thrombosis of superficial veins of upper extremity

• 453.72 -- Chronic venous embolism and thrombosis of deep veins of upper extremity

• 453.73 -- Chronic venous embolism and thrombosis of upper extremity, unspecified.

Seven new symptom codes will come in handy when caring for patients suffering from late effects of head injuries or traumatic brain injuries, Adams says.

Remember to use these codes only when you do not know the underlying condition causing the symptom or in cases where they are a late effect of an earlier brain or intracranial injury, she says. List the symptom first, followed by the appropriate late effects code.

Look to these additions:

• 799.21 -- Nervousness

• 799.22 -- Irritability

• 799.23 -- Impulsiveness

• 799.24 -- Emotional lability

• 799.25 -- Demoralization and apathy

• 799.29 -- Other signs and symptoms involving emotional state.

Code V10.9 (Unspecified personal history of malignant neoplasm) is no longer a valid code. Use V10.90 (Personal history of unspecified malignant neoplasm) instead, Adams says.

Long a topic of debate, the 2010 ICD-9 update settles how to code for a pressure ulcer of the coccyx. Use 707.03 (Pressure ulcer; lower back), which has been revised to include the coccyx. Unfortunately, 707.05 (Pressure ulcer; buttock) is currently the only code that supports reimbursement for pressure-relieving pads or cushions for patients with a pressure ulcer of the coccyx. But CMS often goes back in to make coverage changes after the new diagnosis codes go into effect, so that may change, Adams says.

Maybe next year: "I was hoping they would add the 249.xx (Secondary diabetes mellitus) series, which was new last year to the case mix list this year, but that didn't happen," Twombly says. View the summary tables to see all of the new, revised, and invalid codes at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage.