Home Health ICD-9/ICD-10 Alert

V-code updates answer your V07 and cardiac defibrillator questions.

It's that time again. Oct. 1 is right around the corner, when you'll have 122 new, deleted, or revised ICD-9 codes to master. Make certain you're ready with this run down of the changes that will impact home care the most.

You'll find a revised note under 251.3 (Postsurgical hypoinsulinemia) directing you to use an additional code to identify any associated acquired absence of pancreas. New codes V88.11 (Acquired total absence of pancreas) and V88.12 (Acquired partial absence of pancreas) offer greater specificity.

In turn, notes under new subcategory V88.1 (Acquired absence of pancreas) ask that you use an additional code to identify any associated insulin use (V58.67) or secondary diabetes mellitus (249.00-249.91), says Joan L. Usher, BS, RHIA, COS-C, ACE, with JLU Health Record Systems in Pembroke, Mass.

Several new codes under 275.0 (Disorders of iron metabolism) offer more details about patients with conditions who have iron metabolism difficulties. Of special interest is 275.02 (Hemochromatosis due to repeated red blood cell transfusions), says Lisa Selman-Holman, JD, BSN, RN, HCSD, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Previously, there have been no codes for transfusion-associated hemochromatosis -- the iron overload that can result from repeated red blood cell transfusions, Selman-Holman says. Any patient who receives repeated transfusions can develop the problem, but look for it in sickle cell anemia patients who often receive transfusions. Hemochromatosis may result in organ damage, including heart, renal, and liver dysfunction, she says.

Subcategory 276.6x (Fluid overload) gains a fifth digit this year, adding new codes 276.61 (Transfusion associated circulatory overload) and 276.69 (Other fluid overload). TACO typically happens within 6 hours of transfusion.

Tip: Watch for excludes notes under 428.0 (Congestive heart failure, unspecified) and 782.3 (Edema) that advise you not to list 276.69 for patients with these conditions, Usher says. Review HTN CKD Includes Category 403 (Hypertensive chronic kidney disease) has a revised "Includes" note, says Selman-Holman. Code 587 (Renal sclerosis unspecified) had recently been removed from the note, but as of Oct. 1 the "Includes" note reads "any condition classifiable to 585 and 587 with any condition classifiable to 401."

"It was just within the last couple of years that code 587 was removed from this 'Includes' note," Selman-Holman says. No explanation on the change was given by the ICD- 9 Coordination and Maintenance Committee, she says. The official guideline was also altered to reflect this change and directs the coder to "assign codes from category 403, hypertensive chronic kidney disease, when conditions classified to category 585 or code 587 are present with hypertension."

There is no indication as to how to select the fifth digit for 403 when renal sclerosis is present with hypertension, Selman- Holman points out. Fifth digits on the code indicate what stage of chronic kidney disease (CKD) is present. Until further clarification is received, Selman-Holman recommends using fifth digit "0" (with chronic kidney disease stage I through stage IV, or unspecified) unless some documentation of CKD is also present.

Several common symptoms have new or updated codes, Selman Holman says. These include:

• 780.33 (Post traumatic seizures) which excludes posttraumatic epilepsy (345.00-345.91);
• 780.62 (Postprocedural fever) which excludes posttransfusion fever (780.66);
• 786.39 (Cough with hemorrhage); and Four new incontinence of feces codes: 787.60 (Full incontinence of feces), 787.61 (Incomplete defecation) which excludes constipation (564.00-564.09) and fecal impaction (560.32); 787.62 (Fecal smearing) and 787.63 (Fecal urgency).

Changes to V codes for 2011 answer some common coding questions.

We now have clarification on whether V07.x (Need for isolation and other prophylactic measures) should be used only in prophylactic situations, only with treatment measures, or both, Selman-Holman says. These codes can be used in both cases, she says.

The V07 codes can now be found under the term "use of" in the Alphabetic Index, not "prophylactic," Selman-Holman notes. "It is now clear that if a breast cancer patient is taking an estrogen receptor modulator, the V07.5x codes can be used for treatment for current cancer or for prophylactic reasons," she says.

A new inclusion note at code V45.02 (Automatic implantable cardiac defibrillator) clarifies that occasion when the patient has both a defibrillator and a pacemaker. Implantable defibrillators can include pacemakers, leading coders to wonder whether they use both the pacemaker status code and the defibrillator status code, Selman-Holman says. The defibrillator status code now includes the synchronous pacemaker, Selman-Holman says.

Note: You'll find another related new code under V53.3x (Fitting and adjustment of cardiac device). The fitting and adjustment code for the automatic defibrillator is V53.32 (Fitting and adjustment of automatic implantable cardiac defibrillator), Selman-Holman says. "Excludes" notes under V53.31 (Fitting and adjustment of cardiac pacemaker) indicate that you cannot use both V53.31 and V53.32 together.

Get BMI Specificity with Nurse Notes

BMI listings for adults are now very specific, with V85.4x (Body Mass Index 40 and over, adult) gaining a fifth digit, Selman-Holman says.

While physicians will make the determination as to whether a patient is obese, nurses can determine a patient's BMI, Usher says. A recent Q&A in the American Hospital Association's Coding Clinic for ICD-9 advised that it is appropriate to use nursing staff documentation for establishing BMI, she says.

Be thorough: Instructions at 278.0x (Overweight and obesity) advise you to use an additional code from the V85.x subcategory to identify Body Mass Index (BMI) if known. If you don't add in the BMI details you could find yourself on the wrong end of a recovery audit contractor (RAC) audit. The RACs could move the other codes in the top six slots down if you leave off the BMI code, Usher says. If you had a case mix diagnosis sequenced last, you might end up losing points as a result.