Home Health ICD-9/ICD-10 Alert

Approved diagnosis codes will be effective Oct. 1.

If you've been wishing for a slew of more precise codes with this fall's batch of new ICD-9 codes, the Centers for Medicare & Medicaid Services (CMS) may deliver. Its recent proposal indicates a planned debut for over 300 new diagnosis codes.

However, the added details and additional codes may wind up making ulcers and diabetes more confusing to code.

CMS has released the proposed changes in the 2009 Inpatient Prospective Payment Systems document.

Pressure ulcers: Currently, when you choose a 707.0x (Decubitus ulcer) code for a pressure ulcer, you can indicate the site of the ulcer but not the stage. With the proposed changes, you'll be able to indicate the stage with the following new codes:

• 707.21 (Pressure ulcer, stage I);

• 707.22 (Pressure ulcer, stage II);

• 707.23 (Pressure ulcer, stage III); and

• 707.24 (Pressure ulcer, stage IV).

These new codes will better identify the level of care required by the clinician, says Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, program director and instructor with Herzig College in Longwood, FL.

Drawback: These codes could make ulcer coding even more complicated. Because you can't reverse-stage an ulcer, these codes won't show the progress of the ulcer, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. So, for example, if the ulcer is stage IV, you would always code it as stage IV -- even once it has healed, she says.

Diabetes: CMS will introduce 20 long-awaited new codes to represent secondary diabetes conditions (249.00-249.91). This is an acknowledgement that other underlying conditions can create a diabetic situation, says Safian. These conditions include cystic fibrosis, malignant neoplasms and genetic disorders.

You'll need to include five digits to completely code for secondary diabetes when these new codes go into effect. The fourth digit indicates the diabetic manifestation, while the fifth digit indicates whether the diabetes is controlled. For example, 249.50 indicates secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified.

The manifestations for secondary diabetes are expected to mimic the manifestations under code 250, says Selman-Holman. Many of the manifestations of diabetes are case mix diagnoses, so it will be interesting to see whether CMS will include the etiology of the 249 diagnosis as an acceptable etiology for the diabetic manifestations, she says.

Use with caution: Home health coders won't often use these new codes, predicts Sharon Bonner, RN, BSN, HCS-D, COS-C, with Supportive Care Solutions in Southfield, MI. Only 1 to 5 percent of diabetes cases are secondary diabetes, and in home care the percentage is likely even less, she says. So don't jump to use these new codes without solid documentation.

Leukemia: You'll find dozens of new leu-kemia codes on the list, which expand diagnosis coding options for this disease. For instance, new code 207.02 (Acute erythremia and erythroleukemia, in relapse) is more specific than the 2007 code 207.0x (Acute erythremia and erythroleukemia). Because the leukemia codes now earn case mix points, CMS should also include the additional digits for these codes as case mix diagnoses, Selman-Holman says.

Oncology: The 2009 ICD-9 manual could feature an entirely new section, if the proposed codes are made final this August. (Watch Home Health ICD-9 Alert for more on this new section as it develops.)

The new oncology code section is in the 209.00 to 209.69 range and includes 43 new codes that represent both malignant and benign carcinoid tumors of various sites.

Headaches: You'll find an expanded section in the proposed ICD-9 codes that represent headache and migraine codes, such as 346.43 (Menstrual migraine, with intractable migraine, so stated, with status migrainosus) and 339.85 (Primary stabbing headache).

Personal history: Eleven new personal history codes underline the importance of documenting and tracking personal health information to ensure proper follow-up, says Safian. Codes such as V13.51 (Personal history of pathologic fracture) will help track patients who need preventive care, she says. Calcimar injections are covered under the home health benefit when there is a history of spontaneous fractures, so you'll be able to use this new code to indicate a patient with such a history, Selman-Holman says.

Most of the deletions are simply diagnoses that will be replaced by more specific codes. For instance, V15.5 (Personal history of injury) will be deleted, but new code V15.59 (Personal history of other injury) will take its place.

Underlying message: The biggest message the new and changed codes offer is to prepare for ICD-10, says Safian. The multitude of new codes require more specific information just as ICD-10 coding will. The added level of detail will require more conversation between coders and clinicians, she says.