Internal Medicine Coding Alert

Changes allow more specific coding for blood in urine, pressure ulcers

You can head off fall compliance woes by getting a heads-up now on new codes for secondary diabetes, hematuria and pressure ulcers.

ICD-9 has released its preliminary list of new diagnosis codes for late 2008 and 2009, and coders should get familiar with them now because once October rolls around, the law requires that you use these new codes.

Remember: Since the passage of the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Rule, there is no grace period for new ICD-9 codes. You've got to be ready to go with the new codes on Oct. 1, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Chicago.

"This federal law applies to all payers, so in essence, your time to prepare for these codes is now," she says.

The AMA has approved the following codes for use, but slight changes are possible before the list is finalized over the summer. For all the latest news on ICD-9 2009, see future issues of Internal Medicine Coding Alert.

The newest ICD-9 version will have an entire code set for secondary diabetes. While genetics or environmental factors are typically the cause of "primary" diabetes, secondary diabetes exists when an underlying patient condition is causing the diabetes, Gilhooly says.

Impact: "Until these new codes, there was no good way of showing that a patient's diabetes was due to some other problem," says Jeffery F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at Children's Healthcare of Atlanta at Egleston.

Secondary diabetes can often occur in chronic illnesses such as cystic fibrosis, chronic pancreatitis, Cushing's syndrome, malignant neoplasm, certain genetic disorders, pancreatic injury, or late effect of poisoning, Linzer says.

For example, a patient's chronic pancreatitis can severely affect his insulin production, thereby causing diabetes. You would consider the diabetes in this case secondary diabetes, Gilhooly says.

The new code set starts with 249.00 (Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified) and ends with 249.91 (Secondary diabetes mellitus with unspecified complication, uncontrolled).

In between, you'll find a host of codes that describe the patient's diabetes and the underlying factor causing the condition. (See chart at the bottom right of this page for a complete list.).

Example: An established patient with benign hypertension and chronic pancreatitis reports to the internist with abdominal pain and episodes of vomiting. The internist performs and documents a level-four office visit. Based on the examination and a review of laboratory data, the internist diagnoses the patient with diabetes mellitus without complication secondary to chronic pancreatitis.

Beginning Oct. 1, you'll need a code from the secondary diabetes code set in this example.

On the claim, report the following:

• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity) for the E/M

• 249.00 linked to 99214 to represent the patient's secondary diabetes.

• 577.1 (Chronic pancreatitis) linked to 99214 to represent the patient's pancreatitis

• 401.1 (Benign hypertension) linked to 99214 to represent the patient's hypertension.

There are also new ICD-9 codes for hematuria, or blood in the urine, Linzer says:

• 599.70 -- Hematuria, unspecified

• 599.71 -- Gross hematuria. A patient has gross hematuria when blood is visible to the naked eye upon urination. The urine is red or brownish-red when a patient has gross hematuria.

• 599.72 -- Microscopic hematuria. A patient has microscopic hematuria when there is no blood visible to the naked eye upon urination, but blood appears on a urinalysis, Linzer says.

Coders yearning for more specificity on pressure ulcer diagnoses get relief in 2009, as ICD-9 unveils a new code set for the condition, says Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.

Definition: "A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction," according to the National Pressure Ulcer Advisory Panel (NPUAP).

Previously, the only code for pressure ulcers was 707.0x (Decubitus ulcer). Now you will be able to code the ulcers by stage.

Here's a rundown of the new codes, as well as some clinical descriptions of the associated condition:

• 707.20 (Pressure ulcer, unspecified stage) -- Use this code if the internist has not specified the stage of the injury.

• 707.21 (Pressure ulcer, stage I) -- "Intact skin with non-blanchable redness of a localized area usually over a bony prominence" marks a stage I ulcer, according to an NPUAP 2007 release.

• 707.22 (Pressure ulcer, stage II) -- Stage II patients may present with an intact or open/ruptured serum-filled blister. Other characteristics of these ulcers are "partial- thickness loss of dermis presenting as a shallow, open ulcer with a red/pink wound bed, without slough," the NPUAP reports.

• 707.23 (Pressure ulcer, stage III) -- Stage III ulcer sufferers will have full-thickness tissue loss; there may be subcutaneous fat visible at the injury site, but there is no exposure of bone, tendon or muscle. The internist may use undermining or tunneling on stage III ulcer patients.

• 707.24 (Pressure ulcer, stage IV) -- Patients with stage IV ulcers will have full-thickness tissue loss with some exposed bone, tendon or muscle. The internist very often selects undermining or tunneling for these patients, NPUAP says.