Internal Medicine Coding Alert

But 425.1 will bring instant denials as of October 1.

Don't consider your ICD-9 2012 update lists final until you've studies these late additions for coronary atherosclerosis and hypertrophic cardiomyopathy.

Although coders get a sneak peek at ICD-9 changes each summer in CMS's proposed Inpatient PPS rule, those changes aren't the last word for updates. The codes below

weren't finalized in time to be included in the proposed rule, but they are effective Oct. 1, 2011, all the same.

414.4 Helps Single Out Coronary Lesions

ICD-9 2012 adds 414.4 (Coronary atherosclerosis due to calcified coronary lesion), following a proposal by Jeffrey Chambers, MD, for a unique code for severely calcified coronary lesions (ICD-9-CM Coordination and Maintenance Committee Meeting, March 9-10, 2011 www.cdc.gov/nchs/data/icd9/2011March_Summary_%20HA.pdf).

Chambers' goal was to be able to distinguish a calcified lesion from other ischemic lesions, according to the Meeting Agenda (www.cdc.gov/nchs/data/icd9/TopicpacketforMarch2011_HA1.pdf). Calcified lesions are not the same as lipid rich plaque (414.3, Coronary atherosclerosis due to lipid rich plaque) and chronic total occlusions (414.2, Chronic total occlusion of coronary artery). And 414.8 (Other specified forms of chronic ischemic heart disease) is too general to pinpoint the nature of the lesion.

Calcified lesions "can be detected both by x-ray during coronary angiography and with intravascular ultrasound," and may be more difficult to treat than other coronary lesions, the Meeting Agenda notes. If the physician can't cross the calcified lesion, he may have to discontinue the treatment and the patient may then require medical management or a more invasive procedure.

Term tip: The code definition states "calcified coronary lesion," but a note with the code clarifies that it is appropriate when the physician documents "Coronary atherosclerosis due to severely calcified coronary lesion."

"Severely" is an important part of the diagnosis, Chambers said. But coders may not see the term "severely" in the documentation, noted Jeffrey Linzer, MD, representing the American Academy of Pediatrics at the meeting.

Another instruction with 414.4 tells you to "Code first coronary atherosclerosis (414.00-414.07)." So your first-listed code should indicate the atherosclerosis (such as 414.01, Coronary atherosclerosis of native coronary artery). Then report 414.4 if the physician documents the condition is related to a calcified coronary lesion.

425.1 Now Requires a 5th Digit

In response to a proposal from Jerre F. Lutz, MD, of the Emory Clinic, ICD-9 2012 features new coding options for hypertrophic cardiomyopathy, effective Oct. 1, 2011.

Reason: "Hypertrophic cardiomyopathy can have two levels of manifestation, obstructive or nonobstructive. Whether or not it is obstructive can impact the need for different medical or surgical treatments," the Meeting Agenda states.

2011: Under ICD-9 2011, 425.1 was a valid code defined as "Hypertrophic obstructive cardiomyopathy." If you needed to report nonobstructive hypertrophic cardiomyopathy, you reported 425.4 (Other primary cardiomyopathies).

2012: The update revises 425.1 (now defined as Hypertrophic cardiomyopathy) so that it is no longer a valid code ��" you must add a fifth digit for it to be valid:

• 425.11, Hypertrophic obstructive cardiomyopathy Hypertrophic subaortic stenosis (idiopathic)
• 425.18, Other hypertrophic cardiomyopathy Nonobstructive hypertrophic cardiomyopathy.

The changes give you one code for hypertrophic obstructive (425.11) and another code for other hypertrophic, including nonobstructive (425.18). To conform with the changes to the 425.1x range, ICD-9 deletes the terms "hypertrophic" and "nonobstructive" from under 425.4.