Internal Medicine Coding Alert

Chronic embolism, swine flu codes top the list of respiratory coding changes.

If you've struggled with how to indicate an existing clot, an H1N1 outbreak, or a sedation failure, ICD-9 2010 solves the puzzle.

Starting Oct. 1, new diagnosis codes for a chronic pulmonary artery clot, swine flu, and failed sedation procedures let you explain these situations. Here's how to paint a more accurate picture to payers and when to use these ICD-9 additions.

Add 416.2 (Chronic pulmonary embolism) to your repertoire of diagnosis codes. Report the new pulmonary embolism code when a patient with unexplained dyspnea (786.09) or with a history of pulmonary hypertension (416.8) displays evidence of pulmonary embolism on a CT scan or pulmonary angiogram, without evidence of a recent event, explains Philip Marcus, MD, MPH, FACP, FCCP, chief of pulmonary medicine at the St. Francis Hospital Heart Center in Roslyn, N.Y.

Difference: Use 416.2 to explain chronic symptoms rather than a new, acute pulmonary embolism, which would necessitate reporting either 415.11 (Iatrogenic pulmonary embolism and infarction), 415.12 (Septic pulmonary embolism), or 415.19 (Pulmonary embolism and infarction; other).

Differentiating between an old or chronic thrombus (416.2) and a new or acute thrombus allows you to document the need for continuing an established therapy versus initiation or intensification of anticoagulant therapy, according to an Agency for Healthcare Research and Quality Coordination and Maintenance Committee statement.

The V code (V12.51, Personal history of venous thrombosis and embolism, pulmonary embolism) would apply when there is a history of a pulmonary embolism, but it is no longer present and not relevant to the reason for a current evaluation, Marcus clarifies.

Example 1: You may choose to report a chronic pulmonary embolism (416.2) when the internist works up a patient with secondary pulmonary hypertension (416.8) and finds an existing, undissolved clot in one of the pulmonary arteries, says Jill M. Young, CPC, CEDC, CIMC, of Young Medical Consulting in East Lansing, Mich.

Example 2: Also rely on 416.2 when a patient presents with signs and symptoms of chronic obstructive pulmonary disease (491.21) and gives a history of having a small subsegmental pulmonary embolism for which they are no longer on active therapy, Marcus offers. Don't forget to describe the event leading to a pulmonary embolism, usually from a clot arising in the deep venous system of the lower extremity, notes Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

The major difference is the distinction between acute and chronic venous embolism.

For acute embolisms, you'll use the following revised and new codes:

• 453.40 -- Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity, deep vein thrombosis NOS.

• 453.41 -- Acute venous embolism and thrombosis of deep vessels of proximal lower extremity, such as femoral, thigh, upper leg NOS

\• 453.42 -- Acute venous embolism and thrombosis of deep vessels of distal lower extremity, such as calf or lower leg NOS

• 453.84 -- Acute venous embolism and thrombosis of axillary vein

• 453.87 -- Acute venous embolism and thrombosis of other thoracic veins.

For chronic embolisms, use the following new codes:

• 453.50 -- Chronic venous venous embolism and thrombosis of deep vessels of unspecified vessels of lower extremity

• 453.51 -- Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity

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

One additional revision was for 453.2 (Other venous embolism and thrombosis of inferior vena cava), which now is more specific. This code currently describes only venous embolism and thrombosis of the vena cava.

In 2010, you have two new codes for reporting influenza: 488.0 (Influenza due to identified avian influenza virus) and 488.1 (Influenza due to identified novel H1N1 influenza virus).

Careful: Just because ICD-9 provides the codes doesn't mean you should use them. The 2009 coding guidelines instruct you to code only confirmed cases of avian influenza (488.0), which is an exception to the hospital inpatient guidelines (Section II.H) on uncertain diagnosis, relates Young. While "confirmation" does not require documentation of positive laboratory testing specific for avian influenza, you should base the coding on the provider's diagnostic statement that the patient has avian influenza.

If the provider records "suspected or probably H1NI influenza," however, do not assign 488.1 -- instead, use the appropriate influenza code from category 487. "In reality, to report a specific strain, one should have proof," says Marcus. "Otherwise, it's best to report influenza (487.x) and not speculate."

Symptoms: The similarity in symptoms among various flu strains adds to the confusion. "At the present time, there are no easy ways to decide which strain of influenza is responsible for an individual infection. In fact, with the recent outbreak of H1N1 infection, most of the presumed cases were indeed negative when specifically tested for H1N1 antigen," Marcus explains.

Since the symptoms are nearly identical, consider a diagnosis of H1N1 only when other cases have been diagnosed in the area, Marcus suggests.

ICD-9 2010 introduces two new codes to describe failed sedation attempts: 995.24 (Failed moderate sedation during procedure) and V15.80 (Personal history of failed moderate sedation).

Example 1: If the internist was performing a procedure and the moderate sedation he administered for the procedure was not effective, then you could use 995.24. To tell the insurer that the physician had to terminate the procedure before completing it, append modifier 53 (Discontinued procedure) to the procedure. Using 995.24 would help explain why the procedure was shortened or aborted.

Example 2: A patient has had sedation for a procedure that failed (995.24) and now requires another procedure with sedation. You would use V15.84 to alert the sedation staff, such as a gastroenterologist performing a colonoscopy, that the patient had a failed moderate sedation session.

View a complete list of the new and revised ICD-9 2010 codes at www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp.