Internal Medicine Coding Alert

Now you can describe significant pain with these new ICD-9 codes

Simpler times ahead: Beginning Oct. 1, you'll no longer have to submit paperwork to identify "acute bronchospasm" thanks to ICD-9 2007, which creates this and more than 200 other designations.
 
Internists should mainly be concerned with two changes related to respiratory system conditions, says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP in Fort Lauderdale, Fla. Although you will face a large list of new ICD-9 codes this fall, many "are not likely to be common management diagnoses for an internist," he says. Here are some of the additions that you should be concerned with.

Revamp Your System With 2 Pulmonology Changes

When you update your superbill this fall, make sure to add a specific code for acute bronchospasm (519.11, Acute bronchospasm). ICD-9 2007 separates out acute bronchospasm and identifies it as a separate and distinct condition, says Carol Pohlig, BSN, RN, CPC, in the department of medicine at Hospital of the University of Pennsylvania in Broomall.
 
That's a big change from the current two-tiered approach. "You have to identify it as a general acute component of another condition (such as acute exacerbation of bronchiolitis, emphysema, bronchitis, COPD, etc.) or lump it into the general category (519.1, Other diseases of trachea and bronchus, not elsewhere classified) if no other disease process is present," Pohlig says.
 
Don't forget: To avoid denials when you do have to use the other code, starting Oct. 1 add a fifth-digit of 9 to the current "other code." In other words, 519.1 will become 519.19.

Use Pain Dx to Support Services

Until the introduction of the new pain section (338.x), you've never had a way to describe "significant" pain like "acute pain due to trauma" (338.11), says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, coding manager for the University of Washington's physician group in Seattle. That includes pain that is outside what you'd expect (e.g., 338.29, Other chronic pain), or requiring extra treatment (e.g., 338.21, Chronic pain due to trauma) such as joint injections (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) or pain service visits (e.g. 99201-99215, new or established patient office visit), Bucknam says.
 
Benefit: The ability to code for acute (338.18, Other acute postoperative pain) or chronic (338.28, Other chronic postoperative pain) postoperative pain will be useful for several different purposes, says Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies in Powder Springs, Ga.
 
For example, you can use these codes to justify a pain management visit (99201-99215), admitting a patient postoperatively (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...), or prolonging the patient's hospital stay (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).
 
The new section also describes syndromes including
 
• 338.0 -- Central pain syndrome
 
• 338.4 -- Chronic pain syndrome.

Emphasize Test's Exact Reason With New Sign Dx's

The march toward specificity continues with more options that get you out of the taboo "other" or "other specified" zone. "I always like it when ICD-9 offers more specific signs and symptoms," says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va. "It helps to support the medical necessity of diagnostic tests and exams." Look for these opportunities to better describe a patient's symptom.
 
Opportunity 1: A patient has a postnasal drip, but the internist doesn't diagnose the patient with allergies. You now end up with a potential payment problematic "other" code (784.9, Other symptoms involving head and neck). But ICD-9 2007 will allow you to pinpoint the symptom with specific code 784.91 (Postnasal drip). The "other" code will also morph into a fifth-digit code: 784.99 (Other symptoms involving head and neck).
 
Chance 2: You'll be able to avoid another "other" code when an internist orders an MRI of the brain due to altered mental status. Now, you have to use 780.99 (Other general symptoms) to explain this procedure. Starting in October, you'll be able to use 780.97 (Altered mental status), Miller says.
 
Another option: New symptom codes will also exist to describe additional urination abnormalities. Indicate urinary hesitancy (788.64) and straining on urination (788.65) with specific codes, rather than an "other" code (788.69).

Mark 4, Not 5 Numbers in These IM Sections

Each year, ICD-9 turns numerous four-digit codes into five-digit codes, and 2007 is no exception. The following nuggets highlight four of these chapter-specific changes.
 
Neoplasms: The unspecified code for myelodysplastic syndrome (238.7, Other lymphatic and hematopoietic tissues) will require a fifth digit of "5" (238.75, Myelodysplastic syndrome, unspecified). You'll also have an exact code for thrombocythemia (238.71, Essential thrombocythemia).
 
Blood and blood-forming organs: Neutropenia was covered under agranulocytosis (288.0), but now it has its own codes (288.00-288.09), including cyclic neutropenia (288.02) and drug-induced neutropenia (288.03). The update also adds 11 other codes for white blood cell count disorders (288.4-288.69).
 
Digestive system: 528.00 (Stomatitis and mucositis, unspecified) breaks out into four codes, including two for ulcerative mucositis due to antineoplastic therapy (528.01) and due to other drugs (528.02).
 
Injury and poisoning: ICD-9 2007 also adds fifth digits to code 995.2 for unspecified adverse effect of drug. The six new codes will allow you to identify unspecified effects of insulin (995.23), other drug allergy (995.27) or other substance (995.29), as well as requiring a "0" for effects of an unspecified substance (995.20).
 
"Prior to the creation of these new adverse effect codes, reactions/effects to these types of drugs were generalized, assigning them to the same unspecified code (995.2)," Pohlig says. Benefit: "It always helps coders, insurers, and patient care when a condition can be reported to the highest level of specificity."
 
Catch a further glimpse: For a complete list of new codes that affect internists, e-mail the editor, Jennifer Godreau, at jgodreau@medville.com with the subject line "IM ICD-9 2007."