Medicare Compliance & Reimbursement

Use these tactics to help your physician's documentation line up with new specific coding options.

You can get a head start on the mental shift from ICD-9 2007 to ICD-9 2008 today with this preview of the codes you'll soon be using for brain imaging, swallowing studies, and more.

Note: Consider these changes tentative until ICD-9 releases the final list, which may include more changes.

Remember: You must begin using ICD-9 2008 codes for services on Oct. 1, 2007.

1. Forget 331.3 For INPH

The preliminary list of 2008 ICD-9 codes includes 331.5 (Idiopathic normal pressure hydrocephalus [INPH]).

"Normal pressure hydrocephalus is a relatively common finding in head imaging studies, but ICD-9 has not contained a specific code for this condition," says radiology coding expert Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, GA.

The most appropriate code for the condition in ICD-9 2007 is 331.3 (Communicating hydrocephalus).

With the addition of 331.5, providers will be able to show the specific type of documented hydrocephalus, Miller says.

A separate code for this clinically treatable, distinct hydrocephalus form is especially important because it is common in the elderly population, which is increasing, says Michael A. Williams, MD, with the adult hydrocephalus program at Johns Hopkins, in his presentation to the ICD-9 committee: "Support for Creation of an ICD-9 Code for Normal Pressure Hydrocephalus."

Resource: You can find behind-the-scenes information on the new codes in the ICD-9-CM Coordination and Maintenance Committee minutes, online at www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm, Miller says.

2. Point Out Increased CTO Procedure Complexity

Interventional radiologists have to put in extra work to help patients with chronic total occlusion (CTO), and you'll soon have a code that will clue payors in to the added complexity of the procedure right away: 440.4 (Atherosclerosis; chronic total occlusion of artery of the extremities).

"Chronically occluded vessels are very difficult or impossible to cross with a guide wire," Miller says. The physician has to get a guide wire across the lesion before placing a balloon catheter to dilate the lesion, and there are a variety of new devices available to get through the blockage, she adds.

3. Chew On 6 New Dysphagia Codes

"Radiologists do several types of exams designed to study the swallowing function," Miller says. And the swallowing process has several phases as the food bolus moves from the mouth to the pharynx to the esophagus, she says.

ICD-9 2007 offered only one dysphagia code, 787.2 (Dysphagia), so you could not identify the malfunctioning part of the cycle with your code, she says.

The preliminary ICD-9 2008 list shows many codes that will help you report the condition with greater specificity:

• 787.20--Dysphagia, unspecified
• 787.21--Dysphagia, oral phase 
• 787.22--Dysphagia, oropharyngeal phase
• 787.23--Dysphagia, pharyngeal phase
• 787.24--Dysphagia, pharyngoesophageal phase
• 787.29--Other dysphagia.

Problem: More specific codes can create problems if your physicians' documentation doesn't match your new options.

Solution: Give your physicians a job aid listing the more specific codes, says South Carolina reimbursement and coding professional Erin Goodwin, CPC, CMC. Send an e-mail or memo with the new codes, and let them know that better documentation has the double benefit of helping you do your job more efficiently and backing up what you billed when the payor asks for records, she says.

4. Move Malignant Ascites Search To Back Of Book

The preliminary ICD-9 2008 list adds a code for malignant ascites in Chapter 16 (Symptoms, Signs and Ill-Defined Conditions), Miller says. You have another code for other ascites:

• 789.51--Malignant ascites
• 789.59--Other ascites.

Malignant ascites is ascites, or excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity), containing cancer cells.

The new malignant ascites code is an improvement because ICD-9 2007 indexes malignant ascites under 197.6 (Secondary malignant neoplasm of respiratory and digestive systems; retroperitoneum and peritoneum), but the 197.6 entry doesn't reference ascites, Goodwin says. Snag: Code 789.51 is in the signs and symptoms chapter of the ICD-9 manual rather than being listed in a malignant code category.

5. Hail More Specific TIA Hx Code

ICD-9 2008 should offer you a better way to report history of a transient ischemic attack (TIA) when a patient presents for subsequent diagnostic studies, such as brain MRI, following a previous TIA, Miller says.

You'll be able to report V12.54 (Personal history of transient ischemic attack [TIA], and cerebral infarction without residual deficits) rather than your current options of coding the TIA as a current condition (such as 435.9, Unspecified transient cerebral ischemia) or using a non-specific history code (V12.59, Personal history of certain other diseases; disease of circulatory system; other), which payors typically don't cover, Miller says.

Plan ahead: When you get the official list of new codes, type up a list for each coder in your department to post on her desk or computer as a reminder, Goodwin says. And be sure to update your software system to alert you if you try to use a deleted code.

Resource: The code changes were published as part of the Inpatient Prospective Payment System notice of proposed rule making (IPPS NPRM) on April 13 as Tables 6A-F, starting at the bottom of page 867: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-P.pdf.