Medicare Compliance & Reimbursement

Confirm documentation before you report the new morbid obesity codes.

Come October 1, you must be ready to report the new and changed 2011 ICD-9 codes. Now that CMS has finalized the update, you can get a jump start on the changes.

Starting in October, you'll need to code with a higher degree of specificity when it comes to reporting fluid overload.

2010's 276.6 (Fluid overload) category will expand to include the following:

276.61 -- Transfusion associated circulatory overload

276.69 -- Other fluid overload.

Transfusion-associated circulatory overload (TACO), a heart-related condition, "is a circulatory overload following transfusion of blood or blood components," said Mikhail Menis, PharmD, MS, of the FDA CBER, who presented the proposal for this change at the September 2009 ICD-9-CM Coordination and Maintenance Committee meeting.

The patient may experience "acute respiratory distress, increased blood pressure, pulmonary edema secondary to congestive heart failure, positive fluid balance, etc., during or within 6 hours of transfusion."

The new code 276.69 includes fluid retention. Another related addition at 782.3 (Edema) excludes fluid retention.

Codes in the 488.0x (Influenza due to identified avian influenza virus) and 488.1x (Influenza due to identified novel H1N1 influenza virus) subcategories will provide greater specificity, come October. The co-operating parties figured out that these sub-categories didn't provide the level of detail that category 487 (Influenza) does; so they have expanded the codes at 488.0 and 488.1. That means six new influenza with pneumonia codes for the 2011 ICD-9 update:

488.01 -- Influenza owing to identified avian influenza virus with pneumonia

488.02 -- Influenza owing to identified avian influenza virus with other respiratory manifestations

488.09 -- Influenza owing to identified avian influenza virus with other manifestations

488.11 -- Influenza owing to identified novel H1N1 influenza virus with pneumonia

488.12 -- Influenza owing to identified novel H1N1 influenza virus with other respiratory manifestations

488.19 -- Influenza owing to identified novel H1N1 influenza virus with other manifestations.

Tip: If you've previously wondered how to code for encephalopathy as a late effect of H1N1, 488.19 is your code.

You'll also find that ICD-9 2011 adds specificity to fecal-related diagnoses with the following five new codes:

560.32 -- Fecal impaction

787.60 -- Full incontinence of feces

787.61 -- Incomplete defecation

787.62 -- Fecal smearing

787.63 -- Fecal urgency.

"The new fecal incontinence code (787.60) is a change that we will have to remember," says Lisa Selman-Holman, JD, BSN, RN, HCSD, COSC, consultant and principal of Selman- Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. The new code for fecal impaction excludes constipation, Selman-Holman says.

Post-traumatic seizures are acute, symptomatic seizures following a head injury. In a Centers for Disease Control & Prevention release, the ICD-9-CM Coordination and Maintenance Committee explains that "a unique code for this type of seizure is important because these patients need to be followed for treatment as well as prognostic and epidemiologic considerations."

Result: The creation of 780.33 (Post traumatic seizures) will further specify this type of seizure. Currently, you must look to the 780.3x (Convulsions) subcategory in order to report a patient's symptoms.

As with other kinds of seizures, post-traumatic seizures may not occur until weeks or months after the injury, when the seizure may be considered a late effect of the head injury. But before you code for a seizure as a late effect, you'll need documentation that shows the causal relationship between the current condition/symptom/sign and the underlying etiology.

Bottom line: Rely on documentation to determine whether to also code one of the late effects ICD-9 codes, such as 907.0 (Late effect of intracranial injury without mention of skull fracture), as a secondary diagnosis.

The 2011 ICD-9 update expands the body mass index (BMI) codes to demonstrate higher BMIs with five new codes. In the past, you had just one V code to represent a BMI index over 40 (V85.4), but the new edition of ICD-9 will provide additional sub-classifications, ranging from a BMI of 40.0 to 44.9 (V85.41) through a BMI of 70 and over (V85.45).

Official guidelines state that BMI can be coded based on clinical assessment, however obesity must be documented by the physician before you can list a code for it, Selman-Holman says.

You'll find two new codes for patients who have previously had a pancreatectomy:

V88.11 -- Acquired total absence of pancreas

V88.12 -- Acquired partial absence of pancreas.

These codes will help provide additional information about patients with low insulin (251.3, Postsurgical hypoinsulinemia) following pancreatectomy. But until Oct. 1, you should continue using V45.79 (Other acquired absence of organ) to describe this condition.

Several of the new ICD-9 codes fall under categories with current diagnosis codes. These include newly expanded 287.4 (Secondary thrombocytopenia) which now includes:

287.41 -- Posttransfusion purpura and

287.49 -- Other secondary thrombocytopenia.

This change will allow precise reporting of posttransfusion purpura (PTP), which usually arises five to 12 days after transfusion of blood components, Menis noted in his presentation.

Four new aortic ectasia codes also fall under a current category.

"Ectasia" means dilation or enlargement, and aortic ectasia typically refers to enlargement that is milder than an aneurysm. But ICD-9 2010 does not distinguish ectasia from aneurysm, indexing aortic ectasia to 441.9 (Aortic aneurysm of unspecified site without mention of rupture) and 441.5 (Aortic aneurysm of unspecified site, ruptured).

The 2011 codes are specific to aortic ectasia and differ based on anatomic site:

447.70 -- Aortic ectasia, unspecified site

447.71 -- Thoracic aortic ectasia

447.72 -- Abdominal aortic ectasia

447.73 -- Thoracoabdominal aortic ectasia.

You'll also note the addition of 724.03 (Spinal stenosis, lumbar region, with neurogenic claudication). The code refers to lumbar spinal stenosis, which is a narrowing of the spinal canal, according to the Sept. 16-17, 2009, ICD-9-CM Coordination and Maintenance Committee meeting proposal available at www.cdc.gov/nchs/icd/icd9cm_maintenance.htm. Neurogenic claudication "is a commonly used term for a syndrome associated with significant lumbar spinal stenosis leading to compression of the cauda equina (lumbar nerves)," the proposal states.

ICD-9 2010 includes 724.02 (Spinal stenosis, other than cervical; lumbar region). Andelle Teng, MD, a spine and orthopedic surgeon in Washington, requested a code addition to differentiate patients with and without neurogenic claudication because "with" is a possible surgical condition. The 2011 proposal revises 724.02 to "Spinal stenosis, lumbar region, without neurogenic claudication," in contrast to the 724.03 proposal for patients with claudication.

On the bench: Although CMS had hinted that new codes and modifications to better describe congestive heart failure, multiple sclerosis, complications of cystostomies and aspirationpneumonia resulting from a procedure, these changes didn't make the 2011 update.