Neurosurgery Coding Alert

Avoid symptom centricity and choose a specific code.

ICD-10 brings several new Parkinson’s diagnosis options to consider, so accurate coding will depend on how many details your providers include in their documentation. You will need to make sure you know what is the underlying cause for the symptoms your provider has listed, i.e., tremor, rigidity, gait abnormality, dementia, and others.

Currently, ICD-9-CM has two diagnoses for Parkinson’s disease, and each qualifies the types of conditions included:

• 332.0 (Paralysis agitans) encompasses idiopathic or primary forms of Parkinsonism or Parkinson’s disease, or Parkinson’s NOS.
• 332.1 (Secondary Parkinsonism) includes neuroleptic-induced Parkinsonism or Parkinsonism due to drugs.

ICD-10 changes: Diagnosis 332.0 will change to G20 (Parkinson’s disease) under ICD-10. Coding guidelines state that you shouldn’t report G20 for dementia and Parkinsonism; instead, submit G31.83 under ICD-10. “This is an example of the greater granularity you will see with the update to ICD-10,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Find Specific Code for Secondary Parkinsonism

Diagnosis 332.1 will expand to numerous specific codes instead of a single catch-all code for secondary Parkinsonism. Each code for secondary Parkinsonism excludes dementia with Parkinsonism (G31.83), Huntington’s disease (G10), Shy-Drager syndrome (G90.3), and syphilitic Parkinsonism (A52.19).

Your new options for 332.1 will include:

• G21.0 -- Malignant neuroleptic syndrome
• G21.11 -- Neuroleptic induced Parkinsonism
• G21.19 -- Other drug induced secondary Parkinsonism
• G21.2 -- Secondary Parkinsonism due to other external agents
• G21.3 -- Postencephalitic Parkinsonism
• G21.4 -- Vascular Parkinsonism
• G21.8 -- Other secondary Parkinsonism
• G21.9 -- Secondary Parkinsonism, unspecified.

Several of the new Parkinson’s diagnoses direct you to first code the drug or external agent causing secondary Parkinsonism. Start encouraging your providers to be more specific with their documentation now, for an easier ICD-10 transition later.

Do Not Keep Symptom Focus

Your physician may be treating a patient for a gait disorder. Gait abnormality is a common feature of Parkinson’s disease but listing 781.2 (Abnormality of gait) rather than 332.0 doesn’t really address the treatment that your physician is providing in this case. “One should always try to report a diagnosis rather than a symptom when a diagnosis is known,” says Przybylski.

“You need to look beyond the symptom to locate the definitive diagnosis in the clinical records.”Always drill down to the cause,” says Arlynn Hansell, PT, HCS-D, HCS-O, COS-C clinical excellence program manager at American Mercy Home Care in Cincinnati, Ohio. “Why does the patient have abnormality of gait? Why is the patient falling? You should be able to land on a definitive diagnosis.” Coders should seek to find out what the pathology is and code for that, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCS-O, director of coding with Foundation Management Services in Denton, Texas.

Beware Of the Dementia Component

Exercise caution when you are reporting the diagnosis of dementia with Parkinson’s disease. When your physician confirms that the dementia is associated with Parkinson’s, you can assign a code from the 294.1 subcategory (Dementia in conditions classified elsewhere). These codes are used to indicate the presence (294.11) or absence (294.10) of behavioral disturbances such as aggressive behavior, combative behavior, violent behavior or wandering off. The behavioral aspect of the dementia plays an important role in the treatment and long-term care of patients suffering from this condition.

Note: Your ICD-9 manual instructs you to list the underlying condition first when reporting a code from the 294.1 category. So, if the link between the dementia and the Parkinson’s disease is confirmed, you’ll want to list the Parkinson’s first. Nail down which condition the patient really has, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Be specific: Make sure you list 331.82 (Dementia with lewy bodies) rather than 332.0 for the Parkinson’s disease if there is a causal link. Code 332.0 specifically excludes dementia with Parkinsonism. “One should always try to report the most descriptive diagnosis code possible,” says Przybylski.