Oncology & Hematology Coding Alert

Now is definitely the time to prepare for the upcoming tumor and effusion diagnosis code switch that ICD-9 2009 has in store for you.

Watch for: These changes include the new 209.xx coding series, which contains over 40 new options for coding carcinoid tumors to the highest possible degree of specificity.

Since HIPAA's passage, there is no grace period for new ICD-9 codes. You have to be ready to hit the ground running for the new codes on Oct. 1, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Chicago. If you send in 2008 codes after your payer updates its code list, you-re sure to see denials.

CMS has approved the following codes for use, but slight changes are possible before the list is finalized over the summer. For all the latest news on ICD-9 2009, check out future issues of Oncology & Hematology Coding Alert.

You will receive a powerful new tool for increased coding specificity on Oct. 1, when the 209.xx series goes into effect.

The M.D. Anderson Cancer Center asked for a new category specifically identifying malignant and benign neuroendocrine tumors, and ICD-9 2009 will include carcinoid tumor code range 209.xx as a result.

These new codes cover three general areas primarily involving carcinoid tumors, as well as carcinomas. These codes bring an increased focus on very specific locations for these conditions. These new coding subcategories are as follows:

- 209.00-209.29 -- Malignant carcinoid tumors

- 209.30 -- Malignant poorly differentiated neuroendocrine carcinoma, any site

Note: Code 209.30 is the only new code for neuroendocrine tumors.

- 209.40-209.69 -- Benign carcinoid tumor.

FYI: A carcinoma is any malignant cancer arising from epithelial cells, while Dorland's Illustrated Medical Dictionary notes that "carcinoid" is used to describe "a yellow circumscribed tumor arising from enterochromaffin cells, usually in the small intestine, appendix, stomach, or colon and less commonly in the bronchus."

These new codes offer a more precise option and will provide more accurate statistics than the current 2008 options, 157.4 (Malignant neoplasm of pancreas; Islets of Langerhans) and 259.2 (Other endocrine disorders; carcinoid syndrome), says James C. Yao, MD, associate professor with the University of Texas M.D. Anderson Cancer Center, in his presentation on the new codes, "Neuroendocrine Tumors" at http://www.cdc.gov/nchs/ppt/icd9/att2_Yao_Sep07.ppt#683, 8 -- Neuroendocrine Tumors: Current Situation (1).

Here's an in-depth look at how these codes will work using bronchus and lung examples featuring 2009 codes 209.21 (Malignant carcinoid tumor of the bronchus and lung) and 209.61 (Benign carcinoid tumor of the bronchus and lung).

You currently report 162.9 (Malignant neoplasm of trachea, bronchus and lung; bronchus and lung, unspecified) for malignant lung/bronchial tumors unless the notes indicated a specific section of the bronchus, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

When these tumors are benign, you choose 212.3 (Benign neoplasm of respiratory and intrathoracic organs; bronchus and lung), regardless of specified area, she says.

The addition of 209.21 and 209.61 will end the practice of scrambling to different code sets for carcinoid tumor diagnoses, depending on the tumor type.

For instance: You-ll use these 209.xx codes on your lung biopsy claims that result in a diagnosis of carcinoid tumor, says Alan L. Plummer, MD, professor of medicine at Emory University School of Medicine in Atlanta. These could be repeat biopsies in which you already have a diagnosis, or initial biopsies in which the physician is unsure of the patient's status.

Example: The physician performs bronchial biopsies on a mass in a patient's upper bronchus. Pathology reports come back indicating a malignant carcinoid tumor.

Beginning Oct. 1, report the following:

- 31625 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy[s], single or multiple sites) for the bronchoscopy

- 209.21 (Malignant carcinoid tumor of the bronchus and lung) linked to 31625 to represent the tumor diagnosis.

Be sure you read the descriptors carefully before choosing 209.21 or 209.61 to avoid reporting a benign diagnosis when you should be reporting one that is malignant, or vice versa.

ICD-9 2009 will also bring changes to the pleural effusion code set (511.xx). The new code on the 511.xx block is 511.81 (Malignant pleural effusion). Use this diagnosis code when the pleural fluid is cancerous, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

"A malignant pleural effusion is caused by a cancerous invasion of the pleura. This could be due to cancer within the lung or metastatic disease from any other organ (such as the colon or kidney)," Plummer says. When reporting 511.81, be sure to code for the source of the primary tumor as well, he says.

Now ICD-9 refers coders to 197.2 (Secondary malignant neoplasm of respiratory and digestive systems; pleura) for a malignant pleural effusion, Pohlig says.

But on Oct. 1, you should replace 197.2 with 511.81 for your malignant effusion patients to code accurately and avoid a denial.

Example: X-ray results brought to the physician's office indicate that the patient has a probable malignant pleural effusion from a primary main bronchus malignancy. Beginning Oct. 1, here's how you-ll report the Dx codes for this encounter:

- 511.81 to represent the malignant effusion (Caution: You should wait for the final diagnosis from cytology on the pleural fluid)

- 162.2 (Malignant neoplasm of trachea, bronchus and lung; main bronchus) to represent the underlying cancerous condition.

To make room for 511.81, ICD-9 will move 511.8 (Other specified forms of effusion, except tuberculosis) to 511.89. "The -catchall- descriptor for 511.89 remains the same as it was for 511.8," Plummer says.

Note: But remember, if you continue to use 511.8 after Oct. 1, your claims will be denied for an "invalid diagnosis" code.

For more information: Please feel free to e-mail joec@eliresearch.com for a PDF copy of CMS-1390-P containing the complete listing of all of the preliminary ICD-9 changes.