Oncology & Hematology Coding Alert

Everything from TACO to iron overload has a chance at more specific options.

If you have patients who receive blood transfusions, prepare for some major changes to your diagnosis coding choices in the fall. CMS has posted proposed updates for ICD-9 2011, and transfusion-reaction codes are front and center.

Remember: ICD-9 2011 will go into effect Oct. 1, 2010. The official version will be released in the fall, so the codes below are not yet final.

Expand Your Iron Overload Options

If you need to code hemochromatosis, ICD-9 2010 directs you to 275.0 (Disorders of iron metabolism). But you may have more specific options under ICD-9 2011. The plan is to make 275.0 invalid and replace it with the following:

275.01 -- Hereditary hemochromatosis

275.02 -- Hemochromatosis due to repeated red blood cell transfusions

275.03 -- Other hemochromatosis

275.09 -- Other disorders of iron metabolism.

Proposal: The FDA Center for Biologics Evaluation and Research (CBER) requested a code for transfusion-associated hemochromatosis (iron overload). Hemochromatosis "may result in organ damage, including heart, renal, and liver dysfunction," according to Mikhail Menis, PharmD, MS, of the FDA CBER, who presented the proposal at the September 2009 ICD-9-CM Coordination and Maintenance Committee meeting (proposals, summaries, and presentation slides are available at www.cdc.gov/nchs/icd/icd9cm_maintenance.htm).

Transfusion-associated hemochromatosis may affect sickle cell anemia patients who have repeated transfusions, noted Jeffrey Linzer Sr., MD, FAAP, FACEP, who represented the American Association of Pediatrics at the meeting. The code may be helpful when patients require chelation. You may see sequencing notes with sickle cell codes and inclusion terms added, such as Linzer's suggestion of "iron overload due to chronic transfusions," to help you match documented terms to ICD-9 definitions.

David Berglund, MD, MPH, medical officer at the CDC's National Center for Health Statistics, presented a proposal for hemochromatosis codes, as well. He noted that a code for hereditary hemochromatosis could represent HFE-associated (type 1), juvenile (type 2), transferrin receptor 2 mutations (type 3), and ferroportin mutations (type 4).

The code for "other hemochromatosis" could include diagnoses such as aceruloplasminemia and dysmetabolic iron overload syndrome, Berglund suggested.

Bottom line: When ICD-9 2011 becomes official, pay careful attention to any notes with the codes to be sure you're pairing your case to the proper ICD-9 option.Time for a New TACO Code

ICD-9 2011 also proposes to expand 2010's 276.6 (Fluid overload) to include the following:

276.61 -- Transfusion associated circulatory overload

276.69 - Other fluid overload.

Menis presented this proposal, as well. He explained that transfusion-associated circulatory overload (TACO), a heart-related condition, "is a circulatory overload following transfusion of blood or blood components." 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," he noted.

Pair PTP With 287.41

Another proposal would expand 287.4 (Secondary thrombocytopenia) to include the following:

287.41 -- Posttransfusion purpura

287.49 -- Other secondary thrombocytopenia.

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

Expect to Find FNHTR With Fevers

Patients may experience febrile nonhemolytic transfusion reaction (FNHTR) within four hours of transfusion, Menis noted. Signs include fever, chills, and rigors without hemolysis, he added.

Menis proposed the addition of 999.83 (Febrile nonhemolytic transfusion reaction [FNHTR]), which would have placed it under 999.8 (Other infusion and transfusion reaction).

The proposed rule, however, lists 780.66 (Febrile nonhemolytic transfusion reaction), placing FNHTR under 780.6 (Fever and other physiologic disturbances of temperature regulation).

Tackle Acute/Delayed for 999.xx Accuracy

A slew of other potential new transfusion-reaction codes -- shown in the chart below -- add specificity to reporting incompatibility reaction type and timing (acute or delayed).

Acute: According to Menis's presentation, acute hemolytic transfusion reaction (AHTR) is "accelerated destruction of red blood cells less than 24 hours after transfusion." Proposed codes 999.62, 999.72, 999.77, and 999.84 all specify acute.

Delayed: Delayed hemolytic transfusion reaction (DHTR), on the other hand, refers to "accelerated destruction of red blood cells which usually manifests 24 hours to 28 days (one month) after a transfusion," Menis noted. Proposed "delayed" codes include 999.63, 999.73, 999.78, and 999.85.

Incompatibility: Menis's proposal indicates the Rh incompatibility codes (such as 999.72-999.73) refer to "incompatibility related to Rh antigens (C) (D) (E) (c) (e)."On the other hand, non-ABO incompatibility codes (such as 999.77-999.78) refer to "incompatibility related to minor antigens (Duffy) (Kell) (Kidd) (Lewis) (M) (N) (P) (S), etc."

Check CMS Site for Full List

With more than 130 proposed new codes, chances are you'll need to use at least some of them for your patients. Many of the proposed codes are "V" codes, such as V49.86 (Do not resuscitate status). There are also several proposed symptom codes, including 786.30 (Hemoptysis, unspecified), 786.39 (Other hemoptysis), 787.60 (Full incontinence of feces), and 799.52 (Cognitive communication deficit).

So be sure to scan the proposed codes, and be prepared to start using the final version released in the fall. You can find the proposed codes as part of the Inpatient Proposed Payment System, available online at www.cms.gov/AcuteInpatientPPS/IPPS2010/list.asp. To review the codes, click "Files for FY2011 Proposed Rule," and then download "Proposed Tables 6A-6K." Table 6A includes proposed new codes, Table 6C shows the proposed deletions, and Table 6E has revised diagnosis code titles.