Oncology & Hematology Coding Alert

See what could be coming down the pike for hemophilia, LEMS, and anaphylaxis, too.

With the next round of revisions, ICD-9 may offer a chance to report skin neoplasm types more accurately. That's the news from recently posted proposed changes for ICD-9 2012, effective Oct. 1, 2011.

Although the overall list of proposed ICD-9 updates is fairly short, quite a few apply to your oncology and hematology claims. (See this article's last section for links to the complete lists.) Here are the main proposals to watch for when the codes are finalized in the fall.

Get Specific About Basal and Squamous Cell

CMS's proposed changes to ICD-9 2012 include an expansion of 173.x (Other malignant neoplasm of skin). Each code in that series will get new fifth digit options, which will provide further details of the skin neoplasm type, says Kelly C. Loya, CHC, CPC-I, CPhT, managing consultant with Sinaiko Healthcare Consulting Inc.

The changes in the 173.xx skin cancer codes follow a pattern where the fifth digit of "0" refers to an unspecified malignant neoplasm, "1" denotes basal cell cancer (BCC), "2" refers to squamous cell carcinoma (SCC), and "9" describes "other" specified malignant neoplasm. BCC and SCC are the two most common types of skin cancer.

The ICD-9 Coordination and Maintenance Committee expanded the code series following a request from the New York State Cancer Registry to help distinguish reportable skin cancers from non-reportable skin cancers, such as BCC and SCC. The way these common neoplasms behave clinically is different enough that separating them would be useful, according to National Center for Health Statistics (NCHS) medical officer David Berglund, MD, at the September 2010 ICD-9 committee meeting (page 55-57, www.cdc.gov/nchs/data/icd9/Transcript91610Morning.pdf).

Example: Under ICD-9, you report 173.0 (Other malignant neoplasm of skin of lip) for any non-melanoma malignant lip neoplasm. But using the proposed codes, you will choose from:

• 173.00, Unspecified malignant neoplasm of skin of lip
• 173.01, Basal cell carcinoma of skin of lip
• 173.02, Squamous cell carcinoma of skin of lip
• 173.09, Other specified malignant neoplasm of skin of lip.

Caution: The expansion means the four-digit 173.x codes will become invalid in October because each code in the range will require a fifth digit to be complete. "Preparing for the new and revised ICD-9 code changes requires creating better documentation habits. Encourage practitioners to document the type, specific location, and nature of the disease process when it is known," says Loya. For example, you may code a case of primary SCC (neck) with positive cervical nodal involvement using new code 173.42 (Squamous cell carcinoma of scalp and skin of neck) with 196.0 (Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck).

Not only will improving documentation allow you to code these conditions more specifically beginning October 2011, but it will help prepare you for ICD-10's general increase in documentation requirements, Loya says. The switch to ICD-10 is planned for October 2013.

Acquired Hemophilia Earns Its Own Code

You also should plan for ICD-9 2012 to expand current four-digit code 286.5 (Hemorrhagic disorder due to intrinsic circulating anticoagulants) into a new range of five-digit codes:

• 286.52, Acquired hemophilia
• 286.53, Antiphospholipid antibody with hemorrhagic disorder
• 286.59, Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors.

The changes allow for more specific identification and will help track "trials on the cause, self-correction, and pharmaceutical treatment of these disease types of hemophilia," Loya explains. Pharmaceutical company Novo Nordisk requested the revisions (pages 52-54, www.cdc.gov/nchs/data/icd9/Transcript91610Morning.pdf).

Terms you may see connected to 286.52 include autoimmune hemophilia, autoimmune inhibitors to clotting factors, and secondary hemophilia. Code 286.53 may be used most often to report the hemorrhagic disorder with an antibody known as lupus anticoagulant or systemic lupus erythematosus.

Learn Where to Search for LEMS

ICD-10 2012 may add three new codes related to Lambert-Eaton myasthenic syndrome (LEMS):

• 358.30, Lambert-Eaton syndrome, unspecified
• 358.31, Lambert-Eaton syndrome in neoplastic disease
• 358.39, Lambert-Eaton syndrome in other diseases classified elsewhere.

LEMS is an autoimmune condition in which the electrical impulses between nerves and muscle cells are disrupted.

Take note that 358.31 is a neoplastic-associated diagnosis, says Loya. "LEMS is closely associated with cancer, in particular small cell lung cancer," states the March 9-10, 2010, Diagnosis Agenda (page 18, www.cdc.gov/nchs/data/icd9/TopicpacketforMarch2010.pdf).

Under ICD-9 2011, LEMS falls under 358.1 (Myasthenic syndromes in diseases classified elsewhere). The code has an instruction to "code first underlying disease." For example, you may choose the appropriate malignant neoplasm code from 140.0-208.9. Be sure to watch for similar coding instructions when reporting 2012 codes.

Tip: If you try to look up "Syndrome, Lambert-Eaton" in ICD-9 2011, you'll be out of luck. You instead have to go to "Syndrome, Eaton-Lambert" or "Eaton-Lambert syndrome."

The proposed codes change the word order (from Eaton-Lambert to Lambert-Eaton) because ICD-10's definition for G73.1 (Lambert-Eaton syndrome) places the term Lambert before Eaton, noted NCHS's Beth Fisher at the March 10, 2010, ICD-9 committee meeting (page 20, www.cdc.gov/nchs/data/icd9/Transcript3_10_2010.pdf).

Update Your Anaphylaxis Terminology

If you need to code anaphylactic or serum reactions underICD-9 2012, be sure to check the index. A variety of new codes will shift the options you may be used to.

995.0: ICD-9 2011 defines 995.0 as "Other anaphylactic shock." A proposed change for ICD-9 2012 would change this to "Other anaphylactic reaction." This change will help clarify that the code is appropriate for anaphylactic reaction even if it doesn't advance to shock. Chances are your physician refers to "anaphylaxis" rather than anaphylactic shock, noted Jeffrey Linzer, MD, representing the American Academy of Pediatrics at the ICD-9 committee's March 10, 2010, meeting (page 3, www.cdc.gov/nchs/data/icd9/March10CMsum.pdf).

999.4x-999.5x: ICD-9 2012 proposes to expand 999.4 (Anaphylactic shock due to serum, not elsewhere classified) and 999.5 (Other serum reaction, not elsewhere classified) so that you must use a fifth digit. The changeswill allow you to report more specific information regarding the cause of the adverse reaction (and provides another reason for a documentation improvement initiative), Loya notes. The proposed codes are:

• 999.41, Anaphylactic reaction due to administration of blood and blood products
• 999.42, Anaphylactic reaction due to vaccination
• 999.49, Anaphylactic reaction due to other serum
• 999.51, Other serum reaction due to administration of blood and blood products
• 999.52, Other serum reaction due to vaccination
• 999.59, Other serum reaction.

V13.8x: Current code V13.8 (Personal history of other specified diseases) also will likely see an expansion to:

• V13.81, Personal history of anaphylaxis
• V13.89, Personal history of other specified diseases.

This change makes V13.89 the new "catch all" history code because V13.8 will no longer be a valid code, warns Loya.

Here's Where to Learn More

CMS has posted the proposed codes as part of the FY2012 Hospital Inpatient PPS proposed rule. As of publication time, you can find the complete lists of proposed changes by going to www.cms.gov/AcuteInpatientPPS/IPPS2012/list.asp and choosing the link for "FY 2012 Proposed Rule and Correction Notice Tables." On the new page, click the link to download tables 6A-6F. Table 6A shows new diagnosis codes, table 6C shows invalid codes, and table6F shows revised codes.

You'll find code proposals, meeting summaries, and transcripts at www.cdc.gov/nchs/icd/icd9cm_maintenance.htm, with additional resources at www.cms.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp.

Final note: The list of proposed ICD-9 updates is shorter than you may be accustomed to. That's as expected for this soon-to-be-obsolete system, notes Loya. These limited updates are in accordance with section 503(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. For the same reason, you can expect to see only limited updates to ICD-9 codes that will go into effect Oct. 1, 2012.