Oncology & Hematology Coding Alert

Pancytopenia, CVC infections, and more land a spot in the update.

Although you can get a glimpse at ICD-9 updates each summer in CMS's proposed Inpatient PPS rule, ICD-9 can fit in plenty of changes before the new code set becomes official.

Check out the codes below, which weren't finalized in time to be included in the proposed rule, but are effective Oct. 1, 2011, all the same.

Is Your Documentation Up to the Thalassemia Challenge?

ICD-9 2012 will add six new codes for thalassemia:

• 282.40, Thalassemia, unspecified
• 282.43, Alpha thalassemia
• 282.44, Beta thalassemia
• 282.45, Delta-beta thalassemia
• 282.46, Thalassemia minor
• 282.47, Hemoglobin E-beta thalassemia.

Under ICD-9 2011, "there is a single ICD-9-CM code [282.49, Other thalassemia] to capture all non-sickle cell related thalassemias. This one code includes the entire spectrum from asymptomatic patients (silent carrier or thalassemia trait) to patients with severe disease (thalassemia major)," states the Diagnosis Agenda for the ICD-9-CM Coordination and Maintenance Committee Meeting, March 9-10, 2011 (www.cdc.gov/nchs/data/icd9/TopicpacketforMarch2011_HA1.pdf). Jeanne Boudreaux, MD, Medical Director & Director of the Thalassemia Program at the Aflac Center & Blood Disorders Service at Children's Healthcare of Atlanta, provided clinical background about the proposal for the meeting.

The vast majority of thalassemia patients are asymptomatic. Those with the most severe forms (with severe anemia) "require life-long monthly blood transfusions, iron overload monitoring, chelation therapy, and they are candidates for hematopoietic stem cell transplant," the Diagnosis Agenda states.

Crucial: Be sure to review the inclusion lists for all of the 282.4x codes. For example, the list with 282.46 clarifies the code is appropriate if documentation indicates "silent carrier" or "thalassemia trait."

Additionally, revisions to the inclusion notes for 282.41 (Sickle-cell thalassemia without crisis) and 282.49 reveal a change for how you code microdrepanocytosis.

Rather than coding the condition to 282.49 (as you did in 2011), the 2012 inclusion note revisions instruct you to code the condition to 282.41.

Mark 284.1 as Invalid for Pancytopenia

Another important change is that as of Oct. 1, 2011, 284.1 (Pancytopenia) is no longer a valid code. You now need to add a fifth digit:

• 284.11, Antineoplastic chemotherapy induced pancytopenia

Excludes: aplastic anemia due to antineoplastic chemotherapy (284.89)

• 284.12, Other drug-induced pancytopenia

Excludes: aplastic anemia due to drugs (284.89)

• 284.19, Other pancytopenia.

Under ICD-9 2011, coders were confused about how to code drug-induced pancytopenia. The Diagnosis Agenda indicates 284.89 (Other specified aplastic anemias) as the 2011 code. But because "pancytopenia related to drugs would not necessarily be related to aplastic anemia," ICD-9 added the more specific 284.1x codes, the Diagnosis Agenda states.

Split 793.1 to Get New SPN Code

Be sure to highlight this change in your coding references, too: 793.1 (Nonspecific [abnormal] findings on radiological and other examination of lung field) is not a valid code under ICD-9 2012.

The updated code set adds required fifth digit options for 793.1x:

• 793.11, ... solitary pulmonary nodule

Coin lesion lung

Solitary pulmonary nodule, subsegmental branch of the bronchial tree

• 793.19, ... other nonspecific abnormal finding of lung field

Pulmonary infiltrate NOS

Shadow, lung

The changes allow for more specific reporting of a solitary pulmonary nodule (SPN). A patient may have more than one SPN present and each may be in a distinct anatomic area. Physicians may detect SPNs using X-ray, CT, or PET, and biopsy can later identify the nature of the disease or condition the SPN is related to. Alexander Chen, MD, of Washington University School of Medicine and Barnes Jewish Hospital presented the clinical background for the ICD-9 committee.

Index tip: ICD-9 2011 included an index entry for "Nodule(s), nodular; lung, solitary," which pointed to 518.89 (Other diseases of lung not elsewhere classified). ICD-9 2012 revises the index to read:

Nodule(s), nodular

Lung

Solitary 793.11

Pulmonary, solitary (subsegmental branch of the bronchial tree) 793.11

Multiple 793.19

See What's New for CVC Infection Coding

ICD-9 2012 also revises coding for central venous catheter (CVC) infection. The terms you may see for a CVC include:

• Hickman catheter
• Peripherally inserted central catheter (PICC)
• Portacath (port-a-cath)
• Triple lumen catheter
• Umbilical venous catheter.

2011: Under ICD-9 2011, 999.31 was defined as "Infection due to central venous catheter."

2012: ICD-9 2012 changes the 999.31 descriptor to "Other and unspecified infection due to central venous catheter" to make way for more specific CVC infection codes:

• 999.32, Bloodstream infection due to central venous catheter
• 999.33, Local infection due to central venous catheter

Inclusion lists with the codes tell you that 999.32 is appropriate for central line-associated bloodstream infection (CLABSI). The CDC has defined CLABSI, "as part of its National Healthcare Safety Network (NHSN), as laboratory-confirmed bloodstream infections (LCBI) that are not secondary to an infection at another site," the Diagnosis Agenda states.

Code 999.33 instead applies to exit- or insertion-site infection, port or reservoir infection, or tunnel infection.

Don't miss: There's another new code in this range: 999.34 (Acute infection following transfusion, infusion, or injection of blood and blood products). This code was requested separately from the CVC codes to aid in reporting acute infections resulting from transfusions.

Give All Changes the Attention They Deserve

Take time to review the full list of changes available at www.cms.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage (choose the link that says "effective 10/1/2011").

You may find other codes important to your practice, such as new code V58.68 (Long term [current] use of bisphosphonates). Bisphosphonates help treat conditions that cause fragile bones. Oncologists may prescribe bisphosphonates to treat bone metastasis and multiple myeloma.

Or maybe you'll need the newly expanded 512.8x (Other pneumothorax and air leak) codes:

• 512.81, Primary spontaneous pneumothorax
• 512.82, Secondary spontaneous pneumothorax
• 512.83, Chronic pneumothorax
• 512.84, Other air leak
• 512.89, Other pneumothorax.

Check the notes in your ICD-9 resource to be sure you don't miss important instructions. For instance, a note with 512.82 indicates you should report the underlying condition (such as "Cancer metastatic to lung [197.0]") before reporting the secondary pneumothorax (512.82) on your claim. You'll also learn that 512.89 is appropriate for pneumothorax "not otherwise specified" (NOS).

For more information: See analysis of the oncology/hematology-related ICD-9 codes proposed in the inpatient PPS in Oncology & Hematology Coding Alert, vol. 13, no. 8, "173.xx Leads List of Proposed ICD-9 Updates for October."