Oncology & Hematology Coding Alert

Plus: See what the guidelines say about your SIRS reports

The latest CMS-approved ICD-9 Official Guidelines are out -- and we-ve broken down the oncology-related changes you need to know.

1. Set Yourself Up for SIRS Coding Success

The most recent ICD-9 guidelines explain that -Systemic inflammatory response syndrome (SIRS) generally refers to the systemic response to infection, trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis.- (See Section I.C.1.b and Section I.C.17.g.)

Note: Don't fall prey to the common mistake of confusing -sepsis- and -SIRS- diagnoses with infection, says James Kennedy, MD, CCS, vice president of MA Health Solutions Inc. in Nashville, Tenn. A patient cannot develop sepsis without first having SIRS, and SIRS may or may not result from infection.

Coding rules: The updated guidelines say, -The code for the underlying cause (such as infection or trauma) must be sequenced before the code from subcategory 995.9 Systemic inflammatory response syndrome (SIRS),- when the physician doesn't document subsequent infection. The physician must document either the term sepsis or SIRS to assign a code from subcategory 995.9.

Example: A patient develops SIRS due to cancer, and the physician documents SIRS without subsequent infection, then you should report:

1. the code identifying the cancer (such as 157.0, Malignant neoplasm of pancreas; head of pancreas) and then

2. the appropriate SIRS code, such as 995.90 (Systemic inflammatory response syndrome, unspecified), 995.93 (Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction), or 995.94 (Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction).

For 995.94, you also need to report the code to specify the acute organ dysfunction, such as 584.5 (Acute renal failure; with lesion of tubular necrosis), in addition to reporting the noninfectious process.

2. Find New Code V86.x Fast

The latest update includes a new, more user-friendly V code table with columns showing whether each code is first listed, first or additional, additional only, or non-specific diagnosis (page 68).

Previously you had to search through multiple lists to locate a specific V code, says Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

Watch for: The new V code table lists V86.x (Estrogen receptor status), meant for use with breast malignant neoplasm codes 174.x (Malignant neoplasm of female breast) and 175.x (Malignant neoplasm of male breast), which say to -use additional code to identify estrogen receptor status.-

When you look up the new V codes in the ICD-9 manual, you-ll see a note to -Code first malignant neoplasm of breast (174.0-174.9, 175.0-175.9).-

Example: For a female patient with a malignant breast neoplasm and estrogen receptor positive status, you should report the neoplasm (174.x) and then the estrogen receptor status with V86.0 (Estrogen receptor positive status [ER+]). For negative status, you would instead report 174.x for the neoplasm and then V86.1 (Estrogen receptor negative status [ER-]).

You can read up on these codes in the guidelines in Section 1.C.18.d.3.

3. Use 338.3 for Acute and Chronic Neoplasm Pain

Although 338.3 (Neoplasm-related pain [acute] [chronic]) applies to patients with both acute and chronic pain, whether you report this code first or second depends on the reason for a patient's visit. (See Section I.C.6.a.5.)

The basic rule: You should not report the new pain codes in category 338.x (Pain, not elsewhere classified) if you know the underlying (definitive) diagnosis, unless the reason for the encounter is pain control rather than for management of the underlying condition, Miller says.

You can use a code from category 338 as the principal or first-listed diagnosis when the encounter is for pain control, even if you know the pain's cause, she adds. If you know the pain's cause, you should code the cause as a secondary diagnosis, Miller says.

Example: A patient arrives for treatment of a malignancy, but the physician also documents pain associated with the malignancy. You report the code for the malignancy first, but you may also report 338.3 as an additional diagnosis.

If your practice offers pain management for malignancy-related pain, and a patient presents for this service, first report 338.3 and then report the proper code for the malignancy causing the pain.

4. Update Your -Uncertain Diagnosis- Definition

The updated guidelines remind you to use signs and symptoms codes in the office setting when the documented diagnosis is uncertain, adding the phrase in bold: -Do not code diagnoses documented as -probable,- -suspected,- -questionable,- -rule out,- or -working diagnosis- or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit- (Section IV. I).

Coding Clinic for ICD-9-CM previously instructed coders not to code diagnoses described as -consistent with,- and the new instruction in the guidelines emphasizes that you should not code unconfirmed conditions regardless of the physician's specific wording indicating that the condition is unconfirmed, Miller says.

Note: HIPAA requires adherence to these official rules, so you should take the time to learn them. You can review the -ICD-9-CM Official Guidelines for Coding and Reporting,- updated Nov. 15, 2006, at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf.