Oncology & Hematology Coding Alert

When the oncologist documents SIRS resulting from cancer, ICD-9 has very specific rules for how to assign ICD-9 codes. Hint: If you report just one diagnosis code, you're setting yourself up for rejection. Help your claims sail through with these tips.

You must report at least two codes for systemic inflammatory response syndrome (SIRS) resulting from cancer with no subsequent infection: a code for the underlying cause (in this case, cancer) and "a code from subcategory 995.9[x] (Systemic inflammatory response syndrome)," instruct the ICD-9 official guidelines, Section 1.C.17.g, effective Oct. 1, 2009 (www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm).

You should sequence the diagnosis for the underlying cause first, followed by the SIRS diagnosis. And remember to assign a fifth digit for 995.9x to describe the presence or absence of acute organ dysfunction, as explained below.

For SIRS with organ dysfunction, you will need three ICD-9 codes:

1. First code the underlying condition (neoplasm).

2. Then report 995.94 (Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction) for the SIRS.

3. Finally, use an additional diagnosis to specify the acute organ dysfunction (such as 584.5, Acute renal failure; with lesion of tubular necrosis).

Watch for: For SIRS without acute organ dysfunction, two codes may suffice: the underlying condition and the SIRS code.

Example: The oncologist documents SIRS without acute organ failure resulting from pancreatic cancer. According to Helen Avery, CPC-I, CHC, senior coding and revenue cycle consultant at Los Angeles-based Sinaiko Healthcare Consulting Inc., you should report the following:

• 157.x (Malignant neoplasm of pancreas ...) as the primary diagnosis

• 995.93 (Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction) for SIRS without organ dysfunction.

Be sure to pay attention to the note with 995.93 which specifies that you should code the underlying condition first, Avery advises.

Unspecified: If the physician doesn't specify "with"or "without" acute organ dysfunction, you'll have to use "unspecified" SIRS diagnosis code 995.90 (Systemic inflammatory response syndrome, unspecified).

Caution: Just because organ failure is present with SIRS, you can't assume a relationship between the two conditions. The ICD-9 guidelines also warn, "If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried."

Be sure your clinicians' documentation habits distinguish SIRS from sepsis because the oncologist's documentation must include the term "SIRS" for you to assign the 995.9x codes discussed above. Thorough  documentation helps eliminate a guessing game when choosing the proper code, says Rita Huelar, CPC, a billing specialist with Nemours Health System in Jacksonville, Fla.

"Sepsis and SIRS are not synonymous terms," Avery stresses. "Educate your physicians on how to properly document each by using the official ICD-9 guidelines to illustrate how complex the coding for these conditions can be and the importance of their documentation."

ICD-9 definitions: 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," according to ICD-9 guidelines (section I.C.1.b). Sepsis (995.91), on the other hand, "generally refers to SIRS due to infection," and severe sepsis (995.92) generally refers to sepsis with associated acute organ dysfunction," the guidelines state.

When you start using ICD-10 codes in 2013 in place of your trusty ICD-9 codes, your SIRS code options will look a little different:

R65.10 -- Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction

R65.11 -- Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction.

Tip: A note under R65.10 indicates you should use that code for SIRS NOS (not otherwise specified). As noted above, this logic differs slightly from current coding conventions.

Remember that the transition date for ICD-10 codes is Oct. 1, 2013, as CMS's Stewart Streimer noted during a CMS-sponsored open door forum.

But today isn't too soon to start thinking about ICD-10, says Avery. The more familiar you are with the changes, the easier the transition will be. "Obtain education and understanding early on so that you will be well equipped. Start by speaking with your physicians now about improving their clinical documentation detail which will be the most important aspect for them and should be started prior to the change," Avery says.

Coders also should be involved when practices communicate with "information system vendors (for EMR, claims processing, etc.) about their plans for the new code set implementation," advises Avery.

ICD-10 resource: You can find the 2010 ICD-10 index and tabular list at www.cdc.gov/nchs/icd/icd10cm.htm#10update.