Oncology & Hematology Coding Alert

Oncology coders will finally be able to report different forms of sickle-cell disease with greater specificity, thanks to new ICD-9 codes that take effect Oct. 1. CMS unveiled the new diagnosis codes, several of which affect oncology practices, in the May 19 Federal Register.

Also, CMS new and revised diagnosis codes have something in common: fifth digits. CMS has introduced several oncology-related diagnosis codes that will make your signs and symptoms coding more accurate and more specific.

Discriminate Between Diagnoses 
 
Beginning Oct. 1, you will have two more options when assigning diagnosis codes for sickle-cell disease: You will able to specify whether Haemoglobin C (Hb-C) disease is associated with sickle cell and if a patient has an unspecified form of sickle cell with crisis. CMS adds codes 282.64 (Sickle-cell/Hb-C disease with crisis) and 282.68 (Other sickle-cell disease without crisis) to the sickle-cell diagnoses for 2004.

Medicare revised the wording for the remaining sickle-cell codes, including clarifying the descriptor for sickle red blood cells, which the code defines as Hb-SS. The revised codes are 282.61, (Hb-SS disease without crisis) and 282.62 (Hb-SS disease with crisis). CMS is also revising 282.60 (Sickle-cell disease, unspecified), 282.63 (Sickle-cell/Hb-C disease without crisis) and 282.69 (Other sickle-cell disease with crisis).

The revised codes more accurately describe a sickle-cell patients condition, says Margaret M. Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant based in New Orleans. A sickle-cell patient in crisis takes much more time and care than a patient who is not in crisis, she says. So, if a patient with crisis requires more of your physicians work, your physician can choose a more specific diagnosis code to demonstrate the extra effort.

Codes 282.41 (Sickle-cell thalassemia without crisis), 282.42 (Sickle-cell thalassemia with crisis) and 282.49 (Other thalassemia) will replace 282.4 (Thalassemias).

Your oncologist cannot treat a patient with sickle-cell thalassemia and other thalassemia the same way, so you should have a more specific code to justify the required medical procedures, Hickey says. CMS deleted 282.4 so coders can more effectively discriminate between the sickle-cell and thalassemia diagnoses.

Know How to Code Hypercoagulable State

Two new codes, 289.81 (Primary hypercoagulable state) and 289.82 (Secondary hypercoagulable state), address a rare but fatal occurrence in some cancer patients. Hypercoagulable states can vary in intensity from simple changes in coagulation lab results to massive blood clots. Primary hypercoagulable states commonly refer to patients with a genetic disorder. In cancer patients, your oncologist will find 289.82 more applicable, Hickey says. For example, your oncologist administers chemotherapy treatment to a patient with lung cancer (162.9), and during treatment the patient develops a secondary hypercoagulable state. Studies show that thrombosis due to secondary hypercoagulable state occurs in 20 percent of lung cancer patients, she says.

CMS will add 289.89 (Other specified diseases of blood and blood-forming organs), which replaces 289.8. Code 289.89 includes hypergammaglobulinemia, myelofibrosis and pseudocholinesterase deficiency.
 
Report Inoculations With a Fifth Digit

Starting in October, you will need to report a five-digit diagnosis code for patients who need inoculations for their compromised immune systems. Also, you will have more inoculation codes to choose from. Codes V04.81 (Need for prophylactic vaccination and inoculation, influenza), V04.82 (... respiratory synctial virus [RSV]) and V04.89 (... other viral diseases) replace V04.8.

You might need to report an inoculation code, for example, if your oncologist were treating an elderly patient for advanced breast cancer (174.x), and the patient runs a risk for developed influenza (487.x), which threatens her life given her multiple medical problems. Your physician administers a flu shot, which you would report as G0008 (Administration of influenza virus vaccine) for Medicare patients, or 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]) and +90472 (... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) for most private insurers. You would list the diagnosis for vaccination as V04.81.

Medicare may have added V04.81-V04.89 to separate these inoculation codes from routine vaccinations, such as certain hepatitis shots, which CMS and other carriers may not cover, says Linda L. Lively, MHA, CCS-P, RCC, CHBME, president and chief executive officer of AMAC, a coding consultant firm in Atlanta.

CMS also created a new procedure code for high-dose Interleukin-2 (IL-2) infusion (00.15). For example, you would report 00.15 if your oncologist used the infusion to increase the T-cell count, which fights infections, in a patient with a kidney tumor (189.x). Dont confuse a high-dose IL-2 infusion with a low-dose infusion (99.28).

Another new code, 785.52 (Septic shock), describes a condition that usually occurs in the elderly or children who are severely neutropenic (288.0) cancer patients. For instance, a child with leukemia (208.9x) suddenly has extremely low blood pressure (458.x) and shortness of breath (786.05) common symptoms of septic shock.  Septic shock can lead to kidney failure (584.x) and death. Your oncologist treats the patient with antibiotics and intravenous fluids to support blood flow. To justify these procedures, you would report 785.52.