Pathology/Lab Coding Alert

Get up to speed on CMS's final proposed update to ICD-9-CM code set.

Pathologists will need to report fifth digits for all "other" skin cancer diagnoses beginning Oct. 1 if the proposed ICD-9 codes become final.

You'll find that and other new, invalid, and revised codes that will impact your lab recently posted on the CMS Website. The changes are the final full set that the agency will make to ICD-9 codes. After the new codes take effect on Oct. 1, CMS will only add new ICD- 9 codes on an emergency basis as it prepares to switch over the diagnosis coding system to ICD-10.

Get Ready for Skin Cancer Details

The latest ICD-9 proposed changes will expand 10 current codes (173.x, Other malignant neoplasm of skin) to 40 new codes (173.xx).

Skin site distinguishes the 10 existing codes (173.0-173.9) that will become "invalid." The same site distinctions remain in the new codes, but ICD-9 2012 adds a fifth digit to each four-digit code to differentiate cancer type, such as basal cell or squamous cell carcinoma.

Break it down: The new "other malignant neoplasm of skin" codes (that require a fifth digit) are as follows:

• 173.0x -- Skin of lip
• 173.1x -- Eyelid, including canthus
• 173.2x -- Skin of ear and external auditory canal
• 173.3x -- Skin of other and unspecified parts of face
• 173.4x -- Scalp and skin of neck
• 173.5x -- Skin of trunk, except scrotum
• 173.6x -- Skin of upper limb, including shoulder
• 173.7x -- Skin of lower limb, including hip
• 173.8x -- Other specified sites of skin
• 173.9x -- Skin, site unspecified.

The following fifth digits distinguish each site-specific four-digit code based on neoplasm details:

• 0 -- Unspecified malignant neoplasm of ...
• 1 -- Basal cell carcinoma of ...
• 2 -- Squamous cell carcinoma of ...
• 9 -- Other specified malignant neoplasm of ...

For example: If your pathologist diagnoses a basal cell carcinoma removed from thepatient's neck after Oct. 1, you'll assign 173.41 (Basal cell carcinoma of scalp and skin of neck) instead of invalid code 173.4 (Other malignant neoplasm of scalp and skin of neck).

Don't wait: With only a few months before implementation, the time to act is now, says Pamela Biffle, CPC, CPC-P, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Austin, Texas. "Coders will have to make sure their systems are updated with the new codes," she notes.

Expand E. coli Pathogen Code Choices

When your lab performs microbiology or other tests to identify shiga-toxin producing Escherichia coli (E. coli) strains that can cause gastrointestinal infections, the Oct. 1 update will give you more specific diagnosis codes to report the findings.

The ICD-9 update will replace 041.4 (Escherichia coli [E. coli] infection in conditions classified elsewhere and of unspecified site) with the following four codes:

• 041.41 -- Shiga toxin-producing Escherichia coli [E. coli] (STEC) O157
• 041.42 -- Other specified Shiga toxin-producing Escherichia coli [E. coli] (STEC)
• 041.43 -- Shiga toxin-producing Escherichia coli [E. coli] (STEC), unspecified
• 041.49 -- Other and unspecified Escherichia coli [E.coli].

Know the background: Many E. coli bacteria are harmless, but certain strains can cause digestive problems ranging from diarrhea to hemorrhagic colitis. These strains are known as Shiga-toxin producing E. coli (STEC)*, and labs identify them by culture or other tests to detect the Shiga-toxin or the genes that produce the toxin. The most common STEC in the U.S. is E. coli O157:H7. If the lab isolates this strain in a culture, no further testing is needed to call the organism STEC. When the culture isolates non-O157 E. coli strains, or E. coli O157 with the H antigen not identified as H7, the lab will perform other tests before the organism can be identified as STEC.

Depending on the test results, you'll choose from the four new ICD-9 codes to report the findings, starting Oct. 1. According to Jeffrey Linzer Sr., MD, FAAP, FACEP, representing the American Association of Pediatrics at the ICD-9-CM Coordination and Maintenance Committee Meeting (proposals, summaries, and presentation slides available at www.cdc.gov/nchs/icd/icd9cm_maintenance.htm), many inclusion terms represented in the proposed new codes will be seen in the medical record, including microbiology laboratory results.

For instance: The physician orders a stool culture and a Shiga toxin test for a patient with bloody stool and diarrhea. The lab performs a culture for Salmonella/Shigella and inoculates sorbitol-MacConkey (SMAC) broth for E. coli O157. "The lab might also perform an infectious agent antigen detection by enzyme immunoassay (EIA) for Shiga toxin, such as 87427 (Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Shigalike toxin)," says Bobbi Andera, BSMT, AMT, Business/Regulatory Manager for Sanford Laboratories in Sioux Falls, S.D.

If the culture identifies E. coli but does not definitively identify serogroup O157, and the separate EIA test is positive for Shiga toxin, you would report 041.43.

*Editor's note: Shiga toxin is also known as verotoxin or verocytotoxin, so you might see STEC organisms referred to as VTEC. Some sources also refer to these organisms as enterohemorrhagic E. coli (EHEC).