Pathology/Lab Coding Alert

If you don't get your 2009 ICD-9 code changes down pat, you might find yourself in the wrong category for diabetes and pleural effusion diagnoses. Let our experts walk you through these and other ICD-9 changes that go into effect on Oct. 1.

Note: These codes appear in a proposed rule published in the April 30 Federal Register. ICD-9 may announce more changes, so look to Pathology/Lab Coding Alert for more details in the coming months.

You-ll find 27 new leukemia codes in categories 203.x (Multiple myeloma and immunoproliferative neoplasms) to 208.x (Leukemia of unspecified cell type). The new codes help distinguish leukemia in relapse, which may require different interventions.

With these new codes, you-ll need to keep a close watch on fifth digits, says Dianne Wilkinson, RHIT, compliance auditor with West Tennessee Healthcare in Jackson.

ICD-9 2009 updates the leukemia codes by adding a new fifth digit -- 2 (in relapse) --for codes 203.02 through 208.92. ICD-9 also changes the wording of fifth- digit 0 (without mention of having achieved remission) to clarify the intent.

What it means to you: Although your pathologists may diagnose leukemia based on cytology, you-ll need to be aware that relapse or remission information the clinician supplies may impact diagnosis code assignment.

The proposed ICD-9 changes introduce a new category to describe a patient who has diabetes caused by another condition -- 249.x (Secondary diabetes mellitus). The 20 new codes parallel existing category 250.x (Diabetes mellitus) codes with the same fourth-digit manifestations, such as 1 (ketoacidosis).

Watch the fifth digit: You must report category 249 codes to the fifth digit to indicate the patient's level of diabetes control -- 0 (not stated as uncontrolled, or unspecified) or 1 (uncontrolled).

What it means to you: Physicians often order lab tests based on diabetes complications, and your lab must be ready to use these new ICD-9 codes if you want to show medical necessity for the tests. "We-re seeing more and more secondary diabetes cases, so these codes will be useful," says Randall Karpf with East Billing in East Hartford, Conn.

When physicians order lab tests for the diagnosis and treatment of endocrine abnormalities and abnormal genitalia, you-ll have to be ready to use the following proposed ICD-9 additions to show medical necessity:

- 259.50 -- Androgen insensitivity, unspecified

- 259.51 -- Androgen insensitivity syndrome

- 259.52 -- Partial androgen insensitivity.

This set of changes provides further specificity to androgen insensitivity coding, says Christy Shanley, CPC, billing manager for the University of California, Irvine, department of urology.

Old way: The ICD-9 proposed changes delete the prior code you would have used -- 259.5 (Androgen insensitivity syndrome). You won't get paid if you continue to use the four-digit code come October.

The new code on the block for pleurisy diagnosis is 511.81 (Malignant pleural effusion). Use this diagnosis code when the pleural fluid is cancerous, says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

A cancerous invasion of the pleura causes a malignant pleural effusion. "This could be due to cancer within the lung or metastatic disease from any other organ, such as the colon or kidney," says Alan L. Plummer, MD, professor of medicine at Emory University School of Medicine in Atlanta. When reporting 511.81, be sure to code for the source of the primary tumor as well, he says.

2008 way: ICD-9 now refers you to 197.2 (Secondary malignant neoplasm of respiratory and digestive systems; pleura) for a malignant pleural effusion, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. On Oct. 1, replace 197.2 with 511.81 when your final cytologic diagnosis is malignant pleural effusion.

Move over: To make room for 511.81, ICD-9 moved 511.8 (Other specified forms of effusion, except tuberculosis) to 511.89. "The -catchall- descriptor for 511.89 remains the same as it was for 511.8," Plummer says.

Effective Oct. 1, you will need to remember to apply the fifth digit (511.89) when the patient has a pleural effusion that does not include cancer or tuberculosis. If you continue to use 511.8, expect claim denials for an "invalid diagnosis" code.

Starting Oct. 1, you-ll no longer have ICD-9 code 599.7 (Hematuria, benign, essential) to report. In its place you will have three new ICD-9 codes:

- 599.70 -- Hematuria, unspecified

- 599.71 -- Gross hematuria

- 599.72 -- Microscopic hematuria.

Because labs often perform a urine culture (such as 87086, Culture, bacterial; quantitative colony count, urine and 87088, - with isolation and presumptive identification of each isolate, urine) based on abnormal urinalysis findings, you-ll need to update your hematuria codes to include the fifth digit. Using 599.7 to show medical necessity for a urine culture will get a denial starting Oct. 1.

ICD-9 will create a new subcategory V07.5 (Prophylactic use of agents affecting estrogen receptors and estrogen levels) to capture data on many women who receive Tamoxifen and Raloxifene or similar agents following breast cancer treatment. This data may provide important information for the pathologist's interpretation of breast findings.

Adding the fifth digit allows physicians to include different classes of drugs that the patient might be taking for this type of therapy. The new V codes are as follows:

- V07.51 -- Prophylactic use of selective estrogen receptor modulators (SERMs)

- V07.52 -- - aromatase inhibitors

- V07.59 -- - agents affecting estrogen receptors and estrogen levels.

Note: From an ICD-9 coding guideline perspective, you can use the cancer code with one of these codes following the cancer treatment. However, the long-term use of a drug falling under the V07.5x category may not require the continued use of the cancer code.

Some of the biggest ICD-9 changes for labs and pathologists involve the new carcinoid tumor category (209, Neuroendocrine tumors) and new Pap smear-related codes (795.07-796.79, as well as V88.01-V88.03, Acquired absence of other organs and tissue ...).

See "Don't Get Caught Using 2008 -Benign- and -Malignant- Codes for Carcinoid Tumors " at right to learn about 209.xx, and look for an ICD-9 Pap article next month in Pathology/Lab Coding Alert.