Pediatric Coding Alert

Government officials answer questions by not answering at all.

The recent delay of ICD-10 until 2015 has raised plenty of questions in the coding community, but unfortunately CMS is not ready to answer them all. Several practices asked reps from the agency about the specifics of the delay, but didn’t get the answers they were seeking during CMS’s May 13 Open Door Forum.

“On April 1, 2014, the Protecting Access to Medicare Act of 2014 was enacted, and it says that the secretary may not adopt ICD-10 prior to Oct. 1, 2015,” said CMS’s Chris Ritter during the call. “Accordingly, the US Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning Oct. 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through Sept. 30, 2015.” 

When a caller asked whether that Final Rule will be issued on Aug. 1 (which is when the Inpatient Prospective Payment Final rule is due to be issued), CMS reps declined to answer. “Actually, the handling of ICD-10 is a separate issue,” Ritter said. “The proposed IPPS rule does simply indicate that the recent legislation does delay ICD-10, and the secretary will be issuing a rule separately, but there will be a separate final rule for ICD-10. You can keep your eyes out for that.” 

When a caller asked whether the ICD-9 code freeze will stay in effect or whether new ICD-9 codes will be released in the wake of the ICD-10 delay, CMS’s Diane Kovach responded that the answer has not yet been determined and that CMS will speak on that at a later date.

Another caller asked for rationale regarding the cancellation of ICD-10 end-to-end testing, but CMS stressed that “the agency has committed to end-to-end testing” and that it will happen in 2015. “Like everyone else that has done a lot of work to prepare for ICD-10 for the Oct. 1, 2014 date, we now have to turn our attention to reverting back to ICD-9 codes, so we’ll be doing that for the coming months, and as soon as we have information available, which we hope will be in the not too distant future, we’ll have information to you on end-to-end testing for next year,” Kovach added.

Here’s What You Can Do

Take the extra year to get to know the ICD-10 manual, if you haven’t already studied it. You can start by identifying the ICD-10 code for your most commonly-seen conditions. We’ve profiled many of them in previous issues of Pediatric Coding Alert but you can read on for an example of how you’d report acute respiratory infections next year.

J06.9 will be an easy replacement for 465.9.

Your pediatrician might diagnose an upper respiratory tract infection (or upper respiratory infection, URI) when any of the components of the patient’s upper airway become infected. 

Possible sites of infection include the sinuses, nasal passages, pharynx, and larynx. URIs are some of the most common causes of doctor visits, with symptoms ranging from runny nose, sore throat, and cough to breathing difficulty and lethargy. Although URIs can happen at any time, they are most common in the fall and winter months (from September until March). 

Currently, under ICD-9, you have one diagnosis choice for an acute URI if the physician doesn’t document many details: 465.9 (Acute upper respiratory infections of unspecified site). The diagnosis code includes both acute URI NOS and acute URI. You should include an additional code to identify the infectious organism, if known. 

Example: The infectious organism is often not known at the initial visit since it often requires a culture to determine the specific organism. A culture may be taken, for example a nasal culture and it may come back as staphylococcus aureus.  As such, the diagnosis for staphylococcus aureus would be added with the URI diagnosis at the subsequent visit.  (041.11 Methicillin susceptible staphylococcus aureus in conditions classified elsewhere and of unspecified site)

Note: Do not report 465.9 for pneumonia or influenza. Instead, submit a more detailed diagnosis such as 487.0 (Influenza with pneumonia) or 487.1 (Influenza with other respiratory manifestations). 

Stick With a Single Code, Starting October 2015

You’ll still have only one diagnosis code for unspecified acute URI when ICD-10 is introduced in October 2015: J06.9 (Acute upper respiratory infection, unspecified). 

You’ll find J06.9 in Chapter 10, Diseases of the Respiratory System; under the subsection Acute Upper Respiratory Infections (J00-J06). As with ICD-9, ICD-10 guidelines state that J06.9 will include acute upper respiratory disease and upper respiratory infection NOS.  Like ICD-9, the chapter guidelines for ICD-10 indicate that the infectious organism should be coded additionally if known.

Documentation: You typically make a diagnosis of upper respiratory infection based on review of symptoms, physical examination, and possibly lab tests. The physician will look for swollen and red nasal cavities, redness of the throat, enlargement of tonsils, white secretions on the tonsils, enlarged lymph nodes around the head and neck, redness of the eyes, and facial tenderness. Other signs might include bad breath (halitosis), cough, hoarseness, or fever. 

Because most URIs are caused by viruses, specific testing is not required since there isn’t a specific treatment for different types of viral URIs. If the physician does order lab tests, he could be checking for suspected strep throat, possibly bacterial infection, mononucleosis, or H1N1 flu. Lab tests can also help determine why prolonged symptoms linger. 

Keep These Coding Tips in Mind

Coding guidelines for section J06 (Acute upper respiratory infections of multiple and unspecified sites) state that the category does not include diagnoses for acute respiratory infection NOS (J22), influenza virus (J09-J11), or streptococcal pharyngitis (J02.0). 

One other code is part of the J06 family in ICD-10: J06.0, which you’ll report for acute laryngopharyngitis. Ensure that you submit J06.0 versus J06.9 correctly, based on the documentation.