Pulmonology Coding Alert

If you don't get your 2009 ICD-9 coding down pat, come this fall you'll be in the wrong category for malignant lung tumors and pleural effusions. Our experts walk you through the can't-live-without pulmonology code changes in store for you.

ICD-9 has released its preliminary list of new diagnosis codes for late 2008 and 2009. Since HIPAA's passage, there is no grace period for new ICD-9 codes. You've got to be ready to go with the new codes on Oct. 1, says Joan Gilhooly, CPC, CHCC, president of Medical Business Resources in Chicago.

The AMA has approved the following codes for use, but slight changes are possible before the list is finalized over the summer. For all the latest news on ICD-9 2009, check out future issues of Pulmonology Coding Alert.

Coders will be able to achieve greater specificity on carcinoid lung tumor diagnoses this fall, when ICD-9 rolls out 209.21 (Malignant carcinoid tumor of the bronchus and lung) and 209.61 (Benign carcinoid tumor of the bronchus and lung).

These additions will end the practice of scrambling to different code sets for carcinoid tumor diagnoses, depending on the tumor type.

Old way: Coders now report 162.9 (Malignant neoplasm of trachea, bronchus and lung; bronchus and lung, unspecified) for malignant lung/bronchial tumors unless the notes indicated a specific section of the bronchus, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

For benign tumors, coders choose 212.3 (Benign neoplasm of respiratory and intrathoracic organs; bronchus and lung), regardless of specified area, she says.

That all changes Oct. 1, when 209.21 and 209.61 go into effect. You'll often use these diagnoses on your lung biopsy claims, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy, and Critical Care at Emory University School of Medicine in Atlanta. These could be repeat biopsies in which you already have a diagnosis, or initial biopsies in which the physician is unsure of the patient's status.

Example: The pulmonologist performs bronchial biopsies on a mass in a patient's upper bronchus. Pathology reports come back indicating a malignant carcinoid tumor.

Beginning Oct. 1, report the following:

• 31625 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy[s], single or multiple sites) for the bronchoscopy.

• 209.21 linked to 31625 to represent the tumor.

Remember to wait for the biopsy results before choosing 209.21 or 209.61. You don't want to code a patient's tumor as malignant when it is benign -- or vice versa.

ICD-9 2009 will also bring changes to the pleural effusion code set (511.xx). The new code on the 511.xx block 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 malignant pleural effusion is caused by a cancerous invasion of the pleura. This could be due to cancer within the lung or metastatic disease from any other organ (such as the colon or kidney)," Plummer says. When reporting 511.81, be sure to code for the source of the primary tumor as well, he says.

Old way: ICD-9 now refers coders to 197.2 (Secondary malignant neoplasm of respiratory and digestive systems; pleura) for a malignant pleural effusion, Pohlig says. On Oct. 1, replace 197.2 with 511.81 for your malignant effusion patients.

Example: X-ray results brought to the pulmonologist's office indicate that the patient has a probable malignant pleural effusion. The pulmonologist performs a thoracentesis with tube on a patient with malignant cancer of the main bronchus.

Beginning Oct. 1, report the following for this encounter:

• 32422 (Thoracentesis with insertion of tube, includes water seal [e.g., for pneumothorax], when performed [separate procedure]) for the thoracentesis

• 511.81 to represent the malignant effusion (Caution: Wait for the final diagnosis from cytology on the pleural fluid)

• 162.2 (Malignant neoplasm of trachea, bronchus and lung; main bronchus) to represent the underlying cancerous condition.

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, your claims will be denied for an "invalid diagnosis" code.

Pulmonology coders will also get another pneumonia diagnosis code to add to their arsenals in October. ICD-9 2009 will mark the premiere of 997.31 (Ventilator-associated pneumonia). Use this code when a patient on a respirator develops pneumonia, Berman says.

Old way: Coders would have to use the generic 997.3 (Respiratory complications) for this type of pneumonia before 997.31. The new pneumonia code can better describe the source of the patient's pneumonia.

The new ICD-9 coding also deletes 997.3 and replaces it with 997.39 (Other respiratory complications). This vague diagnosis is for use only as a last resort, if you cannot find a more appropriate diagnosis code, Berman says.

You might find yourself using 997.39 for patients who develop pneumonia after a procedure or for Mendelson's syndrome following surgery, other than for labor and delivery (668.0x).