Radiology Coding Alert

New fifth digit requirements change your old-standby NOS codes.

Before you finalize your ICD-9 2012 update list, be sure you catch these late additions to the lineup for chest and shoulder conditions.

Background: Although coders get a sneak peek at ICD-9 changes each summer in CMS's proposed Inpatient PPS rule, those changes aren't final. The codes below were not finalized in time to be included in the proposed rule, but they are effective Oct. 1, 2011, all the same.

Shift to 512.89 for Pneumothorax NOS

Coding for pneumothorax (air in the pleural space) gets an overhaul for ICD-9 2012. Even if you typically find yourself reporting the code for "not otherwise specified" (NOS) pneumothorax, you'll see a change to how you should code.

2011: Under ICD-9 2011, you used 512.8 (Other spontaneous pneumothorax) to report an acute, chronic, or NOS pneumothorax.

2012: ICD-9 2012 revises 512.8 (Other pneumothorax and air leak) and turns it into a range of codes. In other words, there's a new range of five-digit 512.8x codes, so 512.8 (without a fifth digit) is no longer valid.

Here's an overview of proper use of the new codes.

512.81-512.82: The first two codes specify "spontaneous" and differ based on primary and secondary:

• 512.81, Primary spontaneous pneumothorax
• 512.82, Secondary spontaneous pneumothorax

Code first underlying condition, such as:

• Cancer metastatic to lung (197.0)
• Catamenial pneumothorax due to endometriosis (617.8)
• Cystic fibrosis (277.02)
• Eosinophilic pneumonia (518.3)
• Lymphangioleiomyomatosis (516.4)
• Marfan syndrome (759.82)
• Pneumocystis carinii pneumonia (136.3)
• Primary lung cancer (162.3-162.9)
• Spontaneous rupture of the esophagus (530.4)

Spontaneous means trauma was not the cause. Primary (512.81) means there's no apparent lung disease. Secondary (512.82) means a lung disease is apparent and led to the pneumothorax. As the note above indicates, you should report the underlying condition before reporting the secondary pneumothorax (512.82) on your claim.

512.83: Next is 512.83 (Chronic pneumothorax).

Providers may require extra resources to care for a patient with a chronic pneumothorax, so giving the condition a specific code makes sense, according to Jeffrey Linzer, MD, representing the American Academy of Pediatrics at the ICD-9-CM Coordination and Maintenance Committee Meeting, March 9-10, 2011 (www.cdc.gov/nchs/data/icd9/2011March_Summary_%20HA.pdf).

512.84: The next new code is appropriate for persistent air leaks or other air leaks without a more specific code available:

• 512.84, Other air leak

Persistent air leak

For example, 512.84 would be appropriate "when a chest tube has been placed for a primary spontaneous pneumothorax and the lung re-expands but the air leak persists," states the Diagnosis Agenda for the March meeting (www.cdc.gov/nchs/data/icd9/TopicpacketforMarch2011_HA1.pdf).

To fully understand proper use of 512.84, you also need to be aware of new code 512.2 (Postoperative air leak).

ICD-9 2011 indexed "postoperative air leak" to 512.1 (Iatrogenic pneumothorax), which applies to postoperative pneumothorax. The problem with that indexing was that patients can have a postoperative air leak without a pneumothorax because physicians often place chest tubes to prevent pneumothorax after procedures. To clear the confusion, ICD-9 added 512.2 for postoperative air leaks. Take care not to use 512.84 when 512.2 would be more appropriate.

512.89: Finally, the new code for pneumothorax NOS is:

• 512.89, Other pneumothorax

Acute pneumothorax

Pneumothorax NOS

Spontaneous pneumothorax NOS

As the notes show, this code is also appropriate for an acute pneumothorax or for a spontaneous pneumothorax when documentation doesn't specify whether it's primary or secondary.

ICD-9 Splits 793.1 to Get New SPN Code

Be sure to highlight this change in your coding references, too: 793.1 (Nonspecific [abnormal] findings on radiological and other examination of lung field) is not a valid code under ICD-9 2012.

The updated code set adds required fifth digits to 793.1 for two new codes:

• 793.11, Solitary pulmonary nodule

Coin lesion lung

Solitary pulmonary nodule, subsegmental branch of the bronchial tree

Pulmonary infiltrate NOS

Shadow, lung

The change allows for more specific reporting of a solitary pulmonary nodule (SPN). A patient may have more than one SPN present and each may be in a distinct anatomic area. Radiologists may detect SPNs using X-ray, CT, or PET, and biopsy can later identify the nature of the disease or condition the SPN is related to. Alexander Chen, MD, of Washington University School of Medicine and Barnes Jewish Hospital presented the clinical background for the ICD-9 committee meeting.

Index tip: ICD-9 2011 included an index entry for "Nodule(s), nodular; lung, solitary," which pointed to 518.89 (Other diseases of lung not elsewhere classified). ICD-9 2012 revises the index to read:

Nodule(s), nodular

Lung

Solitary 793.11

Pulmonary, solitary (subsegmental branch of the bronchial tree) 793.11

Multiple 793.19

Rotator Cuff Options Vary for 'Partial' and 'Complete'

Pulmonary revisions aren't the only ones to watch for. You also should take note of 726.13 (Partial tear of rotator cuff).

According to the Diagnosis Agenda, a partial tear refers to rotator cuff tendon damage in which the tear doesn't go completely through the tendons. If documentation instead shows a complete tear, you should report 727.61 (Complete rupture of rotator cuff).

Resource: To see the complete lists of final revisions, head to www.cms.gov/icd9providerdiagnosticcodes/07_summarytables.asp and click the download for codes effective 10/1/2011. Also check out "415.13 and 747.3x Put Pulmonary Changes in the Spotlight" in Radiology Coding Alert, vol. 13, no. 8, for information on even more ICD-9 2012 codes affecting radiology.