Wiki icd 9 code for 33968

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I need an ICD 9 code for the removal of the intra-aortic ballon device.
I have seen 414.01 work in the past. Patient is one day status post CABG or should I use the V45.81 (removal vascular cath). Clearing house is rejecting the 414.01.
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for the removal 33968 I always use the same code that was used for the implant 33967. typically it is performed for hypotension but can also be done for other serious conditions. I'm surprised the clearinghouse would be preventing that code from going through.

and V45.81 is just status post CABG, doesn't state anything about removal of a vascular cath
 
It is inappropriate to use a dx code if the patient does not currently have that condition, if the encounter is just to remove a device and there is no complication or issue, then use the V53.39 (Z45.09) code for the removal. Fitting and adjustment of the device includes the removal of the device.
 
mitchellde said:
It is inappropriate to use a dx code if the patient does not currently have that condition, if the encounter is just to remove a device and there is no complication or issue, then use the V53.39 (Z45.09) code for the removal. Fitting and adjustment of the device includes the removal of the device.
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I see your point but I disagree in this situation. I also forgot to mention earlier that we add a -58 modifier to the 33968 when the patient is post CABG
 
Disagree why? If the patient is not hypotensive and the device is being removed because they are NOT hypotensive then that is an incorrect diagnosis for the procedure. If there is no other complication necessitating the removal of the device then there is no acute code that can be used , it is just a simple encounter to remove the device and that is a V (Z) code.
 
I disagree because when the physician inserts a device like an IABP it is expected to be removed within a relatively short period of time once the patient has stabilized. Obviously the patient should not be hypotensive any longer which is why it can safely be removed. Some of our insurances do not accept V codes as the primary diagnosis, which is why I revert back to the original reason for the IABP placement.

When the patient is in the hospital, all conditions are ongoing until they are released whether or not that condition is actively present during the encounter. The only diagnosis that falls outside of this is cardiac arrest which can only be coded if it is active during an encounter, otherwise history of cardiac arrest must be used.
 
The payer cannot dictate the dx code. You have stated exactly what I said, the patient is no longer hypotensive, the reason for the removal of the device is the absence of this status. You cannot use a dx code for a condition that does not exist. V codes are perfectly acceptable as a primary dx code , there are just certain V codes that are secondary only allowed such as the V45.81. You never use the dx code for the reason for a procedure as the dx for the aftercare. This covered in the coding guidelines.
 
I agree that V codes are or should be acceptable as primary diagnosis codes, but if some of our payers do not accept them (typically state funded insurance plans) then there isn't anything else to do but use another code.

In this case, it is acceptable to use 458.9 as the primary and only diagnosis code for the removal 33968. This tells the payer that the device is being removed and the patient required the device at some point for this condition. It isn't incorrect coding to use 458.9 on 33968. The IABP was inserted for that condition, so repositioning, adjusting, or removing the device can be billed with the same diagnosis.
 
I disagree it is never acceptable to use a dx code for a condition the patient does not currently possess. The coding guidelines are mandated to followed under the HIPAA.
The guidelines state:
Aftercare visit codes cover situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.
The aftercare codes are generally first listed to explain the specific reason for the encounter.
Status V codes may be used with aftercare V codes to indicate the nature of the aftercare. For example code V45.81, Aortocoronary bypass status, may be used with code V58.73, Aftercare following surgery of the circulatory system, NEC, to indicate the surgery for which the aftercare is being performed.

The fitting and adjustment V code is the one that tells the payer the device is being removed. You stated in your earlier post that the patient is no longer hypotensive and that is the reason the device is being removed. Yet you continue to communicate with the 458.9 that the patient stills has the hypotensive condition.
The payer is required to accept the V codes when properly used. They can have coverage issues that are for the encounter as a whole but not just because you use a V code properly.
 
I understand everything you said except I disagree with this statement, "The fitting and adjustment V code is the one that tells the payer the device is being removed". Actually, the CPT code 33968 tells the payer that the device is being removed. The diagnosis code is just to tell them why it is being removed, and yes 458.9 is not the most accurate code but if it allows the claim to be paid and V53.39 creates a denial then I will use 458.9.

I try my best to provide accurate coding but this isn't a non-profit organization. We typically don't have the luxury of going to war over every policy discrepancy, especially over a code that pays $34. We can simply agree to disagree, that's the great about coding, there are usually several correct answers.
 
jeremym@pimaheart.com said:
I understand everything you said except I disagree with this statement, "The fitting and adjustment V code is the one that tells the payer the device is being removed". Actually, the CPT code 33968 tells the payer that the device is being removed. The diagnosis code is just to tell them why it is being removed, and yes 458.9 is not the most accurate code but if it allows the claim to be paid and V53.39 creates a denial then I will use 458.9.

I try my best to provide accurate coding but this isn't a non-profit organization. We typically don't have the luxury of going to war over every policy discrepancy, especially over a code that pays $34. We can simply agree to disagree, that's the great about coding, there are usually several correct answers.
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The reason I so vehemently disagree is that you know the 458.9 is incorrect and yet you use it. You cannot use a code just to get a claim paid, you use a dx code to accurately capture the patient diagnosis for the encounter. The provider does not document that the patient is currently experiencing a hypotensive condition which means you as a code absolutely cannot use that dx code. You are required to use the code for the patient diagnosis for the specific encounter.
This is a huge issue and we cannot agree to disagree. It is wrong to assign a condition to a patient that is not documented and they do not have at that encounter.
The guidelines must be adheared to at all times.
The question is have you even tried to use the V53.39? It is an allowable code first listed but the V45.51 is not allowable first listed. The payer (unless Work Comp) cannot state that they do not accept V codes since the V codes are an integral part of the required code set.
As a patient I want you to use the code that describes me, since my future premiums and benefits depend on it.
 
General Coding Guidelines, paragraph 4 & 5:

Code or codes from 001.0 through V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter visit.

The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the admission/encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc).

That is taken straight from 2014 ICD-9-CM which tells me that any diagnosis active during the "hospital admission" can be used throughout that admission to describe E/M visits and procedures. So, 458.9 is not an unacceptable or inaccurate diagnosis code for removing the IABP. The patient's condition is illustrated through CPT and ICD-9 codes, not just ICD-9 codes. The payer already knows the device is being removed because that is the exact definition of 33968. Typically, the claim for the removal is sent a couple days after the claim for the insertion 33967, so the payer is already expecting to receive a charge for removal. V53.39 isn't necessary and is too generic for this situation.

Also, what about coding for MI or a chronic condition? If a patient is admitted to the hospital for an acute MI of the anterior wall the appropriate diagnosis code is 410.11, right? Immediately intervention is performed which resolves the acute MI. Subsequent visits for that patient during that hospital admission will still be coded with 410.11 along with all other relevant ICD-9 codes because that code demonstrates the reason for the visit. Same goes for chronic conditions like atrial fibrillation. Sometimes a patient will have atrial fibrillation for years but occasionally will spontaneously convert to normal sinus rhythm. Even when the patient is not in atrial fibrillation we would still code an office visit with 427.31 because it is an ongoing chronic condition and it will be taken into account when changing medications or ordering diagnostic tests.
 
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Ok but it does not state you eliminate the V codes and it clearly states the provider determines the patients diagnosis. You stated the documented reason for the procedure is that the patient is no longer hypotensive . Therefore you cannot assign a code for hypotension. You must use the aftercare V codes.
You need to read all the guidelines page 1 included.
 
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mitchellde said:
Ok but it does not state you eliminate the V codes and it clearly states the provider determines the patients diagnosis. You stated the documented reason for the procedure is that the patient is no longer hypotensive . Therefore you cannot assign a code for hypotension. You must use the aftercare V codes.
You need to read all the guidelines page 1 included.
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I just saw on your signature that you are a CPC-H, I hope this discussion isn't because we are in two different coding worlds. I'm strictly talking about out patient physician coding and the rules specific to physicians not employed by a hospital.
 
jeremym@pimaheart.com said:
General Coding Guidelines, paragraph 4 & 5:

Code or codes from 001.0 through V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter visit.

The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the admission/encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc).

That is taken straight from 2014 ICD-9-CM which tells me that any diagnosis active during the "hospital admission" can be used throughout that admission to describe E/M visits and procedures. So, 458.9 is not an unacceptable or inaccurate diagnosis code for removing the IABP. The patient's condition is illustrated through CPT and ICD-9 codes, not just ICD-9 codes. The payer already knows the device is being removed because that is the exact definition of 33968. Typically, the claim for the removal is sent a couple days after the claim for the insertion 33967, so the payer is already expecting to receive a charge for removal. V53.39 isn't necessary and is too generic for this situation.

Also, what about coding for MI or a chronic condition? If a patient is admitted to the hospital for an acute MI of the anterior wall the appropriate diagnosis code is 410.11, right? Immediately intervention is performed which resolves the acute MI. Subsequent visits for that patient during that hospital admission will still be coded with 410.11 along with all other relevant ICD-9 codes because that code demonstrates the reason for the visit. Same goes for chronic conditions like atrial fibrillation. Sometimes a patient will have atrial fibrillation for years but occasionally will spontaneously convert to normal sinus rhythm. Even when the patient is not in atrial fibrillation we would still code an office visit with 427.31 because it is an ongoing chronic condition and it will be taken into account when changing medications or ordering diagnostic tests.
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It does not matter what my certification is I can code in all worlds. You are applying too broad an interpretation. A physician coder cannot chose any diagnosis for the admission, you must code for the encounter
As far as the acute MI goes you change the 5th digit to account for the subsequent encounters. As faras it still being an acute MI. The definition of acute status for 8 weeks (4 with ICD-10) is handed to us in the guidelines.
Hypotension is not the same as afib and cannot be compared.
As a physician coder you must use codes for that encounter and clearly hypotension is not the condition of this patient for this encounter.
I will continue to argue this every time. I run into this same issue in every class and every state.
These are the diagnosis of the patient you must always be correct for that encounter.
 
Also you state the payer knows why the device is being removed... no they do not. The CPT code tells them the procedure. The dx code tells them why. When you use hypotension it tells the payer the device was ineffective and the patient still has the condition.
 
mitchellde said:
When you use hypotension it tells the payer the device was ineffective and the patient still has the condition.
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That's not true, you are assuming that they are assuming that. They should not believe that the device was ineffective unless it was billed with a complication code, 996.09.

In either case, I still believe using 458.9 on 33968 is not incorrect coding. I said before that we should agree to disagree and I'll say it again. V53.39 is too generic and does not specifically explain the reason for the removal, it does not tell the payer that the condition has resolved. V53.39 can be used for lots of different situations including "programming" and "EOL" parameters. Obviously those don't apply in this situation but the payer doesn't know that.

Throughout an entire hospital admission (including hospital transfers), 410.41 would be an accurate code even though the condition may have resolved. Using 410.42 or 412 would not be correct. And I only mentioned 427.31 because I'm curious how you would code a chronic condition that is not present during an encounter but still taken into consideration during medical decision making.

You want to be specific, yet you revert back to a generic "other" code. You're inconsistent but I still don't think you are wrong.
 
even though V 53.39 is an "other" code it is still correct as there is no other more specific code for this device.
You are confusing inpatient and physician. The inpatient coder will use the 410.01 as they based on discharge for the reason for the admission. However the physician coder will use the 410.01 only for the encounter when the MI is diagnosed. After that each encounter is a subsequent encounter for the patient. This will change for ICD-10. As for the afib, if the provider is checking the meds then I use V58.83 with the V58.61. It just depends on what the provider documents.
In you case for this encounter I am betting the provider does not state that the patient presents with hypotension so the device will be removed. I am thinking they state something like now that the hypotension has resolved.... you must code only from the documentation for that encounter, you cannot use diagnosis from previous encounters and when you do you are coding what is not documented.
Lets just suppose the patient had been discharged (i know this will,never happen), then came to the outpatient setting for the device removal. You would not have an entire admission to say hypotension had been the diagnosis. You must apply the same logic across the board.
As a patient i expect the coder to code accurately, and to not use a code for a condition i no longer possess.
 
This isn't getting us anywhere. I quoted the guidelines from ICD-9-CM which apply to this situation. You referenced page 1 of the guidelines but none of that information specifically applies to what we're talking about.

In summary, you're wrong about the MI and a-fib codes. 410.01 would be appropriate for an entire hospital admission as we see the patient each day. It is an ongoing condition even after intervention has been performed. The code specifically states "initial episode of care"....an entire hospital admission spanning several days may be used to treat the MI even though the patient's EKG may currently by normal. As for the a-fib, chronic conditions can be reported even when the condition is not present during that encounter....that's why it is a chronic condition and still requires treatment. You can't accurately represent an E/M visit by using V codes all the time. V58.61 does state what the encounter was partially for, but that code doesn't represent any condition that the patient has like a-fib. It is just another generic code, you need to be more specific.
 
the physician coder does not code for the entire hospitalization you code for each individual encounter. After the initial dx of the MI then each visit fromthe patient perspective is a subsequent encounter for the acute MI. You must always code from the diagnosis perspective which is the patient, again these are diagnosis codes not provider encounter codes. The V58.83 with the V58.61 is the specific code for a medication adjustment encounter. You simply cannot use a diagnosis code that the patient no longer has. and Yes you can use V codes for E.M visits if that fits the diagnosis per the provider documentation. The physician coder is not allowed to use an entire encounter to code a single visit or procedure. Sorry but that is very incorrect. I have quoted to you many sections from the guidelines. Page one is the one that tells you the provider renders the diagnosis. You quoted only from general guidelines that tells you to select from the entire classification, I also gave you the guidelines for follow up and aftercare encounters.
unfortunately each time you indicate initial encounter for an MI you indicate a new MI has occurred.
"initial EPISODE of care" does not indicate the entire hospitalization for a physician coder. I will not back down from this. You just cannot code for what you feel will be reimbursed.
 
I'm not going to back down either, some of things you are stating are way off base and not accurate. "unfortunately each time you indicate initial encounter for an MI you indicate a new MI has occurred" That is not true at all, re-read the definition of the MI codes...initial episode of care means the first time we are treating the patient for this condition. It concerns me that you only use V codes for day-to-day diagnoses. V58.61 does not tell the whole story, it does not show what condition is being treated. Patient's require ongoing treatment of a diagnosis, even after the symptoms have resolved. Coding for symptoms is much different than coding for a confirmed diagnosis.
 
Ok going back to the original post, you cannot code a resolved condition as still being present. You do not code the preprocedural condition as the aftercare diagnosis. I use V codes when they are documented for. The diagnosis are to represent the condition as documented by the provider. And yes when you use the initial episode MI code it does indicate a new MI has occurred. That is the purpose of that code. It is the first initial treatment of the patient for an acute MI each subsequent visit cannot be coded as an initial episode. I do not know how you can argue with this when the guidelines so clearly point this out.
per the codebook
initial - to designate the first episode of care for a newly diagnosed MI.
subsequent - to designate an episode of care following the initial episode for MI that has received initial treatment but is still less than 8 weeks old.
458.9 is unspecified hypotension which is an abnormally low BP.
Again this is not what is stated as being documented as the reason for the removal of the device.
Let me ask this:
If a patient has severe diverticulitis and has had a temporary colostomy. Now after a period of time it is determined that the condiciton no longer exisits and the need for the colostomy has passed so they are going to perform a colostomy take down.. would you code diverticulitis as the reason for surgery? because this is what matches the logic you are using, or would you use the V code encounter for clousure of colostomy, which matches the logic I am using as well as the coding guidelines.
 
I don't code GI, I only code cardiology so I don't know the disease process for those types of conditions. It is clear you do not understand the disease process for cardiovascular disease or code specific guidelines in ICD-9. This is a pointless conversation, you're wrong and that is the end of it. you're taking the information in ICD-9 too far and not accurately representing the patient's condition or how they were treated during their office visit or hospital admission.
 
I am sorry but yes I do in fact code for cardiology, I am saying that the logic for these two encounters is exactly the same. It does not change from one specialty to the other. They only time we can deviate from the overall guidelines is when a chapter specific guidelines states differently for that disease chapter. I am not taking the information too far, I am saying as a physician coder you cannot use the diagnosis from any part of the admission as a diagnosis for a single encounter. It just does not make good sense and it is contrary to the guidelines. I am sorry that you cannot see the sense of this but you are in fact assigning a code not represented by the physician for a particular encounter.
I am truely attempting to educate you on an aspect that you have been ill taught in the past. You need to take a minute and really look at what is being stated.
 
I understand what you are explaining but I disagree in the case of 33968, acute MI codes, and chronic atrial fibrillation. You may code cardiology but you don't understand the clinical aspect of what we are trying to represent to the payers. A diagnosis does not just go away even though the signs and symptoms are gone. It is one thing to code "leg pain" (symptom) when the patient is not currently experiencing leg pain. It is a completely different situation to code a-fib when the patient is currently in normal sinus rhythm but has been chronic for years and has a fluke EKG with normal rhythm.
 
The logic must work in all cases that is what I am trying to point out. The acut MI codes are very explanatory. You are assuming the payers know things they absolutely do not. Your claims are processes by machines these machines report data and statistics. Part of this confusions is why the ICD-10 CM system is better and has changes certain things like the acute MI. However for now you do need to use subsequent for the visits following the initial, the patient's risk factor is adjusted with every dx code you submit. and one more time, you cannot use the code for hypotension when the provider does not document that dx as the reason for the procedure.
As long as a condition is being treated we can code it, so a fib is still being treated to keep it under control, diabetes is still being treated. But an MI is initial once then it is subsequent, and hypotension is not the reason for removal of a device. You must code what is documented.
If the patient is seeing the provider only to adjust meds for the afib then the appropriate diagnosis is the V58.83 and V58.61.. this is documented in coding clinics. The same goes for any chronic condition where the provider is checking the labs and adjusting the medications. Coding clinics are a valuable tool and are considered the final and authoritative word on compliant coding. I highly recommend them. I never stated the diagnosis had gone away, I stated that the provider had not documented hypotension as the reason for the removal of the device, and I stated that you cannot use any diagnosis documented during a hospitalization, for physician coding.
 
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