Coordination and Maintenance 2009

September Meeting Offers Surprises, Old Arguments

By Tina Cressman, MALS, CPC, CPC-I, CPC-H-I, CPC-P, CCS-P, MCS-P, MCS-I, CMC

Where were you when you first learned about ICD-9-CM? If you have been in health care since 1977, when it was first proposed, you remember when ICD-9-CM was new and exciting. If you have any old ICD-9-CM coding books, you can see how the changes in the past 10 years increased the number of codes and require you to keep on top of your coding skills.

Changes to ICD-9-CM germinate in an auditorium at the giant Centers for Medicare & Medicaid Services (CMS) headquarters in Baltimore. Proposals come from all over—statisticians, providers, manufactures, government agencies, and coders. The ICD-9-CM Coordination and Maintenance Committee meetings are held in March and September. The coordinating parties, made up of representatives of the National Committee for Vital Health Statistics (NCVHS) and CMS, are the leaders who maintain ICD-9-CM.

The second 2008 ICD-9-CM Coordination and Maintenance Committee Meeting of 2008, Sept. 24 and 25, left no hints about the future of the code set. While ICD-10 was discussed, ICD-9-CM changes took center stage.

The Department of Health and Human Services (DHHS), parent of CMS, published proposed changes to the Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set Rules on Aug. 22. These proposed changes eliminate use of ICD-9-CM as the standard code set. Oct. 1, 2011 would be the date for reporting diagnoses with ICD-10-CM. Check out the Federal Register website and search for 73 Fed. Reg. 49796 for the details of the proposed rule. Unlike HIPAA implementation, there are no staggered dates, which mean all organizations, including those classified as “small” and “large,” will have to comply on the same date.

Patricia Brooks, CMS, presented a history of ICD-9-CM, along with a list of the system flaws, to the committee and audience. The shortcomings of the ICD-9-CM system discussed at these meetings for several years include the current system is filling up quickly and in many areas it doesn’t allow for specifics such as if the patient is treated for an initial, subsequent, or late effect of an illness or injury.

What Happens at These Meetings?

On the first day, physicians, device manufacturers, and researchers attend the meeting to support their needs for new Volume 3 (inpatient procedural) codes. Presenters provide clinical and statistical information about new technologies, and take questions from both clinicians and coders regarding the proposed changes and additions.

Diagnosis code requests are reviewed on the second day. No reimbursement issues are discussed at these meetings. On this meeting’s agenda for unique diagnosis codes consideration or changes to existing classifications were the following topics:

Traumatic brain injury (TBI)—A physician commenter had a very strong opinion that better coding education for physicians helps avoid coding confusion between the terms.

External cause status—This proposed move has future worker’s compensation tracking implications, which would require E code usage by everyone.

Embedded fragments—These codes’ intended use are for non-medical foreign bodies.

Venous thrombosis and embolism—The Agency for Healthcare Research and Quality (AHRQ) found in a study the majority of patients with a chronic or recurrent thrombus that did not go away had codes inappropriately going to the “history of” codes.

Endometrial intraepithelial neoplasia (EIN)—New codes were requested due to changes in how pathologists view the lesions, a change primarily brought on by technology. Women with EIN have a highly increased chance of having cancer in the next few years and should be monitored.

Epilepsy vs. seizure—This topic, which arose last meeting, prompted a good deal of discussion. Seizures can attribute to a brain injury or stroke, so the patient doesn’t have epilepsy, it is more like a late effect of the insult to the brain’s electrical system.

Dysphonia—Changes to codes describing this disorder were generally accepted, especially separating hyper and hypo nasality. Hyper and hypo nasality are not voice problems; they are disorders of resonance, and dysphonia is a voice production issue.

Fluency problems—Current placement of stuttering and tics is in 307 Special symptoms or syndromes, not elsewhere classified in the Mental Disorders chapter. Stuttering is not a psychiatric issue, and it can also be a late effect of a transischemic attack (TIA); however, the American Psychiatric Association commented that stuttering and tic disorders are related, and they think the codes should stay where they are.

Gout—Patients with gout have a higher rate of mortality and morbidity. It is most common in men over age 40 and can lead to kidney problems and cardiac problems.

Acute life threatening event (ALTE)—Infants with ALTE have a greatly increased chance of having SIDS and benefit from apnea and bradycardia monitoring. To report it correctly, the physician needs to use a “code first” for the manifestation, if known.

Wrong site, surgery, patient—The question asked was, “Would a late effect code be needed?” The answer was, “Probably. Yes.” This again supports the proposal that E codes are mandatory. CMS is coming out with new NDCs to create a definite need for the “wrong” codes.

Failed sedation—During a discussion of a code for failed sedation, the committee agreed “conscious” is an outdated term and not appropriate.

Antineoplastic chemotherapy induced anemia—There is concern over physicians documenting this correctly. The intent is for the new codes to be specifically used due to chemotherapy. There are existing code rules for anemia and chemotherapy, and this change requires a revision to those rules.

Vomiting—The American Academy of Pediatrics feels a different code to indicate persistent vomiting versus the signs and symptoms of vomiting is needed. They argue the two are different clinically and may indicate an emergency requiring surgery.

Colic—Should age range be part of the code description?

Inconclusive mammogram—The evidence justifies follow-up for further study, and this change was generally accepted as beneficial.

Other topics included the following:

  • Venous thromboembolism
  • Congestive heart failure
  • Fitting or adjustment of gastric banding
  • Merkel cell carcinoma
  • Sleep maintenance
  • Tumor lysis syndrome
  • Activity Codes

The meeting discussion regarding mid-year implementation was short and to the point: Jeanne Yoder, MPA, CPC, CPC-I, CCS-P, RHIA, remarked that unless the reasons for adding new codes mid-year was related to a public health concern or truly breakthrough technology, the enormous costs of adding new codes mid-year outweighs the possible benefits. Others in the audience agreed with Yoder’s comments. When asked for further comments after the meeting, Yoder elaborated on the burden of changes to multiple computer systems.

Anyone can attend these meetings. Like in the development of HCPCS Level II, this is a public forum. Registration is online and is available about one month before the events. You can sign up for one or both days, and attendance is free. CEUs are available from AAPC and AHIMA. Due to security issues, preregistration is required.

Find More Information Online

The summary report of the Procedure part of the September 24 and 25, 2008 ICD-9-CM Coordination and Maintenance Committee meeting is posted on the CMS website.

The summary report of the Diagnosis part of the September 24 and 25, 2008 ICD-9-CM Coordination and Maintenance Committee meeting report will be posted on the NCHS website.


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