Cardiology Coding Alert

The 453.x facelift will require you to hunt for more specific upper extremity codes.

Oct. 1 and implementation of the 2010 ICD-9 codes may still be a few months away, but CMS is offering a sneak peak at the added, deleted, and revised codes youll need to know. Keep your focus on the embolism and thrombosis codes so youll be ready to report them from day one.

Where to look: CMSs proposed Inpatient Prospective Payment System rule includes a list of the expected changes to ICD-9 2010 (http://edocket.access.gpo.gov/2009/pdf/E9-10458.pdf, page 409). The proposed rule is also available in the May 22 Federal Register.

Phlebitis Frustrations? Join the Club

In 2009, your coding options are 451.0-451.9 (Phlebitis and thrombophlebitis) and 453.0-453.9 (Other venous embolism and thrombosis).

Problem: Thrombophlebitis is a term that is now rarely used, due to the lack of clinical significance of phlebitis, according to Patrick Romano, MD, MPH, professor of medicine and pediatrics at University of California at Davis, in his Phlebitis and Thrombophlebitis presentation to the ICD-9 Coordination and Maintenance Committee. He presented the proposal on behalf of the Agency for Healthcare Research and Quality.

Coding has paralleled this reduced use of thrombophlebitis, with 453.x (embolism and thrombosis) reported much more frequently than 451.x (phlebitis and thrombophlebitis), Romano said.

An expansion of the 453.x (embolism and thrombosis) range should help you choose codes more in line with current clinical terminology. As described below, the new codes offer options based on location as well as the acute vs. chronic nature of the problem. (See the new codes in the chart on page 59.)

Need for Upper Extremity Codes Revealed

Trend: Increasing use of PICC lines, central catheters, tunnel dialysis catheters, and wired cardiac devices has increased incidence of DVT [deep venous thrombosis] in thorax and upper extremities, typically the axillary, subclavian, [and] brachiocephalic vein, Romano said.

But ICD-9 2009 doesnt offer the same specificity in upper extremity codes that it does for lower extremities.

The current thrombosis categories are incomplete, says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

451.x lower: The 2009 451.x codes allow you to distinguish phlebitis and thrombophlebitis involving:

" Superficial veins of lower extremities (451.82)

" Deep veins of upper extremities (451.83)

" Upper extremities, unspecified (451.84).

451.x upper: But the 2009 embolism and thrombosis 453.x range doesnt offer codes to distinguish superficial thromboses or upper extremity thromboses, Romano said.

You have to resort to 453.8 (Other venous embolism and thrombosis; of other specified veins).

ICD-9 2009 also doesnt offer codes for venous thrombosis affecting thorax and neck vessels, as the ICD-9-CM Coordination and Maintenance Committee Meeting, March 19-20, 2008, Diagnosis Agenda indicates. (You can locate the agenda here: www.cdc.gov/nchs/data/icd9/agendaMa08.pdf.)

453.x lower: ICD-9 2005 introduced 453.40-453.42 (Venous embolism and thrombosis of deep vessels of lower extremity &) which distinguished distal DVT from proximal DVT in the leg, Romano said.

453.x upper: This change did not address upper extremity or upper thoracic clots, Romano said.

The result is that you cant choose a specific code for upper extremity clots unless the physician uses the terminology of thrombophlebitis, Romano said, which is unlikely.

As indicated in the chart on p. 59, the 2010 codes will allow you to choose more specific codes. To report the most specific option, you will need to know the location:

" Superficial veins of upper extremity

" Deep veins of upper extremity

" Axillary veins

" Subclavian veins

" Internal jugular veins.

Documentation Alert: Chronic Vs. Acute Matters

Your 2010 coding options wont be divided only based on location -- youll need to know whether the condition is acute or chronic, as well.

Why it matters: Physicians may keep DVT and pulmonary embolism patients on oral anticoagulation for three to six months or more. The patient may require a subsequent hospital admission to treat a complication, such as anticoagulant-related bleeding. When rehospitalized, these patients are generally coded with 451 or 453, Romano said, but the condition is no longer acute.

So the ICD-9 committee responded to the need by including acute or chronic in the new 453.x code descriptors. Watch for: The final addenda may include instructions on whether chronic codes are appropriate for chronic or unspecified and whether you may use the new codes with complication codes (such as 996.7, Other complications of internal & device &), Miller advises.

Revision red flag: ICD-9 2010 will revise a few codes, as well, to stay consistent with the acute vs. chronic wording, adding acute to the beginning of the 453.4x descriptors:

" 2009: 453.40 -- Venous embolism and thrombosis of unspecified deep vessels of lower extremity

" 2010: 453.40 -- Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity.

" 2009: 453.41 -- Venous embolism and thrombosis of deep vessels of proximal lower extremity

" 2010: 453.41 -- Acute venous embolism and thrombosis of deep vessels of proximal lower extremity.

" 2009: 453.42 -- Venous embolism and thrombosis of deep vessels of distal lower extremity

" 2010: 453.42 -- Acute venous embolism and thrombosis of deep vessels of distal lower extremity.

Policy potential: All these embolism and thrombosis coding changes could mean payers will be adding covered diagnoses to their prothrombin time monitoring policies, so watch out for updates once the new codes go into effect in October. Well keep you posted.

Pass On the Good Word to Providers

Any time we get diagnosis codes that provide additional specificity, I think that is great, says Marvel J, Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver.

But remember that once the new codes become final, youll need to share the changes with your providers so they know what you need to see in the documentation to choose among the more specific coding options. Once payers update their systems, they may require the more specific options (instead of an other code) to prove medical necessity.

Resource: You can download Romanos presentation slides at www.cdc.gov/nchs/about/otheract/icd9/maint/classifications_of_diseases_and1.htm. Under Proposals (3/19-20, 2008), click on the Attachment 4 to Minutes --Romano link.