Cardiology Coding Alert

Plus: Check out embolus and anaphylaxis ICD-9 updates.

ICD-9 2012 is set to ease your search for pulmonary saddle embolus and arteriovenous malformation codes.

That's the news from recently posted proposed updates to the code set. The finalized version will become effective Oct. 1, 2011, so here are the main proposals to watch.

Separate Aorta and Pulmonary Saddle Embolus Options

ICD-9 2012 may add new code 415.13 (Saddle embolus of pulmonary artery). "A saddle embolus is where you have a very large blood clot that dislodges and then goes through the blood stream and lands in a big division of an artery," explained National Center for Health Statistics (NCHS) medical officer David Berglund, MD, at the March 2010 ICD-9 Coordination and Maintenance Committee meeting (page 21, www.cdc.gov/nchs/data/icd9/Transcript3_10_2010.pdf).

A pulmonary artery saddle embolus can block blood flow to the lungs, making this a severe, potentially fatal type of embolism, Berglund said. After realizing there's no ICD-9 index entry pointing to an appropriate pulmonary saddle embolus option, NCHS proposed that the diagnosis get its own code.

In contrast: ICD-9 does currently link the term "saddle embolus" to the aorta. If you look under 2011 code 444.0 (Arterial embolism and thrombosis; of abdominal aorta), you'll see "saddle embolus" in the inclusion list.

But ICD-9 2012 will take that connection a step further. Code 444.0 should expand to provide more precise coding:

• 444.01, Saddle embolus of abdominal aorta
• 444.09, Other arterial embolism and thrombosis of abdominal aorta.

Code 444.09 "would include aortic bifurcation syndrome, aortoiliac obstruction, and Leriche syndrome. These basically are thromboses involving the bifurcation of the aorta rather than an embolus," Berglund said. Those diagnoses currently fall under 444.0.

Don't miss: A current pulmonary embolism isn't the only diagnosis getting attention. ICD-9 plans to add V12.55 (Personal history of pulmonary embolism) to provide a unique code for this part of the patient's history.

Sidestep 2 Potential 747.3x Pitfalls

Continuing the focus on pulmonary diagnoses, you can expect ICD-9 2012 to expand 747.3 (Anomalies of pulmonary artery) to a range of five-digit codes:

• 747.31, Pulmonary artery coarctation and atresia
• 747.32, Pulmonary arteriovenous malformation
• 747.39, Other anomalies of pulmonary artery and pulmonary circulation.

Coarctation and atresia: The first proposed code, 747.31, refers to coarctation and atresia, both of which currently fall under 747.3. Coarctation is another term for narrowing or stenosis of the pulmonary artery. Atresia (also called agenesis) refers to failure of the pulmonary valve to form, so the pulmonary artery's origin doesn't connect to the heart. You'll typically see this "with a patent ductus arteriosis that transfers blood from the left heart circulation to the pulmonary circulation" (page 37, www.cdc.gov/nchs/data/icd9/Topic_packet_for_Sept2010.pdf).

AVM: Proposed code 747.32 will allow you to report a code specific to pulmonary arteriovenous malformation (AVM), a communication between pulmonary veins and arteries. You may see these documented as pulmonary arteriovenous aneurysm, Berglund noted at the September 2010 ICD-9 committee meeting (page 43, www.cdc.gov/nchs/data/icd9/Transcript91510Afternoon.pdf). Another possible term is pulmonary arteriovenous fistula.

ICD-9 2011 doesn't index pulmonary AVM, but it does include AV aneurysm under 747.3. The addition of the new code will clear confusion about how to report the pulmonary AVM.

Pitfall 1: Berglund noted that pulmonary AVMs are usually congenital, but they can be acquired. Acquired pulmonary AV fistulae are reported using417.0 (Arteriovenous fistula of pulmonary vessels).

Pitfall 2: Also be sure to pay attention to whether the documentation refers to a pulmonary artery aneurysm or a pulmonary arteriovenous aneurysm. The expectation is that a congenital pulmonary artery aneurysm will belong under 747.39. A congenital pulmonary arteriovenous aneurysm instead will fall under 747.32. Check your index and the inclusion notes when the codes become official in the fall. That way you'll be sure to choose the appropriate code.

Update Your Anaphylaxis Terminology

If you need to code anaphylactic or serum reactions under ICD-9 2012, be sure to check the index. A variety of new codes will shift the options you may be used to.

995.0: ICD-9 2011 defines 995.0 as "Other anaphylactic shock." A proposed change for ICD-9 2012 would change this to "Other anaphylactic reaction." Chances are your physician refers to "anaphylaxis" rather than anaphylactic shock, noted Jeffrey Linzer, MD, representing the American Academy of Pediatrics at the ICD-9 committee's March 10, 2010, meeting (page 3, www.cdc.gov/nchs/data/icd9/March10CMsum.pdf). And thischange will help clarify that the code is appropriate for anaphylactic reaction even if it doesn't advance to shock.

You'll see a similar change to the codes in the 995.6x range, currently defined as "Anaphylactic shock due to adverse food reaction." The new code definitions will begin with "Anaphylactic reaction ..." rather than referencing shock.

999.4x-999.5x: ICD-9 2012 proposes to expand 999.4(Anaphylactic shock due to serum) and 999.5 (Other serum reaction) so that you must use a fifth digit. The proposed codes are:

• 999.41, Anaphylactic reaction due to administration of blood and blood products
• 999.42, Anaphylactic reaction due to vaccination
• 999.49, Anaphylactic reaction due to other serum
• 999.51, Other serum reaction due to administration of blood and blood products
• 999.52, Other serum reaction due to vaccination
• 999.59, Other serum reaction.

V13.8x: Current code V13.8 (Personal history of other specified diseases) also likely will see an expansion to:

• V13.81, Personal history of anaphylaxis
• V13.89, Personal history of other specified diseases.

This change makes V13.89 the new "catch all" history code because V13.8 will no longer be a valid code.

Learn More From CMS and CDC Sites

Looking through the complete list of changes is worth your time. For example, you may save yourself a denial by noting that V12.2 (Personal history of endocrine, metabolic, and immunity disorders) will no longer be valid. Instead, ICD-9 plans to add V12.29 with the same  descriptor to allow for the addition of V12.21 (Personal history of gestational diabetes).

But remember that these codes will not be official until the fall, and you will need to apply any new guidelines and index changes, as well. For example, discussions on new code 997.32 (Postprocedural aspiration pneumonia) centered around whether there should be an instruction to report an additional code identifying the complication (pages 25-29, www.cdc.gov/nchs/data/icd9/Transcript3_10_2010.pdf).

CMS has posted the proposed codes as part of the FY2012 Hospital Inpatient PPS proposed rule. At publication time, you can find the proposed changes by going to www.cms.gov/AcuteInpatientPPS/IPPS2012/list.asp and choosing the link for "FY 2012 Proposed Rule and Correction Notice Tables." On the new page, click the link to download tables 6A-6F. Table 6A shows new diagnosis codes, table 6C shows invalid codes, and table 6F shows revised codes.

You'll find code proposals, meeting summaries, and transcripts at www.cdc.gov/nchs/icd/icd9cm_maintenance.htm, with additional resources at www.cms.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp.