Medicare Compliance & Reimbursement

Lower extremity embolism codes got a facelift in 2005, and upper extremity coding will be playing catch up in 2010. But to keep things consistent, the lower extremity codes will be seeing updates, too, with new concepts such as acute and chronic options.

Check it out: CMS has offered a sneak peak at the added, deleted, and revised codes you'll need to know when ICD-9 2010 goes into effect Oct. 1, 2009 -- and if cases involving extremity embolisms regularly cross your desk, you're better be prepared.

In 2009, your diagnosis options fall in two code families: 451.0-451.9 (Phlebitis and thrombophlebitis) and 453.0-453.9 (Other venous embolism and thrombosis). But those aren't necessarily the most clear-cut choices.

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 terminology use. As described below, the new codes offer options based on location as well as the acute versus chronic nature of the problem.

Trend: The increased use of PICC lines, central catheters, and tunneled dialysis catheters has increased the incidence of DVT (deep venous thrombosis) "in thorax and upper extremities, typically the axillary, subclavian, [and] brachiocephalic vein," Romano said.

Coding accurately for these situations raises challenges because ICD-9 2009 doesn't offer the level of specificity in upper extremity diagnoses that it does for lower extremities. Consider this comparison between upper and lower extemity options within the 451.x and 453.x code families.

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

• superficial vessels of upper 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 doesn't 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). Note that ICD-9 will delete 453.8 in 2010.

ICD-9 2009 also doesn't 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(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 can't choose a specific code for upper extremity clots unless the physician "uses the terminology of 'thrombophlebitis,'" Romano said, which he said is unlikely.

The 2010 codes will allow you to choose more specific upper extremity 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.

Keep in mind: These codes may be particularly useful for interventional coders, especially if you report dialysis access procedures, and your patients develop central venous thromboses.

If you report embolism and thrombosis codes based on a catheter or graft complication, watch for 2010 guidelines on whether you should report an additional complication code, such as 996.73 (Complications peculiar to certain specified procedures; due to renal dialysis device, implant,and graft) "when thrombosis develops as a result of the AV fistula or graft," says Jackie Miller, RHIA, CCS-P, CPC, vice president of product development for Coding Metrix Inc. in Powder Springs, Ga.

Your 2010 coding options won't be divided based only on location -- whether the condition is acute or chronic will also guide your code choice.

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 responded to the need by including "acute" or "chronic" in the new 453.x code descriptors.

Revision red flag: ICD-9 2010 also will revise a few codes 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.

Reality: If you're reporting diagnostic imaging, you may not know whether the thrombosis is acute or chronic, notes Miller. Watch to see whether the 2010 ICD-9 addenda offer guidelines on which codes to use when acute or chronic isn't specified, she says. For example, chronic codes may be appropriate for "chronic or unspecified."

Resource: You can download Romano's presentation slides online 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.