Oncology & Hematology Coding Alert

Tumor lysis syndrome is getting its own code -- will you know where to look?

CMS has revealed the 2010 ICD-9 code updates, and the main lesson is that using your ICD-9 index may prove more important than ever.

Heres why: Most of the new codes will offer additional specificity to existing diseases (unique Merkel cell carcinoma codes, for example), which can help you code more accurately. And getting new diagnosis codes that provide additional specificity can certainly be a plus, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver.

But the revised code list doesnt just add specificity to your options. You may find that not all the new codes are located where you expect (dont make any assumptions about where youll find Merkel cell for unknown primary site).

Get the full picture: CMSs proposed Inpatient Prospective Payment System (IPPS)  rule includes a list of the expected changes to ICD-9 2010 (http://edocket.access.gpo.gov/2009/pdf/E9-10458.pdf, page 409). Youll find the proposed rule published in the May 22 Federal Register, as well.

1. Add 285.3: Antineoplastic Chemotherapy-Induced Anemia

Chemotherapy-induced anemia is one of the most common side effects of treatment, but in 2009, you dont have a code that distinguishes this anemia from other types.

Oct. 1, youll be able to report 285.3 (Antineoplastic chemotherapy induced anemia) for the condition.

285.22 note: One commenter asked that the there be an exclude note for this new code placed with 285.22 (Anemia in neoplastic disease), according to the ICD-9-CM Coordination and Maintenance Committee 2008 Summary (www.cdc.gov/nchs/data/icd9/Sep08CMsum.htm).

This note is a helpful reminder that 285.22 is appropriate when the anemia is caused by the cancer (such as ovarian cancer with intratumor bleeding), not by the treatment.

Documentation: A commenter at the meeting also noted that getting providers to document chemotherapy as the cause may be difficult, just as it is difficult to get providers to document common conditions like blood loss anemia, the summary states.

So once ICD-9 releases the official codes and addenda, alert your providers to your specific documentation needs. Hopefully, if your office reports non-ESRD ESA treatment, your doctors are already accustomed to documenting anemia due to chemotherapy.

Tip: Stay alert for payers updating ESA policies once the new ICD-9 codes go into effect, advises oncology coding expert Cindy Parman, CPC, CPC-H, RCC, principal with Coding Strategies Inc. in Powder Springs, Ga.

And remember to report E933.1 (Drugs, medicinal and biological substances causing adverse effects in therapeutic use; antineoplastic and immunosuppressive drugs) along with new code 285.3, Parman says.

2. Find Tumor Lysis Syndrome at 277.88

After cancer treatment -- for lymphoma or leukemia in particular -- patients may develop complications known as tumor lysis syndrome. These complications are caused by the breakdown products of dying cancer cells and include hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and acute renal failure, states the ICD-9-CM Coordination and Maintenance Committee Meeting September 24-25, 2008 Diagnosis Agenda (www.cdc.gov/nchs/data/icd9/agendaSep08.pdf). Tumor lysis syndrome also may occur before treatment, but in this case it is not associated with hyperphosphatemia (elevated blood phosphate level), the September agenda states.

2009: Tumor lysis syndrome is not specifically indexed in the 2009 manual. Advice given in the American Hospital Associations Coding Clinic for ICD-9-CM. (Nov/Dec 1985, page 1) advised coders to use code 584.8, Acute renal failure with other specified pathological lesion in kidney, along with external cause code E933.1, Adverse effects of antineoplastic and immunosuppressive drugs, if the tumor lysis syndrome is post-chemotherapy, the September agenda states.

Problem: Acute renal failure is only one of the syndromes manifestations.

2010: You will be able to use 277.88 (Tumor lysis syndrome) for encounters on or after Oct. 1, placing it in the 277.8x (Other specified disorders of metabolism) category. This placement should match where youll find the syndrome listed in ICD-10.

3. Merkel Cell CA: Switch 173.x for 209.3x

One group of new diagnosis codes ICD-9 2010 will introduce covers Merkel cell carcinoma, an aggressive neuroendocrine skin cancer that has roughly 1,500 new cases each year. That number is on the rise, and the new codes should help identify and track patients, according to the September agenda.

Merkel cell carcinoma tends to grow quickly and may metastasize at an early stage. Oncologists may use radiation to shrink the carcinoma, and radiation or chemotherapy to treat metastases.

2009: You currently report 173.x (Other malignant neoplasm of skin) for Merkel cell carcinoma.

2010: You will have more specific options in 2010:

" 209.31 -- Merkel cell carcinoma of the face

" 209.32 -- & of the scalp and neck

" 209.33 -- & of the upper limb

" 209.34 -- & of the lower limb

" 209.35 -- & of the trunk

" 209.36 -- & of other sites.

Careful: The ICD-9 committee stated that 209.30 (Malignant poorly differentiated neuroendocrine carcinoma, any site) is not appropriate for Merkel cell carcinoma of unknown site, according to the ICD-9 Committee 2008 summary.

4. Merkel Cell Joins Secondary Neuroendocrine Set

The CMS IPPS proposed rule indicates you will have to take your coding hunt to 209.75 (Merkel cell carcinoma, unknown primary site) if the primary site is unknown.

Code 209.75 sits near the end of a new list of secondary neuroendocrine tumor codes:

" 209.70 -Secondary neuroendocrine tumor, unspecified site

" 209.71 -- of distant lymph nodes

" 209.72 -- of liver

" 209.73 -- of bone

" 209.74 -- of peritoneum

" 209.75 -Merkel cell CA, unknown primary site

" 209.79 -Secondary neuroendocrine tumor of other sites.

This new category is connected to a new personal history code, as well. ICD-9 2010 will revise V10.9 (Unspecified personal history of malignant neoplasm) to include two four-digit codes:

" V10.90 - Personal history of unspecified type of malignant neoplasm

" V10.91 - Personal history of malignant neuroendocrine tumor.

5.When Personal Drug Hx Counts, Look Here

The V87.4 (Personal history of drug therapy) category

will have two new additions in October to watch for:

" V87.43 -Personal history of estrogen therapy

" V87.46 -Personal history of immunosuppressive therapy.

Remember that you should use these codes for encounters when the personal history directly affects the patients complaints or status.

6. 239.8 Revision Offers Unspecified Nature Insight

ICD-9 2010 will delete 239.8 (Neoplasms of unspecified nature; other specified sites) and will require a fourth digit for codes in this category:

" 239.81 -Neoplasms of unspecified nature, retina and choroid

" 239.89 -- other specified sites.

Reason: New York ophthalmologist Bruce Hyman, MD, requested a unique code to identify suspicious areas in the retina that require observation over time. The location makes biopsy difficult, so physicians typically take a watch-and-see approach until the spot grows.

Even if you wont have reason to report 239.81, be sure you remember to trade 239.8 for 239.89.

239.xx tip: You dont need histologic confirmation to report these unspecified nature codes, according to the ICD-9-CM Coordination and Maintenance Committee Meeting March 19-20, 2008, Diagnosis Agenda  (www.cdc.gov/nchs/data/icd9/agendaMa08.pdf).

But take care. You shouldnt flip to this section of the Neoplasm Table and report an unspecified nature code  the ICD-9-CM Index will point to this code based on the patients condition, Parman explains.

7. Forego 279.49 for ALPS in 2010

ICD-9 2010 also adds fourth digit options to 279.4 (Autoimmune disease, not elsewhere classified):

" 279.41 -Autoimmune lymphoproliferative syndrome

" 279.49 -Autoimmune disease, not elsewhere classified.

Impact: The change allows you to report

Autoimmune Lymphoproliferative Syndrome (ALPS) with a unique code. ALPS is an inherited immune system disorder that involves high numbers of lymphocytes (white blood cells) accumulating in the lymph nodes, liver, and spleen. ALPS can cause anemia (low red blood cell count), thrombocytopenia (low platelet count), and neutropenia (low count of neutrophils, which are white blood cells).