AHIMA Comments on the Proposed Diagnosis Code Modifications Presented at the April 1st ICD-9-CM Coordination and Maintenance (C&M) Committee Meeting

April 13, 2005

Donna Pickett, MPH, RHIA
Medical Classification Administrator
National Center for Health Statistics
3311 Toledo Road Room 2402
Hyattsville, Maryland 20782

Dear Donna:

The American Health Information Management Association (AHIMA) welcomes the opportunity to provide comments on the proposed diagnosis code modifications presented at the April 1st ICD-9-CM Coordination and Maintenance (C&M) Committee meeting.

I will first address those proposals that have been recommended for implementation in October 2005:

Sleep Disorders
AHIMA supports the recommendation to implement the full set of proposed codes for sleep disorders in October 2005. The American Academy of Neurology made recommendations regarding the placement of some of the proposed sleep disorder codes at the October 2004 C&M meeting. We support their recommendations and believe corresponding modifications should be made to the October 2004 proposal.

Aspiration Syndrome
While AHIMA supports the expansion of codes for fetal and newborn aspiration, we are concerned that it may not always be clear to coders when the proposed codes for "with respiratory symptoms" should be used. The fact that the inclusion terms are medical conditions (such as pneumonia) rather than just symptoms may contribute to this confusion. If the intent of the new codes for "with respiratory symptoms" is that a respiratory condition or specific manifestation must be present in order for these codes to be assigned, the code titles should be changed from "symptoms" to "conditions" or "manifestations." If the intent was not to limit the use of these codes to circumstances when a respiratory medical condition is present, it would be helpful to include examples of additional situations when these codes should be assigned.

We agree with the suggestion made at the meeting at the modifications proposed for October 2006 should be implemented in conjunction with the October 2005 modifications.

Genetic Testing
We support implementation of codes for genetic screening not associated with procreative management in October 2005 to coincide with the implementation of codes for genetic testing associated with procreative management.

Encounter for Pregnancy Test, Pregnancy Confirmed
AHIMA supports creation of a code for pregnancy examination or test with positive result. Immunotherapy
We fully support creation of a unique code for encounter for immunotherapy for neoplastic condition and urge you to implement this modification in October 2005.

2006 Proposals:

Epilepsy

We support the revisions to the codes for epilepsy and seizures.

To clarify the distinctions between category 345 and code 780.39, the description of code 780.39 should be revised to state "Other convulsions, single episode." Excludes notes should be added under code 780.39 to refer people to category 345 for recurrent seizures and to code 345.9 for seizure disorder NOS.

Cracked Tooth
We support the establishment of a new code for a cracked tooth that is caused by normal wear and tear rather than by an injury.

The code descriptor for the proposed new code should be revised to state "cracked or broken tooth" to make it clear that both broken and cracked teeth are classified to this code, rather than providing this clarification in an inclusion term alone.

"Cracked tooth due to injury" should clearly be excluded from the new code and should clearly be included in existing codes 873.63 and 873.73.

Compartment Syndrome
While we support the creation of new codes for nontraumatic and traumatic compartment syndrome, we question whether specific codes for all of the anatomic sites outlined in the proposal are necessary. For example, could the codes for upper arm and forearm be combined into a single code for arm? Also, since "upper" is in parenthesis in proposed codes 729.71 and 958.91, it appears as though "upper" is a non-essential modifier, and, therefore, the forearm is not clearly excluded from these codes. This is also true of "lower" in the descriptors of the codes for compartment syndrome of the leg. Since "lower" is in parentheses, and the thigh is part of the leg, the thigh is not clearly excluded from the codes for (lower) leg.

Inclusion terms and index entries are needed to identify the appropriate code for sites that are not specifically identified. For example, which codes should be assigned for non-traumatic and traumatic compartment syndrome of the wrist or ankle?

The default code for nontraumatic compartment syndrome NOS (when the specific site isn't specified) should be identified.

Hematology Issues
AHIMA supports the creation of unique codes for several hematology conditions. Refractory anemia is currently indexed to code 284.9 and is listed as an inclusion term under this code. No modifications to code 284.9 were included in the proposal. However, the inclusion term for "refractory anemia" will need to be deleted under code 284.9 and an Excludes note added directing coders to proposed code 238.72 for this condition.

An additional new code should be created for drug-induced neutropenia.

The codes for elevated and decreased white blood cell count should be combined into a single code.

Given the number of conditions still listed as inclusion terms under code 288.8, it would be beneficial to create distinct codes for some of these conditions, such as lymphocytosis.

Psoas Muscle Abscess
We support the creation of a unique code for psoas muscle abscess.

We wondered why the tuberculous form of this condition is indexed to a code for infections involving bone (code 730.88) if this is an abscess of the muscle. Does it extend into bone? If so, does the nontuberculous form also extend into bone? If it does, should an osteomyelitis code be assigned?

Dental Code Modifications
AHIMA supports the proposed modification to the dental codes as presented at the C&M meeting.

Torsion Dystonia and Athetoid Cerebral Palsy
We support the proposed modifications to the codes for dystonia and athetoid cerebral palsy. We also agree with the suggested revisions made during the C&M meeting, including the addition of "secondary Parkinsonism" to the Excludes notes under proposed codes 333.72 and 333.85.

Myelitis
We support the proposal for new and revised codes for myelitis.

"Acute myelitis" should be listed as an inclusion term under the appropriate code (perhaps under "acute transverse myelitis," as recommended by the American Academy of Neurology) and should also be indexed.

Currently, unspecified myelitis is indexed to code 323.9. Should it continue to be classified to this code, or should it be classified to the proposed code for acute transverse myelitis NOS?

West Nile fever should be added to the Excludes note under proposed code 323.01.

The title of existing code 323.9 should be revised to state "unspecified cause of encephalitis, myelitis, and encephalomyelitis."

Postnasal Drip
AHIMA supports the creation of a new code for postnasal drip.

The various causes of postnasal drip should be indexed to the main term "Drip," and cross-reference "postnasal drip" to this main term.

Nonasthmatic Bronchospasm
We support the creation of a unique code for acute bronchospasm.

"Bronchospasm NOS" should be listed as an inclusion term under the proposed new code and should be indexed to this code.

Body Mass Index, Pediatric
We support the creation of body mass index (BMI) codes for the pediatric population. We also concur with the recommendation made during the meeting that the phrase "for age" be added to the new code titles to clarify that the percentiles referenced in these codes are linked to the patient's age.

Transfusion Related Acute Lung Injury (TRALI)
AHIMA supports the creation of a unique code for transfusion related lung injury (TRALI).

Inconclusive Imaging Tests due to Excessive Body Fat
We support the creation of a unique code to identify that an imaging test is inconclusive due to excessive body fat.

We believe this code is more appropriately located in the V codes than in category 793, as this situation does not represent an "abnormal finding." It is not an abnormal test result, but rather an indication that no conclusion can be made concerning the test results.

Encounter for Hearing Examination Following Failed Hearing Screening
We support the creation of a code for encounter for hearing examination following failed screening.

Central Pain Syndrome, Postoperative Pain
AHIMA supports establishment of a unique code for postoperative pain. However, we do not believe this code should be in a postoperative complication category. Rather, we believe it should be located in either the nervous system or symptom chapter.

The code for postoperative pain should continue to be used for as long as the patient's physician documents this diagnosis.

We would concur with the American Academy of Neurology suggestion to place a new code for central pain syndrome in the nervous system chapter.

Sensorineural Hearing Loss
We support the proposed modifications to the sensorineural hearing loss subcategory.

Other Conditions or Status of Mother Complicating Pregnancy
We support the expansion of codes to identify additional conditions that affect pregnancy.

A "use additional code" note for body mass index (if known) should be added under proposed subcategory 649.1.

If the proposed changes to the epilepsy codes are approved, the Excludes note under subcategory 649.4 will need to be revised (since recurrent seizures would be classified to category 345 and code 780.39 would be limited to isolated seizures).

Should the title of subcategory 649.6 state "uterine size and date discrepancy?"

Bariatric Surgery Status
AHIMA supports creation of a new code in subcategory V45.8 to identify bariatric surgery status.

Elevated Tumor Associated Antigens
We support creation of a new subcategory for elevated tumor associated antigens.

Antepartum Testing on Father
While we understand the value of identifying encounters for genetic testing of the father, the sex of the patient is already captured on the reimbursement claim form. Therefore, we do not believe it is necessary to distinguish between genetic testing of females and males in ICD-9-CM. The patient's sex reported on the claim will indicate whether the service was performed on a male or female.

Macrophage Activation Syndrome
We support creation of a single code to capture hemophagocytic syndromes.

Unspecified Adverse Effect of Drug, Medicinal and Biological Substance
We prefer option 2, in which drug allergies would continue to be classified in subcategory 995.2. Drug allergies properly belong with adverse effects rather than with other types of allergic reactions.

The proposed code for "other drug allergy" should be sequenced immediately after the new code for Arthus' phenomenon rather than after the code for "unspecified adverse effect of insulin." That way, "other" makes sense. It doesn't make sense if "other drug allergy" follows a code that is not a type of drug allergy.

Addenda

If female genital mutilation status, type 4, is going to be classified to code 629.20, then the title of this code should be revised to state "Female genital mutilation status, other and unspecified." Currently, the code title just says "unspecified," and type 4 is a specified form of female genital mutilation status. Another alternative would be to create a distinct code for type 4, since the other three types have unique codes.

We support the other proposed addenda revisions.

Other Topics:

Sepsis Coding

It was clear from the discussion at the C&M meeting, as well as from Cooperating Party discussions and input received from coding professionals and clinicians, that sepsis and SIRS are complex and confusing from both a coding and clinical perspective. The current structure of the sepsis and SIRS codes, and the associated instructions, has contributed to the confusion surrounding the coding of these conditions. Therefore, the problematic coding issues cannot be resolved through modifications to the official coding guidelines alone, but will require modifications to the codes themselves.

For starters, I recommend that the SIRS codes be collapsed into two codes - SIRS with and without organ dysfunction. It seems as though part of the confusion stems from the phrase "due to infectious process" and "due to non-infectious process," particularly in those instances when the initial precipitating event was non-infectious, but it led to the development of sepsis. Also, the "code first" note for SIRS due to non-infectious process with organ dysfunction that appears under code 785.52 is confusing because septic shock is always due to sepsis and sepsis always involves an infectious process. The "use additional code" note for septic shock that appears under code 995.94 is confusing for the same reason.

Consideration should also be given to revising the instructional notes such that an organ dysfunction, such as respiratory failure, can be sequenced first when it meets the definition of principal diagnosis.

The "code first" note under subcategory 995.9 needs to be revised because the underlying cause of SIRS is not always an infection (it might be trauma).

I look forward to further discussion by the Cooperating Parties on the topic of sepsis and SIRS coding.

Thank you for the opportunity to comment on the proposed diagnosis code revisions. If you have any questions, please feel free to contact me at (312) 233-1115 or sue.bowman@ahima.org.

Sincerely,

Sue Bowman, RHIA, CCS
Director, Coding Policy and Compliance