The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS), met on April 1-2, 2004 in Baltimore, MD. Donna Pickett, RHIA, from NCHS, and Patricia Brooks, RHIA, from CMS, cochaired the meeting.
Proposed modifications to ICD-9-CM were presented and are summarized below. Once they are approved by CMS and NCHS, some changes may go into effect with discharges on or after October 1, 2004, whereas others may not go into effect until April 1, 2005 or October 1, 2005.
Suggestions for diagnosis code proposals for consideration at a future Coordination and Maintenance Committee may be emailed to Donna Pickett at dfp4@cdc.gov or mailed to: National Center for Health Statistics, ICD-9-CM Coordination and Maintenance Committee, 3311 Toledo Road, room 2402, Hyattsville, Maryland 20782.
Suggestions for procedure code proposals to be considered at a future Coordination and Maintenance Committee, may be emailed to Pat Brooks at PBrooks@cms.hhs.gov or mailed to: Centers for Medicare & Medicaid Services, CMM, HAPG, Division of Acute Care, Mail Stop C4-08-06, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
The next meeting of the ICD-9-CM Coordination and Maintenance Committee is scheduled for October 7-8, 2004 and will be held at the CMS building in Baltimore, MD. New proposals for inclusion on the October agenda must be received by August 7, 2004 . Note that the next meeting immediately precedes the Coding Community meeting and the AHIMA National Convention being held in Washington, DC. Consider making plans to arrive early and attend the Coordination and Maintenance Committee. Continuing education credits are provided for attending this meeting.
Diagnoses
Minutes from the diagnosis portion of the Coordination and Maintenance Committee meeting, as well as complete details of the code proposals, can be found at the National Center for Health Statistics website. The minutes and proposals can be accessed at the following link: www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm.
Complete and Partial Edentulism
Subcategory 525.1, Loss of teeth due to trauma, extraction, or periodontal disease, classifies edentulism based on cause. The University of Illinois College of Dentistry has proposed new subcategories for both partial and complete edentulism based on degree (class I, II, III, and IV). The new codes for degree of edentulism would be sequenced first, followed by a code from subcategory 525.1 for the cause of the edentulism. Attendees at the meeting suggested that the default for edentulism not specified as partial or complete should be identified. Psychalgia
The American Psychiatric Association requested a modification to the instructional notes under subcategory 307.8, Psychalgia, and under code 307.89, Other psychalgia, to allow for the coding of both the pain code and the psychalgia code to indicate a psychological component to chronic intractable pain. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of pain. Currently, the codes are structured such that pain related to psychological factors is distinct from pain due to physical causes. Meeting attendees noted that placing an instructional note indicating that the site of pain should be coded first under subcategory 307.8 appears to imply that the instruction applies to codes 307.80, Psychogenic pain, site unspecified, and 307.81, Tension headache. However, the “code first” note should not apply to these codes, since code 307.80 indicates the site of the pain is unspecified and code 307.81 identifies the specific site. Therefore, it was suggested that the “code first” note be moved under code 307.89.
Stroke and Cerebrovascular Accident
Stroke or cerebrovascular accident (CVA) involves localized death of brain tissue and the causes can be grouped as hemorrhagic or nonhemorrhagic. The coding of stroke or CVA has been problematic, since the record may not clearly state whether the cause was hemorrhagic or nonhemorrhagic. The majority of strokes are nonhemorrhagic. Physicians routinely use the terms “stroke” and “CVA” synonymously with cerebral infarction. However, the terms “stroke” and “CVA” are included under the nonspecific code 436, Acute, but ill-defined, cerebrovascular disease. To allow for improved uniformity in coding and statistical data, it has been proposed that the terms “stroke” and “CVA” be removed as inclusion terms under code 436 and be reindexed to code 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction. Other related terms would also be indexed to category 434. For example, thrombotic stroke would be indexed to code 434.01, Cerebral thrombosis, with cerebral infarction, and embolic stroke would be indexed to code 434.11, Cerebral embolism, with cerebral infarction. Ischemic stroke would be indexed to code 434.91. Meeting attendees were enthusiastically supportive of this proposal and urged NCHS to implement these index changes this year (October 1). It was noted that the coding guidelines would need to be modified to reflect these coding changes. Renal Failure and Renal Insufficiency
Renal failure and renal insufficiency represent a spectrum of disease involving kidney function. These kidney problems can be acute or chronic in nature. Chronic renal failure is generally progressive, with the kidney disease worsening with time, in some cases progressing to end-stage renal disease. It has been proposed that code 585, Chronic renal failure, be expanded to create a unique code for end-stage renal disease. Also, new codes for acute and chronic renal insufficiency have been proposed in subcategory 593.8, Other specified disorders of kidney and ureter. Currently, acute and chronic renal insufficiency are classified to code 593.9, Unspecified disorder of kidney and ureter. Even though renal insufficiency is part of the same spectrum of disease as renal failure, it is not synonymous with renal failure. It was suggested that a default code be identified for renal insufficiency not specified as acute or chronic.
The response to the proposal for a new code for end-stage renal disease was overwhelmingly favorable. While there was support expressed for new codes for acute and chronic renal insufficiency, some attendees expressed concern about the difficulty in distinguishing acute and chronic renal insufficiency from renal failure, particularly given the fact that physicians often use the terms “renal insufficiency” and “renal failure” interchangeably.
Immune Thrombocytopenic Purpura
Idiopathic thrombocytopenic purpura is recognized to be an autoimmune disorder, with development of antibodies to one's own platelets. The platelets are then destroyed by phagocytosis, primarily in the spleen. It can occur in both children and adults. Onset in children is usually acute following a viral infection. Onset in adults is usually more gradual. Low platelet counts lead to purpuric lesions, and potentially to more severe bleeding problems or even death. Treatments can include steroids and splenectomy. Since this condition has a recognized etiology, many more recent references have started using the term “immune thrombocytopenic purpura.” An expansion of code 287.3, Primary thrombocytopenia, has been proposed to create new codes to uniquely identify several different forms of primary thrombocytopenia, including immune thrombocytopenic purpura, Evans' syndrome, and congenital and hereditary thrombocytopenic purpura. Evans' syndrome involves a hemolytic anemia along with thrombocytopenia, related to an autoimmune process affecting both the red cells and platelets. Examples of congenital and hereditary thrombocytopenias include thrombocytopenia with absent radii (TAR) syndrome and Wiskott-Aldrich syndrome. Under the proposal, Wiskott-Aldrich syndrome would continue to be classified to code 279.12.
Vaccination Not Given
The American Academy of Pediatrics has requested an expansion of code V64.0, Vaccination not carried out because of contraindication, to identify various reasons why a vaccination was not carried out. According to the proposal, new codes would be created for vaccination not carried out due to acute illness, chronic illness or condition, immune compromised state, allergy to vaccine or component, patient or caregiver refusal, and religious reasons. It was suggested that the description of subcategory V64.0 would need to be revised, since not all of the proposed codes represent contraindications. It was also suggested that an Excludes note be added under code V64.2, Surgical or other procedure not carried out because of patient's decision, to ensure that this code is not used for vaccinations that are not carried out. Personal History of Illness
The American Academy of Pediatrics requested several additional personal history codes in order to enable the tracking of specific conditions over the lifetime of a patient. New codes would be created for personal history of infections of the central nervous system, pneumonia, urinary tract infection, and nephritic syndrome. Attendees also suggested adding personal history codes for concussion, rheumatic fever, and chickenpox. All of these conditions have the potential to impact future care. However, meeting attendees expressed concern that some of these conditions are extremely common and may not necessarily impact future care, such as urinary tract infections in women. It was suggested that the use of the proposed code for personal history of urinary tract infection be limited to recurrent infections or infections in men. Screening for Genetic Carrier Status
The American College of Medical Genetics has requested a new code for screening for genetic carrier status. It is currently standard medical practice to screen couples either before conception or early in pregnancy to determine carrier status for certain serious genetic diseases. If both partners are carriers, the pregnancy will be managed differently. Carrier status screening has become the professional standard of care for cystic fibrosis, Canavan disease, and Tay-Sachs disease. Also, with the wider use of both neonatal and adult screening for genetic carrier status, relatives of those who screen positive are themselves at risk to be carriers of genetic disease. In addition to a new code for screening for carrier of genetic disease in subcategory V26.3, Genetic counseling and testing, a new code has also been proposed in category V18, Family history of certain other specified conditions, for family history of carrier of genetic disease.
Retroperitoneal Abscess
An expansion of code 567.2, Other suppurative peritonitis, has been proposed in order to uniquely identify generalized peritonitis and peritoneal abscess. A new subcategory for retroperitoneal infections has also been proposed, with specific codes for retroperitoneal abscess and other retroperitoneal infections. Fetal Reduction Status
It is not currently possible in ICD-9-CM to identify women who have undergone elective fetal reduction due a multiple gestation pregnancy. Though the procedure reduces the risk to the remaining fetuses, the pregnancy is still considered high risk. A new code has been requested in category 651, Multiple gestation, for multiple gestation following elective fetal reduction. A concern was expressed that the proposed code may overlap existing codes 651.3x-651.6x, and that the new code should clearly indicate that it is intended for elective fetal reductions, not situations when a fetus is miscarried. A meeting attendee suggested that category V23, Supervision of high-risk pregnancy, might be an alternative location for the new code. The NCHS agreed to contact the American College of Obstetricians and Gynecologists regarding the suggestions. Overweight
In ICD-9-CM, the term “overweight” is classified to the codes for obesity. Requests have been made to create a unique code for overweight and several new codes for Body Mass Index (BMI). BMI is the first determination of a patient's weight in proportion to height. According to the proposal, the description of subcategory 278.0 would be changed to “overweight and obesity” and a new code for overweight would be created in this subcategory. New category V85 would be created for BMI, with specific codes for ranges of BMI values. The BMI codes would apply to both overweight and underweight situations and would be assigned in addition to the appropriate code for overweight, obesity, or underweight. Several concerns were expressed. The terms “overweight” and “obesity” are not commonly documented and, therefore, are not regularly coded. Instructions would need to be clear as to whether one of the new BMI codes would be required whenever a code from category 278 was assigned. Guidance would need to be provided as to which BMI measurement would be reported, if the BMI is measured more than once during a hospitalization. It was felt that the BMI at the time of admission is the measurement that should be reported. It was suggested that the proposed BMI codes might be of greater value if the ranges of measurement were narrower or if specific codes were created for unique measurements instead of creating codes for ranges of measurements. Since the BMI may be documented by a healthcare professional other than a physician, such as a dietician, guidelines would need to stipulate whether these healthcare professionals' documentation may be used for the purpose of assigning the appropriate BMI code.
Family History of Osteoporosis
The American College of Obstetricians and Gynecologists has requested a new code for family history of osteoporosis. A unique code would assist with research on osteoporosis. The new code would be created in subcategory V17.8, Family history of other musculoskeletal diseases. Egg Donor
The American College of Obstetricians and Gynecologists has requested new codes for egg donors that identify the age of the donor and whether the eggs are intended to be used for anonymous donation or for a designated recipient. According to the proposal, a new subcategory for “egg donor” would be created in category V59, Donors. Several new codes would be created to indicate whether the egg donor was over or under the age of 35 and if the donation is intended for a designated or anonymous recipient. It was suggested that the term “ovum” be used instead of “egg.” It was also suggested that the age differentiation is unnecessary because age is captured in other data elements. However, others felt including the age categories in the codes is useful because the donor's age may not necessarily be available in all data sets. Effective October 1, 2004, “sperm donor” will be indexed to code V59.8, Donor of other specified organ or tissue.
Acute Bronchitis with COPD
The modifications to the inclusion terms under code 491.21, Obstructive chronic bronchitis with (acute) exacerbation, has led to confusion among coders as to how to code acute bronchitis with chronic obstructive pulmonary disease (COPD). Although the intention was that the code for acute bronchitis, 466.0, should be used with a code from subcategory 491, if acute bronchitis was present with COPD, the sequencing of these codes posed a problem. In order to allow for the coding of acute bronchitis when accompanying COPD, it has been proposed that a new combination code be created in subcategory 491 for obstructive chronic bronchitis with acute bronchitis. The question arose as to the proper coding when the patient also has an acute exacerbation. It was suggested that this situation be handled the same as it is in ICD-10-CM. In ICD-10-CM, the code for obstructive chronic bronchitis with a superimposed acute infection supersedes the code for obstructive chronic bronchitis with acute exacerbation. Due to the urgent need to resolve coding and sequencing issues related to COPD with acute bronchitis, this proposal is being considered for implementation on October 1, 2004.
Bethesda System
Several important sets of comments from the American College of Obstetricians and Gynecologists and the College of American Pathologists required extensive revisions to the proposal regarding the classification of abnormal Pap smears under the Bethesda system that was presented at the December 2003 Coordination and Maintenance Committee meeting. Please see the complete description of the revised proposal on the NCHS web site. Worn Out Joint Prosthesis
The length of time that artificial joints can be used before replacement of components is necessary has gradually increased since the introduction of components made of metal alloys and synthetic polymers, as well as the reduction of problems with fixation and infection. Many joint replacement components are now lasting as long as 10 years, sometimes longer, after which time it becomes likely that they need to be replaced due to routine wear rather than a mechanical complication. The use of a mechanical complication code for the replacement of a worn-out prosthesis suggests that there is a malfunction or some other problem with the device. A new code in category V49.5, Other problems of limbs, has been proposed for worn-out artificial joint. An additional code for subcategory V43.6 would be assigned to identify the joint replacement site. Meeting attendees were not in favor of this proposal. Many felt that a worn-out artificial joint still represents a type of mechanical complication and that it would be difficult for coding professionals to distinguish between cases when the proposed code should be used and those when the mechanical complication code should be used, since physicians' documentation may not specifically indicate that the reason for replacement is because the joint is worn out.
Effects of Red Tide
Red tides are caused by several species of marine phytoplankton that produce a potent chemical toxin. Red tides occur throughout the world, drastically affecting Scandinavian and Japanese fisheries, Caribbean and South Pacific reef fishing, and shell fishing along the U.S. coast. A red tide results when the algae undergo a mass multiplication, or a “bloom.” It is not possible to predict when a red tide will occur. Irritation of the eyes, nose, throat, and tingling lips and tongue are common symptoms that occur in humans during red tides. Waves, wind and boat propellers disperse toxin particles into the air, causing people along the shore to develop these symptoms. Swimming in a red tide may cause skin irritation. People suffering from severe or chronic respiratory conditions should avoid red tide areas. A new toxic effect code in subcategory 989.8, Other substances chiefly nonmedicinal as to source, has been proposed for red tide. The appropriate External Cause code is E905.7, Poisoning and toxic reactions caused by other plants. An index entry will be added for the external cause.
Erythromelalgia
Erythromelalgia is a rare syndrome of paroxysmal vasodilation with burning pain, increased skin temperature, and redness of the feet, and less often, the hands. Symptoms may remain mild for years or become so severe that total disability results. Diagnosis of erythromelalgia is based on the relationship of complaints to increased skin temperature. The cause is unknown, although it frequently develops spontaneously. It may be the result of vasomotor abnormalities or a dysfunction in the normal constriction and dilation of the diameter of certain blood vessels, leading to abnormalities of blood flow to the extremities. Aspirin may provide prolonged relief. Avoiding factors that produce vasodilation is usually helpful, and vasoconstrictors may also provide relief.
Some individuals who have myeloproliferative disorders, hypertension, venous insufficiency, diabetes mellitus, systemic lupus erythematosus, rheumatoid arthritis, lichen sclerosus et atrophicus, gout, spinal cord disease, or multiple sclerosis may develop erythromelalgia as a result. In these cases, treating the underlying disease should relieve the symptoms of the erythromelalgia.
Currently, erythromelalgia is indexed to code 443.9, Other specified peripheral vascular diseases. A unique code has been requested for this condition.
Encounter for Ventilator Weaning
A new code in subcategory V46.1, Dependence on respirator, has been proposed to identify encounters for ventilator weaning. This code would complement existing codes for ventilator status and encounters for ventilator status patients during a power failure. Encounter for Blood Typing
A new code in subcategory V72.8, Other specified examinations, has been proposed for encounters for blood typing. For example, if a pregnant woman's blood group is Rh negative, knowing whether the father is Rh position or Rh negative helps to identify the risk of Rh sensitization and whether or not she should receive Rh immunoglobulin to prevent sensitization for the rest of the pregnancy. Pre-procedural Examination
It has been proposed that the titles of the preoperative examination codes (V72.81-V72.84) be revised to include the term “pre-procedural” in order to broaden the scope of the codes. Secondary Diabetes Mellitus
Currently, the diabetes mellitus codes in category 250 provide fifth digits for type I and type II diabetes, but there is no code or fifth digit to indicate diabetes secondary to another condition. Advice published in Coding Clinic for ICD-9-CM has stated to assign a code for the underlying condition, followed by code 251.8, Other specified disorders of pancreatic internal secretion. The advice also indicated that codes from category 250 should not be used for secondary diabetes mellitus. It has been proposed that two new fifth digits be created for category 250, Diabetes mellitus, to identify secondary diabetes, not stated as uncontrolled, and secondary diabetes, uncontrolled. This approach would allow the use of the specific codes in category 250 to identify diabetic manifestations, rather than creating an entirely separate category for secondary diabetes mellitus with all of the diabetic manifestation codes. An instructional note would indicate that the underlying condition should be sequenced before the diabetes code, which would be distinctly different from all of the other codes in category 250.
Meeting attendees expressed some concern about this proposal. In particular, it was felt that incorporating the concept of secondary diabetes at the fifth digit level would be confusing, as would a “code first “ note that would apply only when the new fifth digits for secondary diabetes are used. Commenters also noted that the medical record documentation may not clearly reflect whether the patient has secondary diabetes or diabetes that happens to be present in conjunction with one of the conditions known to cause secondary diabetees.
Diagnosis Addenda
Proposed diagnosis addenda changes were reviewed. The proposed revisions include: - Addition of Excludes note for “hernia due to adhesion with obstruction” under code 552.8, Hernia of other specified sites, with obstruction;
- Addition of instructional note under category 758, Chromosomal anomalies, to indicate that additional code(s) should be used to identify associated conditions;
- Addition of Index entry for neonatal acne (706.8);
- Addition of Index entry for conjunctivitis, chemical, meaning corrosion (see Burn, conjunctiva);
• Revision of Index entry for postnasal drip (code to condition); - Addition of Index entry for sclerosing mesenteric (idiopathic) fibrosis (567.8);
- Addition of Index entry for Enterobacter sakazakii infection (041.85);
- Addition of Index entry for age-related infertility (628.8);
- Addition of Index entry for diffuse axonal injury (854.00);
- Addition of Index entry for mesenteric lipodystrophy (567.8);
- Addition of Index entry for microalbuminuria (791.0);
- Addition of several Index entries under “Newborn;”
- Addition of Index entry for postprocedural pseudomeningocele (997.01);
- Addition of Index entry for quadriparesis, meaning muscle weakness (728.87);
- Addition of Index entry for wallet sciatica (724.3);
- Addition of Index entries for Mounier-Kuhn syndrome with bronchiectasis (494.0) and with (acute) exacerbation (494.1);
- Addition of Index entries for tracheobronchomegaly with bronchiectasis (494.0) and with (acute) exacerbation (494.1).
Procedures
Minutes from the procedure portion of the Coordination and Maintenance Committee meeting, as well as complete details of the code proposals, can be found at the CMS Web site. This information can be accessed at the following link: www.cms.gov/paymentsystems/icd9. Left Atrial Appendage Filter System
Atrial fibrillation is the primary cardiac abnormality associated with ischemic stroke. Among patients with atrial fibrillation, there is a five percent (5%) annual risk of stroke, which is about five times greater than for people of the same age who are in sinus rhythm. Most ischemic strokes associated with atrial fibrillation are probably due to embolism or thrombi forming in the left atrial appendage. Due to problems related to safety and tolerability of conventional medical treatment to prevent strokes in patients with atrial fibrillation, a device-based solution for protection agains thromboembolism has been developed for certain patients. A filter is placed just distal to the ostium of the left atrial appendage in order to isolate this appendage. This device is designed to prevent harmful emboli that may form in the left atrial appendage from exiting, thereby preventing the occurrence of ischemic stroke and systemic thromboembolism. The device is placed via a catheter-based delivery system. Creation of a new code in subcategory 37.9, Other operations on heart and pericardium, has been recommended for insertion of left atrial appendage device.
Computer-Assisted Surgery
Computer-assisted surgery (CAS) s an adjunctive surgical process in which the coordinated use of imaging, markers, reference frames, intra-operative sensing and computer workstations allows increased visualization and precise navigation through minimally invasive approaches. Use of CAS results in substantially different surgical methodology, which, in effect, constitutes a unique procedure, compared to the same operation performed conventionally. CAS encompasses three key activities: planning, registration, and navigation. Planning is based on imaging and typically uses preoperative and/or intraoperative images taken by magnetic resonance, computerized tomography, and/or fluoroscopy. Registration is the process of establishing a spatial relationship between all locations on the images and the corresponding locations on the actual patient anatomy in the surgical field. Navigation takes place intra-operatively. It involves the tracking of instruments and tools within the surgical field in real-time and displaying this movement overlaid on the images and 3D models of patient anatomy.
CAS is sometimes referred to as image-guided surgery and image-guided navigation. Computer-assisted orthopedic surgery sometimes uses kinematics (angles and measurements) to determine location of anatomy without the use of images. Since these types of procedures are known as “imageless” or “CT-free,” the phrase “computer-assisted surgery” is an umbrella term to encompass both image-guided and imageless forms of computer-assisted surgery.
Creation of a new category, 00.3, for computer-assisted surgery has been proposed. Various options were presented. One option would differentiate the new codes by body system where the technology was employed and the second option would differentiate the codes by imaging technique. A third option presented was the creation of a single code for computer-assisted surgery in subcategory 99.9, Other miscellaneous procedures. The second option, the creation of several codes differentiated by imaging technique, was favored by the attendees at the meeting, since the affected body system could be identified from the primary surgical procedure code and it was felt that collecting information about the modality would be useful.
Insertion of Palatal Implant
A minimally invasive treatment for snoring and obstructive sleep apnea that does not involve heating or removing tissue is implantation of a device in the palate. Three inserts of non-absorbable polyester material are placed in the soft palate. The inserts serve to promote fibrosis within the soft palate, which reduces the soft tissue flutter that is largely responsible for the snoring sound. In a patient with obstructive sleep apnea, the stiffening effect of the inserts reduces the tendency of the soft palate to create obstruction, without adversely affecting normal palate function. Although the procedure can be performed as a stand-alone procedure, it is usually performed in conjunction with other nasopharyngeal procedures, such as tonsillectomies, uvulopalatopharyngoplasties, laser-assisted uvulopalatoplasties, and various tongue-based procedures.
Creation of a new code for insertion of palatal implant has been proposed in subcategory, 27.6, Palatoplasty.
Internal Limb Lengthening Device
Limb lengthening procedures are primarily performed in adult patients who need osteogenic distraction due to congenital deformities or who have bone loss due to infection, trauma, etc. Osteogenic distraction is the mechanical induction of new bone between surgically cut bone segments that are gradually pulled apart. A corticotomy is required in which the cortex of the bone is cut without severing the outer periosteum surrounding the cortex. This serves to both preserve the blood supply and to deliberately initiate the inflammatory response of the limb to be lengthened. The inflammatory response triggers the movement of osteoblasts from the inner layer of the periosteal sheath to the corticotomy site or the “artificial fracture site.” The periosteal callus fills the gap with newly woven bone. In all methods of gradual osteogenic distraction, the bone is tricked into repeatedly healing itself as the distraction gap widens. Gradual osteogenic distraction is typically achieved in these patients by using traditional external fixation devices alone or in conjunction with an intramedullary nail.
A “closed” limb lengthening system, meaning there are no fixation pins exiting the skin, thus eliminating this portal for entry of infectious organisms, involves implantation of a device in the intramedullary canal. This device provides mechanical stability and support to the bone segments during the distraction, regeneration, and consolidation phases, thus reducing the opportunities for malalignment. Distraction is achieved through small rotational oscillations that occur as the patient ambulates.
It has been proposed to create two new codes in subcategory 84.5, Implantation of other musculoskeletal devices and substances, for implantation of internal limb lengthening device with kinetic distraction and implantation of other internal limb lengthening device. One of the new codes would be assigned in conjunction with a code from subcategory 78.3, Limb lengthening procedures. Removal of the device would be coded with the existing codes for removal of implanted devices from bone (78.60-78.69). An alternative option would be to create a single code, instead of two new codes, to capture implantation of all internal limb lengthening devices.
Carotid Stents
When the carotid artery is blocked, blood flow to the brain is reduced. If it closes up completely, the patient is likely to have a stroke, which can result in death, paralysis, brain damage, or coma. Also, arteries narrowed due to atherosclerosis are an important source of emboli to the brain that can cause transient neurological deficits or permanent strokes. Carotid endarterectomy, which is performed to remove the blockage, involves making an incision, approximately six inches long, along the neck in order to access the carotid artery. Patients undergoing this procedure are usually under general anesthesia and they typically have to remain hospitalized for two to four days. Surgery is always associated with a scar on the neck and, in some patients, may be accompanied by transient or permanent cranial nerve damage. Carotid artery stenting is a promising alternative to carotid endarterectomy. During this procedure, the physician makes a small puncture in the leg and snakes a catheter through it to the carotid artery. Once the catheter is in place, a guide wire is used to deliver the stent to the blockage in the carotid artery. Typically a device, called an emboli capture device, is deployed distal to the lesion prior to the stent deployment and emboli are collected in this device as the blood passes through it. After the stent is deployed, the emboli capture device is removed.
Establishment of a new code in category 39.7, Endovascular repair of vessel, has been proposed for endovascular insertion of non-drug-eluting carotid artery stent(s). It is not felt to be necessary to create a new code for insertion of drug-eluting carotid artery stent(s), as there are no drug-eluting carotid artery stents available at this time and restenosis is less of a problem in the carotid artery than in the coronary arteries.
A suggestion was made that the code description should be broadened to encompass all precerebral arteries. A recommendation was made that a new subcategory, 00.6, be created for “other cerebrovascular procedures” and that new codes pertaining to insertion of precerebral stents be located in that section. It was also suggested that another new code be created for precerebral and cerebral angioplasty or atherectomy.
Vertebroplasty and Kyphoplasty
Vertebroplasty and kyphoplasty are both minimally invasive surgical procedures for treating vertebral compression fractures due to osteoporosis or osteolysis, whereby a cement-like material is injected into the collapsed bone. This stabilizes the fracture and provides immediate pain relief in many cases. Kyphoplasty differs from vertebroplasty in that the procedure involves additional steps in an attempt to restore the collapsed vertebral body back towards its original height. Vertebroplasty is used to strengthen a fractured vertebra that has been weakened by osteoporosis or, less commonly, cancer. The procedure is accomplished by injecting an orthopedic cement mixture through a needle into the collapsed vertebra. A hollow needle, or trocar, is passed into the vertebral bone, and a cement mixture including polymethylmethacrylate, barium powder and a solvent is injected.
Kyphoplasty is indicated in patients with vertebral compression fractures where restoration of the vertebral body height is important, most typically in the majority of acute fractures and some chronic fractures. Kyphoplasty involves placing a narrow tube that creates a path through the back into the fractured area through the pedicle of the involved vertebrae under general anesthesia. A balloon or other device, such as a bone tamp, is inserted through the cannula and inflated, leaving a cavity into which a cement-like material (polymethylacrylate) is introduced. By inflating the balloon, the height of the vertebra will be at least partially re-established. The difference between kyphoplasty and a true fracture reduction is that if the kyphoplasty does not accomplish reduction of the fracture, the surgeon will not try again.
Creation of new codes for vertebroplasty and kyphoplasty in subcategory 81.6, Other procedures on spine, has been proposed. It was suggested that inclusion terms under the proposed new code for kyphoplasty clarify the fact that kyphoplasty procedures do not reduce the fracture, but rather, they simply attempt to restore some of the height lost because of the fracture. It was also suggested that the inclusion terms clarify that insertion of a bone void filler (cement) should not be coded in addition to the new codes.
Percutaneous External Heart Assist Device
Percutaneous external heart assist systems, unlike other heart assist systems, don't require cardiothoracic surgery. This type of system is based on centrifugal flow technology that moves the blood with a spinning impeller through a blood pump located outside the body via use of a percutaneous transseptal catheter inserted directly into the left atrium. This technology provides support for patients whose clinical condition warrants mechanical circulatory support, but who are ineligible for surgery due to their deteriorating clinical condition and would otherwise expire without cardiac support. This procedure is typically performed in the cardiac catheterization laboratory. Following percutaneous access of the femoral vein and artery, a needle and guiding catheter are threaded into the right atrium and a transseptal puncture from the right atrium into the left atrium is performed. A guide wire is placed across the septum into the left atrium. The transseptal inflow cannula of the device is advanced over the wire and placement of the cannula is confirmed through angiography or echocardiography. A second cannula is placed in the femoral artery to allow for return blood flow. Both cannulae are connected to the pump and complete deaeration of the system is performed. The pump is then started and adjusted to the desired level of ventricular unloading. Patients are either maintained on the device until recovery or until other therapy to treat the underlying condition is completed.
Establishment of a new code for insertion of percutaneous external heart assist device has been proposed in subcategory, 37.6, Implantation of heart assist system. An attendee expressed concern with the placement of the new code because this device is not technically “implanted.” However, physicians typically document “implantation” of the device, and this subcategory is where other types of heart assist systems are classified. It was recommended that explanatory notes be added to clarify the difference between the new code and code 37.65, Implant of external, pulsatile heart assist system.
Ultrafiltration of Blood for Removal of Excess Fluid
Ultrafiltration is performed for patients with fluid overload, such as congestive heart failure, renal failure, post-surgical fluid overload, metabolic disease, and hyponatremia. A mechanical ultrafiltration system can remove up to one gallon of excess fluid from the body over an eight-hour period, whereas conventional diuretic treatment typically takes several days. Catheters inserted into a peripheral or central vein connect the patient to the ultrafiltration device. A new code for “aquapheresis” has been proposed in subcategory 99.7, Therapeutic apheresis or other injection, administration, or infusion of other therapeutic or prophylactic substance. The new code would have inclusion terms for extracorporeal aquapheresis, removal of plasma water, and ultrafiltration. Alternative options were presented, including: addition of inclusion terms for “aquapheresis” and “ultrafiltration” under code 39.95, Hemodialysis; addition of inclusion terms for “aquapheresis,” “ultrafiltration,” and “plasma water removal” under code 99.71, Therapeutic plasmapheresis; or not coding this procedure at all, since it represents an auxiliary procedure that is integral to the treatment of patients with fluid retention. Several physician attendees indicated that hemodialysis is a much more invasive procedure than ultrafiltration for removal of excess fluid, and, therefore, both procedures should not be classified to the same code. There was no clear preferred option, so attendees were urged to submit their recommendations for CMS consideration.
Injection of Bone Void Filler
Autologous bone grafts has been considered the gold standard for filling bony voids caused by trauma or surgery (e.g., non-union of fracture, bony tumors). The bone graft is usually harvested from the iliac crest of the patient's pelvis. However, there are a number of disadvantages in using autologous bone grafts, including limited availability of grafting material for filling large defects, donor site morbidity, lack of immediate mechanical stability afforded by the graft, and longer operative times. Significant progress has been made in the development of synthetic products for use in filling bony voids. These synthetic products lack the properties needed for promoting bone growth. However, they eliminate many of the complications from bone graft procurement and difficulties in acquiring enough graft to fill large voids. Many of the synthetic products in use today include calcium-based materials, which offer greater absorption qualities that allow bone growth to slowly replace the absorbed synthetic materials.
There are several types of cement that can be used as alternatives to autologous bone grafts. Polymethylmethacrylate cement is used to mold into a defect. The use of this type of cement does not allow the formation of new bone. Injectable osteoconducive calcium phosphate cements have been introduced as an adjunct to internal fixation for treating selected fractures. These cements develop high compressive strength, share the compressive load of the fracture with the local bone, and are then remodeled slowly into new bone. The main purpose of the cement is to fill voids in metaphyseal bone, thereby reducing the need for bone graft. Cements also may improve the holding strength around metal devices in osteoporotic bone.
Establishment of a new code in subcategory 84.5, Implantation of other musculoskeletal devices and substances, has been proposed in order to uniquely capture the insertion of bone void fillers. There are two major classes of products: those bone void fillers that are directly inserted and those cements that require preparation, including mixing the cements, and then the cement is inserted through special devices. An alternative coding option was presented that would differentiate these two types of products, but it was felt that coding professionals would not be able to readily distinguish between the two types. An alternative option was suggested whereby new codes would be created to distinguish absorbable vs. non-absorbable bone void fillers.
Vasopressors
Vasopressors are used in the treatment of shock, which is a state of inadequate tissue perfusion due to abnormally low systemic blood pressure. Causes of shock include hemorrhage, generalized infection, heart failure, poisonings, and fluid loss from burns and severe hypoxemia. Vasopressors act primarily by causing the arteries of the body to constrict, thereby raising blood pressure, and they are administered via temporary, continuous intravenous infusion. The use of vasopressors implies a higher level of patient acuity. Because these agents are used to maintain blood pressure and prolong life when other measures have failed, it can be easily inferred tht patients who require vasopressors are more ill and more likely to die than those who do not require these agents. Creation of a new code has been proposed in subcategory, 00.1, Pharmaceuticals, for infusion of vasopressor agents.
Procedure Addenda
Proposed procedure addenda changes were reviewed. The proposed revisions include: - Addition of “code also” note for “any synchronous excision of adrenal gland (07.21-07.3)” under subcategory 55.5, Complete nephrectomy;
- Addition of inclusion term for “ovarian drilling” under code 65.99, Other operations on ovary;
- Addition of inclusion term for “antepartum fetal nonstress test” under code 75.34, Other fetal monitoring;
- Addition of Index entry for “drilling, ovary” (65.99);
- Revision of Index entry for “monitoring, fetus, antepartum, nonstress” (75.34 instead of 75.35).
ICD-10-PCS Update
An update on ICD-10-PCS was provided by staff from 3M Health Information Systems. An overview of how the system is constructed was given, followed by a discussion of the appropriate ICD-10-PCS codes for some of the procedure topics presented at the meeting. The American Health Information Management Association (AHIMA), American Hospital Association (AHA), Centers for Medicare & Medicaid Services (CMS), and the National Center for Health Statistics (NCHS) recently met with 3M to discuss the process for development of ICD-10-PCS coding guidelines. 3M will structure the recommendations discussed at this meeting into guidelines. Once a rough draft of the guidelines has been prepared, it will be shared with the public through the Coordination and Maintenance Committee process. CMS will solicit reactions, comments, and suggestions on this draft. Ultimately, the coding guidelines will be posted on the CMS website and can be used by organizations in the development of training materials.
The audience was asked for input on future refinements and enhancements to the system. The value of retaining the laboratory section was discussed. This section is based on an earlier version of the LOINC laboratory system, but has not been updated to stay current with LOINC. The general consensus of the meeting attendees was that the laboratory section of ICD-10-PCS could be eliminated, given the fact that that ICD-10-PCS has only been recommended for replacement of volume 3 of ICD-9-CM. The codes in the laboratory section of ICD-9-CM are not typically reported today and it is unlikely that this section of ICD-10-PCS would be used.
The level of detail contained in the ICD-10-PCS radiation oncology codes was discussed. The audience generally felt that this level of detail should be retained, as there is significant value in capturing this amount of information. Attendees felt that in most cases the medical record documentation necessary for this level of detail would be available. The fifth through seventh characters in the radiation oncology codes provide an “identification not required” option for those hospitals and payers that do not wish to collect this level of detail.
Input on the Administration Section was also sought. Currently, there is not a great deal of detail regarding the devices implanted or drugs used, since detailed information was not desired at the time this section was developed. However, legislation regarding new services and technology has led to the need for ICD-9-CM to more specifically capture information about procedures involving new technology, including devices and drugs. The audience was asked if attempts should be made to provide more extensive detail pertaining to drugs and devices throughout the Administration Section, or add more detail only in response to specific requests. The audience supported waiting for specific requests, rather than undertaking a major expansion of the entire section.
The benefits and challenges of developing a map between ICD-9-CM and ICD-10-PCS were discussed. A mapping from ICD-10-PCS to ICD-9-CM is already available on the CMS website. 3M is working on developing a mapping from ICD-9-CM to ICD-10-PCS, but this mapping is particularly challenging because of the potential for one ICD-9-CM code to be mapped to many ICD-10-PCS codes. For example, ICD-9-CM code 39.31, Suture of artery, could potentially map to hundreds of ICD-10-PCS codes, due to the fact that ICD-9-CM does not specify the artery or approach and ICD-10-PCS specifies both.
At future Coordination and Maintenance Committee meetings, implementation issues will be discussed. The audience suggested the following topics for future discussion:
- Impact on hospitals of a new coding system;
- Training needs;
- Results of previous testing of ICD-10-PCS;
- Number of codes that might be reported with ICD-10-PCS versus ICD-9-CM.
The latest update of ICD-10-PCS is available on the CMS website at the following link: cms.hhs.gov/paymentsystems/icd9/icd10.asp.
| Source: AHIMA Web Site (April 2004) |