AHIMA Comments on ICD-9-CM Diagnosis Code Proposals Presented at September Coordination and Maintenance Committee Meeting

December 15, 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 September 30th ICD-9-CM Coordination and Maintenance (C&M) Committee meeting.

Support Proposal

Acute and Chronic Gingival Disease
AHIMA supports the creation of new codes for plaque-induced and non-plaque-induced acute and chronic gingivitis. The default codes that should be used when the gingivitis is not specified as acute or chronic, or there is no indication of whether it is plaque induced, need to be identified.

Acute and Chronic Periodontal Disease
We support the proposal to create new codes for localized and generalized aggressive and chronic periodontitis, as well as the proposal to re-title subcategory 523.3 to read “aggressive periodontitis.” Since the term “acute” may still be used by some practitioners, we recommend that “acute periodontitis” be listed as an inclusion term under 523.3. Since the presenters indicated that “acute periodontitis” is an outdated term, we do not believe that a unique code should be created for acute periodontitis. A default needs for both the aggressive and chronic forms needs to be identified that should be used when the periodontitis is not specified as localized or generalized.

Unsuccessful Endodontic Treatment
We support the creation of new codes to describe periradicular pathology associated with previous endodontic treatment.

Major Osseous Defects
AHIMA supports the creation of a new code for major osseous defects, with an instructional note indicating that the underlying disease should be coded first, if known.

Takotsubo Syndrome
We support the creation of a unique code for Takotsubo syndrome. However, if Takotsubo syndrome or apical ballooning syndrome is the more common term. Currently, apical ballooning syndrome is indexed and Takotsubo syndrome is not. If apical ballooning syndrome is the more common term, perhaps that should be the code description and Takotsubo syndrome should be listed as an inclusion term.

Familial Mediterranean Fever
We support the creation of a unique code for familial Mediterranean fever.

Altered Mental Status
AHIMA supports the creation of a new code in the Symptom chapter to describe altered mental status. This symptom is frequently documented, yet it has been classified to a very vague code in the past.

Hematology/Aplastic Anemia/Myelofibrosis
We support the addition of a new code for myelophthisis and the proposed Index revisions regarding the appropriate code assignments for terms related to myelofibrosis.

Torsion of Testis
We support the expansion of code 608.2 to create site-specific codes for torsion of testis.

Lower Urinary Tract Symptoms
We support the creation of new codes for urinary hesitancy and straining on urination and the addition of an inclusion term for “enlarged prostate” under category 600, Hyperplasia of prostate.

Cervical Stump Prolapse
We support the creation of a unique code for cervical stump prolapse.

Papanicolaou smear of cervix with Cytologic Evidence of Malignancy
We support the creation of a code for Papanicolaou smear of cervix with cytologic evidence of malignancy.

Estrogen Receptor Status
We support the creation of codes to identify the estrogen receptor status for breast cancer patients.

Support Proposal with Additional Modifications

We support a modified version of option 2 for the creation of new codes for mucositis. Rather than create unique codes for mucositis of various gastrointestinal sites, we recommend that just one code for mucositis of any gastrointestinal site be created. We support creation of new codes for nasal mucositis and mucositis of cervix, vagina, and vulva, and the addition of an inclusion term for mucositis of mouth and oral soft tissues under the existing code for stomatitis. Since physicians may use the terms “oral mucositis” and “stomatitis” interchangeably, we feel that classifying them to the same code is appropriate. Splitting these terms into separate codes might cause confusion and inaccurate data.

Unsatisfactory Restoration of Tooth
AHIMA supports the creation of new codes to describe unsatisfactory restoration of tooth, but perhaps some of the proposed codes could be combined. For example, the proposed codes for fractured restorative material with and without loss of material could be combined into a single code. Also, we are concerned about the proposed code for “contour of existing restoration biologically incompatible with oral health,” as we are not sure everyone will understand what this description means. Consideration should be given to classifying this condition to the proposed code for “other unsatisfactory restoration of tooth” rather than creating a unique code.

Since the tooth may fracture as well as the restorative material, we recommend adding notes indicating that two codes should be assigned in that circumstance. We also recommend that either a code be created for “unspecified unsatisfactory restoration of tooth” or the code description for proposed code 525.69 be changed to read “other and unspecified unsatisfactory restoration of tooth.”

Severe Sepsis
Since there were several proposals presented, our comments are organized by proposal:

Proposal 1: We fully support this proposal, which involved the deletion of instructional notes under codes 785.52 and 995.94, since it is not possible to develop septic shock in the absence of a systemic infection.

Proposal 2: We support changing the titles of codes 995.91 and 995.92 to read “sepsis” and “severe sepsis,” respectively, since these are the terms most commonly documented in clinical practice.

We do not think the phrase “without organ dysfunction” should be deleted from the title of code 995.93, since this phrase is needed to differentiate this code from code 995.94. If the word “acute” is added to the title of code 995.94, then it should also be added to code 995.93 (i.e., the code title for 995.93 would be “Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction.”

We support the addition of the proposed Excludes note and inclusion terms. The excluded terms in the proposed Excludes note under code 995.91 should be listed on separate lines.

Proposal 3: We support deleting the “code first” note under subcategory 995.9, Systemic inflammatory response syndrome (SIRS) and adding the appropriate “code first” note under each of the codes in this subcategory.

Since a clinician commented at the C&M meeting that the underlying infection responsible for SIRS is not always systemic (pneumonia was given as an example), should the “code first” notes under codes 995.91 and 995.92 state “code first underlying infection” (delete “systemic”)? This issue may need to be clarified with the Society of Critical Care Medicine.

The proposed “code first” note under codes 995.93 and 995.94 should be expanded to included additional examples of underlying conditions.

We believe the narrative note at the end of this proposal should be deleted and appropriate instructions added to the ICD-9-CM Official Guidelines for Coding and Reporting instead of including this instructional note in the classification. Perhaps a straightforward instructional note could be included in the classification to indicate that when SIRS due to a noninfectious process leads to sepsis, but the appropriate sepsis and SIRS due to noninfectious process codes should be assigned, and further instructions regarding the sequencing of the codes should be addressed in the official coding guidelines. As written, the proposed note is very confusing. For example, the note is specific to trauma, but there are other types of noninfectious conditions that could be the underlying cause of SIRS. It is not clear how the codes should be sequenced if the underlying cause is not trauma. Can SIRS due to a noninfectious process lead to sepsis that is not severe? That scenario is not addressed in the instructional note. Also, the note assumes that the SIRS is present on admission, whereas it may develop after admission (in which case the normal rules for selecting the principal diagnosis would apply).

Proposal 4: We oppose the reversal of the sequencing of the codes for SIRS and the underlying condition. This would disrupt data trends significantly and also violates the general principle of sequencing the underlying etiology first. To the extent possible, in order to maintain data comparability and consistency and minimize confusion and misinterpretation, coding rules should not be dramatically changed from year to year. We recommend that the current practice of sequencing the underlying condition continue.

Proposal 5: We also oppose the proposal to allow sequencing of the acute organ dysfunction first. We are even more opposed to the suggestion that only certain organ dysfunctions be allowed to be sequenced first, such as respiratory failure. We believe that the sequencing rule regarding acute organ dysfunctions should be consistent across all types of organ dysfunctions. Again, as stated above, stability of the coding rules is needed to maintain data comparability and accuracy.

Proposal 6: AHIMA vehemently opposes the proposal to assign only code 785.52, and not code 995.92, when septic shock is documented. Currently, the code for septic shock is located in the Symptom chapter. This proposal violates the coding rule which prohibits the use of a Symptom code as the principal diagnosis when a related definitive diagnosis has been established. Also, unlike the severe sepsis code, whereby the underlying systemic infection must be sequenced first, it appears that the septic shock code could be assigned without the underlying systemic infection being coded at all (in the proposal, there was no “code first” note under code 785.52 for the underlying systemic infection).

Family History of Colon Polyps
We support the creation of a new code for family history of colon polyps. However, we recommend that this code be created in subcategory V18.5, Family history of digestive disorders, instead of V19.8, Family history of other condition.

Central Pain Syndrome, Postoperative Pain
We support the creation of distinct codes for generalized pain, postoperative pain, and central pain syndrome. However, the codes for generalized pain and postoperative pain might be more appropriately placed in the Symptom chapter rather than the Nervous System chapter. We believe that these codes should be allowed as both principal and secondary diagnoses.

The proposed Excludes note indicating that localized pain should be coded to site is confusing because postoperative pain could be localized. This Excludes note should be revised to clarify that localized pain that is not postoperative should be coded to pain of the affected site. It should also be clarified whether or not the code for pain of a particular site should be coded in addition to the postoperative pain code to provide additional information about the affected site. We recommend that no site-specific pain code be assigned in conjunction with the postoperative pain code because information about the surgical site is available through other code assignments.

While we support the need for a code to describe postoperative pain, we recognize the potential for overuse of this code. Guidance on the appropriate use of this code should be provided in the official ICD-9-CM coding guidelines. In order to minimize the potential for overuse in circumstances when a patient is experiencing normal, expected postoperative pain, perhaps the coding guidelines could limit the use of this code to first-listed or principal diagnosis only (this would limit use of this code to instances when the postoperative pain is significant enough to trigger inpatient admission or 23-hour observation services).

Attention to Surgical Dressings and Sutures
We fully support the creation of new V codes to distinguish encounters for change or removal of surgical and non-surgical dressings.

At the C&M meeting, it was suggested that “non-surgical dressing change” be added as an inclusion term under the proposed code for encounter for change or removal of dressing NOS. However, we recommend changing the code title of proposed code V58.30 to read “Encounter for change or removal of non-surgical dressing” and adding “dressing change NOS” as an inclusion term (in effect, the code title and inclusion term would be reversed from the way they were presented at the C&M meeting). The type of dressing, or at least the type of wound (surgical vs. non-surgical), should be clearly documented in the medical record.

An inclusion term should be added under proposed code V58.31 for removal of packing. An Excludes note should be added indicating that removal of drains is excluded from this code.

Intrauterine Hypoxia and Asphyxia
Since there were several proposals presented, our comments are organized by proposal:

Proposal 1: We support the proposed changes to the titles of category 768 and code 768.9 and the change to the inclusion term under code 768.9. However, since the proposed title of category 768 is a lengthy list of terms, we suggest that consideration be given as to whether there is a shorter, broader description that could be used to encompass these terms.

Proposal 2: We support the proposed changes in terminology in the inclusion terms under codes 768.2, 768.3, and 768.4.

Proposal 3: We support the proposed changes in the title and inclusion term for code 768.3.

Proposal 4: We support option 1 for adding the concept of hypoxic-ischemic encephalopathy to the classification. The default code to use when the condition is not specified as mild, moderate, or severe either needs to be identified or an additional code needs to be created for unspecified hypoxic-ischemic encephalopathy.

Proposal 5: We support the creation of new codes for respiratory arrest of newborn and hypoxemia of newborn unrelated to labor and delivery.

Proposal 6: We support the proposed revision of the title of code 775.7 and the addition of an inclusion term for acidosis NOS in newborn.

Proposal 7: We support the creation of a new code for cardiac arrest of newborn unrelated to birth and the addition of an inclusion term under code 779.2 for cerebral ischemia unrelated to labor and delivery.

Complex Febrile Seizure
We support the creation of a unique code for complex febrile convulsions and agree with the comment made at the C&M meeting that the epilepsy codes should not be used in conjunction with the new code. When the epilepsy codes apply (such as a patient in status epilepticus), only an epilepsy code should be assigned.

Encounter for Testing of Male Partner of Habitual Aborter
We support the addition of new codes for habitual aborter, genetic testing of male partner of habitual aborter, and testing of male for genetic disease carrier status. As recommended at the C&M meeting, the titles of proposed codes V26.31 and V26.34 should be revised to read “testing of female for genetic disease carrier status” and “testing of male for genetic disease carrier status,” respectively.

Complications and Personal History of In Utero Surgery
AHIMA supports the creation of codes to describe complications and personal history of in utero surgery. The title of proposed code V15.22 needs to more clearly specify that the patient was the fetus on whom the in utero surgery was performed. A better code description might be “personal history of in utero surgery as fetus.”

The Excludes note under proposed code 760.61, Newborn affected by in utero surgery, needs to be revised to read “management of pregnancy affected by fetal complications of in utero surgery (678.1)” (the underlined portion denotes the revision).

Do Not Support Proposal

Newborn Post Discharge Check
AHIMA does not believe that a unique code for newborn post discharge check is necessary. We recommend that code V20.2, Routine infant or child health check, continue to be assigned for these encounters. A post discharge check is a type of routine infant health check and is therefore included in code V20.2.

Mild Cognitive Impairment
While we recognize the need to capture data on the incidence of mild cognitive impairment, we are concerned about potential misuse of the proposed code for situations beyond the disease entity described during the C&M presentation. Physicians often use this term to describe cognitive impairment due to conditions such as head trauma, dehydration, malnutrition, late effects of strokes, etc. Unless a more descriptive code title can be devised, one that would clearly distinguish the specific disease entity described by the American Academy of Neurology from these other types of cognitive impairment, we do not recommend creating a new code. We are concerned that misapplication of the proposed code for various types of cognitive impairment would result in useless data. We do not believe that the suggestion made at the meeting that the code title read “mild cognitive impairment, so stated” would solve the problem because physicians often document “mild cognitive impairment” when describing cognitive impairments due to various underlying conditions.

Fifth Digit Title Changes for Categories 403 and 404
We do not agree that the revision of the fifth digits for categories 403 and 404 to indicate the stage range for chronic kidney disease is the appropriate way to resolve the problem with these fifth digits. This proposed revision doesn’t add any information because the specific stage will be identified by the chronic kidney disease code. Since the fifth digits no longer provide any additional information, we believe they are no longer needed and should be deleted. We don’t see the point of retaining fifth digits that add no value.

Regarding the proposed Excluded note under code 585.5 and proposed inclusion term under code 585.6, we recommend that this part of the proposal be included as part of a comprehensive discussion at the March 2006 C&M meeting regarding additional modifications that may need to be made to the chronic kidney disease codes in order to improve their clinical accuracy and clarify their intent. We are concerned about using the performance of a procedure to define a diagnosis code. We also believe that these proposed revisions are related to other issues that have arisen since the September C&M meeting regarding the application of the chronic kidney disease codes.

Inflammation of Post-Procedural Bleb
We support the creation of new codes for inflammation of post-procedural bleb, but recommend that a default be identified, or another code for “unspecified” be created, for those instances when the stage is not documented.

Optic Nerve Hypoplasia
AHIMA supports a new code for optic nerve dysplasia. Since the code description states “optic nerve” but the background material describes this condition as an abnormality of the optic disc, we recommend that clarification from the American Academy of Ophthalmology be sought regarding the appropriate placement of the new code (in subcategory 377.2, Other disorders of optic disc, or 377.4, Other disorders of optic nerve).

We support the proposed Tabular and Index Addenda revisions presented at the September C&M meeting.

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.


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

Source: AHIMA Web Site (December 2005)