April 8, 2004
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 ICD-9-CM Coordination and Maintenance Committee meeting.
Generally support code proposals, with additional comments or recommendations
Complete and Partial Edentulism
AHIMA supports the proposal for new codes for complete and partial edentulism. A default needs to be identified for edentulism NOS.
Stroke and Cerebrovascular Accident
We fully support this proposal and urge NCHS to implement these coding changes this October. These revisions will markedly improve the consistency and accuracy of the coding of strokes.
Renal Failure and Renal Insufficiency
While we recognize that some clinicians expressed concern about the variable ways in which the terms “renal failure” and “renal insufficiency” are used, we support the creation of specific codes for acute and chronic renal insufficiency. These are common diagnoses that should be uniquely classified. Medical literature supports that insufficiency and failure and not the same thing. It would not be appropriate to classify renal insufficiency to the renal failure codes. While it may be true that these conditions represent a progression of the disease process, like many other diseases, proper code selection depends on the physician’s documentation. There are many clinical terms that physicians use in variable ways, such as sepsis or obesity, and our coding instruction has always been to code according to the diagnostic terms used by the physician. So, if he calls the condition “renal insufficiency,” regardless of what another physician might call it, then that is what should be coded.
If the new codes for acute and chronic renal insufficiency are approved, a default needs to be identified for “renal insufficiency NOS.”
Vaccination Not Given
AHIMA supports the creation of new codes identifying reasons why a vaccination was not administered. The code description for subcategory V64.0 should be revised to state “Vaccination not carried out,” since all of the proposed codes do not represent contraindications. Instructional notes, or advice in Coding Clinic for ICD-9-CM, should clarify that it is acceptable to use more than one of the new codes for a single encounter. For example, the patient might be scheduled to receive more than one vaccination and they weren’t administered for different reasons. An Excludes note for “vaccination not carried out” should be added under code V64.2, since this code describes surgical and other procedures not carried out because of patient’s decision.
Personal History of Illness
While we support the expansion of personal history codes, we are concerned about the potential overuse of some of the proposed codes, particularly in the case of personal history of pneumonia and urinary tract infection. Conceivably, these codes could apply to a large number of people without impacting their care in any way. Of course, a personal history would only be coded if it was documented, but we would still recommend that some parameters be put around proper use of these codes. For example, perhaps the proposed code for personal history of urinary tract infection should be limited to recurrent infections.
Screening for Genetic Carrier Status
We support the creation of a new code for screening to identify carriers of genetic diseases. The code description for proposed code V26.31 should be revised to state “screening for carrier of genetic disease.”
Retroperitoneal Abscess
AHIMA supports the expansion of subcategory 567.2, Other suppurative peritonitis. The code description for proposed code 567.22 should be revised to delete the word “other,” so it would state “Peritoneal abscess.”
Fetal Reduction Status
We support the creation of a new code for multiple gestation following elective fetal reduction. We agree with the suggestion made during the meeting that “elective” be added to the code description to clearly distinguish this circumstance from those when the woman has miscarried one or more fetuses. A suggestion was made during the meeting that the new code be created in category V23, Supervision of high-risk pregnancy, instead of category 651, Multiple gestation. Since the codes for multiple gestations when one or more fetuses has been miscarried are currently in category 651, we believe it makes sense to place the proposed code there as well. Also, if the American College of Obstetrics and Gynecology feels that the fetal reduction status is actually a pregnancy complication, then the code would most certainly be more appropriate in category 651.
Overweight
We support the proposal to add a new code for “overweight” and capture information about Body Mass Index (BMI) by ranges. We do not think a greater level of granularity with regard to the BMI would be appropriate in ICD-9-CM. The proposed note under subcategory 278.0, Overweight and obesity, should clearly indicate that an additional code for the BMI only needs to be assigned if the information is documented. It also needs to be clarified, for those cases where the BMI is measured more than once during the admission, which measurement should be used for code assignment. We recommend that the BMI at admission be used.
Egg Donor
We support the creation of new codes for egg donors. We question whether age-specific codes are necessary, since the age of the donor can be obtained from other data elements. If it is felt that this information needs to be in the codes, then the age ranges need to be non-overlapping – “up to age 35” and “35 and over.”
Acute Bronchitis with COPD
We fully support the modifications to improve coding of acute bronchitis with COPD and urge NCHS to implement these modifications this October. Regarding COPD with both acute bronchitis and an acute exacerbation, we recommend that the guideline in ICD-10-CM be applied. In ICD-10-CM, the code for COPD with an acute infection takes precedence over the code for COPD with acute exacerbation.
Encounter for Ventilator Weaning
While we support the proposal for a unique code for encounter for weaning from respirator, we are concerned about the impact this new code would have on the recently-published coding advice (in Coding Clinic for ICD-9-CM) for long-term care hospitals. That advice included sequencing the acute respiratory condition as the principal diagnosis in cases when the reason for admission was ventilator weaning. The long-term care hospital industry has experienced a great deal of confusion regarding accurate coding in their unique healthcare setting, and that confusion could be compounded my any major reversals in such recent advice.
Secondary Diabetes
While we agree that secondary diabetes deserves to be uniquely identified, we are concerned that incorporating it in the fifth digit subclassifications for diabetes mellitus would be confusing and lead to inaccurate coding. These digits for secondary diabetes may be used incorrectly. The instruction regarding codes from category 250 with fifth digits 4 or 5 (indicating that these are secondary codes and must be sequenced after the underlying condition) is a significant departure from the proper application of the other codes in this category, which will add significantly to the confusion. We believe that secondary diabetes should be in an entirely different category. We recognize that this approach would make it difficult to capture the diabetic manifestations, unless a significant number of secondary diabetes codes is created. Perhaps an alternative approach would be to capture the secondary diabetes in a separate code and assign an additional code from category 250 to identify the manifestation(s).
Support code proposals as presented, with no additional comments
Immune Thrombocytopenic Purpura
Family History of Osteoporosis
Bethesda System
Effects of Red Tide
Erythromelalgia
Encounter for Blood Typing
Do not support code proposals as presented
Psychalgia
There seemed to be some confusion between the American Psychiatric Association’s code request and the proposal that was presented at the meeting. Certainly, the proposed “code first” note under subcategory 307.8, Psychalgia, is inappropriate because this note should not apply to all of the codes in this subcategory. We do believe that it makes sense to allow for the coding of both the site of pain and the psychalgia to indicate a psychological component to pain that has a physical cause.
Worn Out Joint Prosthesis
We share the concerns expressed by others at the meeting regarding the creation of a unique code for “worn out artificial joint.” An artificial joint that has “worn out” is still a type of mechanical complication and should continue to be coded as a mechanical complication. Regardless of the cause, the joint is no longer working properly and, therefore, is appropriately classified as a mechanical complication. If a new code is created, we believe it will be very difficult for coding professionals to make the distinction between the use of the mechanical complication code and the “worn out artificial joint” code. We are also concerned about the placement of the proposed code. Since the reason for admission for joint replacement surgery could be the fact that the original artificial joint is worn out and needs to be replaced, the proposed code could be the appropriate principal diagnosis. Subcategory V49.5, Other problems with limb, which is in category V49 (other conditions influencing health status) does not seem like the appropriate location for a significant condition warranting acute care hospitalization and major surgery.
Addenda
We support the proposed addenda revisions, including the additional suggestions made during the meeting.
Thank you for the opportunity to comment on the proposed procedure 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