October 1, 2007 ICD-9-CM Changes Webcast September 27, 2007

1. October 1, 2007 ICD-9-CM Changes Webcast September 27, 2007 Sandy Giangreco, CPC, CPC-H Coding & Reimbursement Educator/Regional Membership Director Wisconsin Medical Society, Copyright 2007CPT codes, descriptions and material only are Copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in applicable FARS/DFARS restrictions to government use

2. What is the impact for FY 2008? 144 New Diagnosis Codes 17 Deleted Diagnosis Codes 5 Revised Diagnosis Codes Remember � We no longer have a grace period!!!! Get these codes loaded and ready to go for encounters for dos 10.1.2007 and after! Let�s Get Excited and Get Started! Let the Fun Begin! I will have all of the New codes on the slides in Red so you can more easily identify those! I will have all of the New codes on the slides in Red so you can more easily identify those!

3. Rationale of Coding Changes Greater specificity Some due to technology More of the �NOS� or �Unspecified� code sets are subdivided into specific categories in preparation for our conversion to ICD-10 New technologies require tracking for effectiveness in dealing with disease or for complications of the new technologies ICD-9 Procedures will not be discussed during our session today

4. New Subcategory 040.4 Other specified botulism Non-foodborne intoxication due to toxins of Clostridium botulinum [C. botulinum] Excludes: botulism NOS (005.1) food poisoning due to toxins of Clostridium botulinum (005.1) New code 040.41 Infant botulism New code 040.42 Wound botulism Non-foodborne botulism NOS Use additional code to identify complicated open wound Botulism is a rare but serious paralytic illness caused by a nerve toxin that is produced by the bacterium Clostridium botulinum. There are 3 main kinds of botulism. Foodborne botulinum is caused by eating foods containing the botulism toxin. Wound botulinum is caused by toxin produced from a wound infected with Clos. Botulinum. Infant botulinum is caused by consuming the spores of the botulinium bacteria, which then grow in the intestines and release the toxins. All forms of botulinum can be fatal. The mortality rate dropped from 50% to 8% during the past 5 years due to the physician�s ability to treat, monitor, and maintain the patient from the point at which they determined the dx. Botulism, which results from traumatic injury or a deep puncture wound and is often caused by abscess, is broken down into the 2 new codes within the subcategory. (See above) These are for the botulism that are not caused by or assoc with food poisoning Instead CMS created the categories because of the increased number of patients who are coming in to the clinics with puncture wounds, in many cases, unfortunately, due to an increase in drug usage. Due to needing to know more about the epidemiology of diseases due to the risk of terrorism, these codes were created. If we know what the appropriate toxins are we can help the patient�s survival rate by using the appropriate anti-toxins and having the ability to inject these in to the patient. Botulism is a rare but serious paralytic illness caused by a nerve toxin that is produced by the bacterium Clostridium botulinum. There are 3 main kinds of botulism. Foodborne botulinum is caused by eating foods containing the botulism toxin. Wound botulinum is caused by toxin produced from a wound infected with Clos. Botulinum. Infant botulinum is caused by consuming the spores of the botulinium bacteria, which then grow in the intestines and release the toxins. All forms of botulinum can be fatal. The mortality rate dropped from 50% to 8% during the past 5 years due to the physician�s ability to treat, monitor, and maintain the patient from the point at which they determined the dx. Botulism, which results from traumatic injury or a deep puncture wound and is often caused by abscess, is broken down into the 2 new codes within the subcategory. (See above) These are for the botulism that are not caused by or assoc with food poisoning Instead CMS created the categories because of the increased number of patients who are coming in to the clinics with puncture wounds, in many cases, unfortunately, due to an increase in drug usage. Due to needing to know more about the epidemiology of diseases due to the risk of terrorism, these codes were created. If we know what the appropriate toxins are we can help the patient�s survival rate by using the appropriate anti-toxins and having the ability to inject these in to the patient.

5. From a Clinical Perspective S/S of infant botulism include: Constipation Floppy weakness due to muscle weakness, and trouble controlling the head Weak cry Drooping of eyelids Tiredness Difficulty sucking or feeding Paralysis S/S of food-borne and wound botulism include: Difficulty swallowing or speaking Facial weakness Double vision Trouble breathing Nausea, vomiting and abdominal cramps Paralysis The Infant Botulism: symptoms often occur 2 weeks after first exposure Foodborne and wound botulism: involve intestinal tract The Infant Botulism: symptoms often occur 2 weeks after first exposure Foodborne and wound botulism: involve intestinal tract

6. New Codes for Viral Illnesses New Section and Category: OTHER HUMAN HERPES VIRUSES 058 New 058 Other human herpes virus category Excludes: congenital herpes (771.2) cytomegalovirus (078.5) Epstein-Barr virus (075) herpes NOS (054.0-054.9) herpes simplex (054.0-054.9) herpes zoster (053.0-053.9) human herpesvirus NOS (054.0-054.9) human herpesvirus 1 (054.0-054.9) human herpesvirus 2 (054.0-054.9) human herpesvirus 3 (052.0-053.9) human herpesvirus 4 (075) human herpesvirus 5 (078.5) varicella (052.0-052.9) varicella-zoster virus (052.0-053.9)

7. Roseola Infantum New code 058.10 Roseola infantum, Exanthema subitum [sixth disease], unspecified New code 058.11 Roseola infantum due to human herpes virus 6 New code 058.12 Roseola infantum due to human herpes virus 7 Roseola infantum is a viral illness in young children, most commonly affecting those between the ages of 6 mos and 2 years. It generally is marked by several days of high fever followed by a distinctive rash just as the fever breaks. Two common and closely related viruses can cause roseola. HHV type 6 and 7. Roseola infantum is a viral illness in young children, most commonly affecting those between the ages of 6 mos and 2 years. It generally is marked by several days of high fever followed by a distinctive rash just as the fever breaks. Two common and closely related viruses can cause roseola. HHV type 6 and 7.

8. New Herpes Encephalitis Codes New subcategory 058.2 Other human herpes virus encephalitis Excludes: herpes encephalitis NOS (054.3) herpes simplex encephalitis (054.3) human herpes virus encephalitis NOS (054.3) simian B herpes virus encephalitis (054.3) New code 058.21 Human herpes virus 6 encephalitis New code 058.29 Other human herpes virus encephalitis Human herpesvirus 7 encephalitis These codes were added in to further specify these. Remember all of the herpes encephalitis codes that were added in last year? These codes were added in to further specify these. Remember all of the herpes encephalitis codes that were added in last year?

9. More Herpes Codes New subcategory 058.8 Other human herpes virus infections New code 058.81 Human herpes virus 6 infection New code 058.82 Human herpes virus 7 infection New code 058.89 Other human herpes virus infection Human herpes virus 8 infection Kaposi�s sarcoma-associated herpes virus infection Doesn�t this sound like a Valtrax commercial? Doesn�t this sound like a Valtrax commercial?

10. Respiratory System Virus New code 079.83 Parvovirus B19 AKA: Human parvovirus Parvovirus NOS Excludes: erythema infectiosum [fifth disease] (057.0) The parvovirus is unique and looks just like these pictures. The child will possibly have the �slapped� red cheeks and or the characteristic lacy rash that spreads up and down the arms. This is highly contagious and can be diagnosed by lab test. All of my children and my nephew (who they had not seen in months) all came down with this just as school was getting out in June. Originally we thought it was due to the fact that they were out in sun. The parvovirus is unique and looks just like these pictures. The child will possibly have the �slapped� red cheeks and or the characteristic lacy rash that spreads up and down the arms. This is highly contagious and can be diagnosed by lab test. All of my children and my nephew (who they had not seen in months) all came down with this just as school was getting out in June. Originally we thought it was due to the fact that they were out in sun.

11. Clinical Aspects of Viral Illnesses DNA Analysis is being used to identify more diseases and further differentiating the viruses causing those Two variants of the herpes virus 6-A causes no disease, B can cause roseola Varying severities are seen with roseola Most have no symptoms May be cause of febrile convulsions Can be as severe as encephalitis and failure of organs Dangerous to immunocompromised patients May use antiviral drugs such as gancyclovir or acyclovir in patients with pityriasis, also caused by these viruses These are becoming more and more in the forefront of research with disease tracking We are wanting to see what the long term effects of viral illnesses may be. In the hospital setting we may not see these viruses unless the patients come in with encephalitis or organ failure, etc. Patients with Renal transplant or any organ transplants in general may have severe complications due to these These are becoming more and more in the forefront of research with disease tracking We are wanting to see what the long term effects of viral illnesses may be. In the hospital setting we may not see these viruses unless the patients come in with encephalitis or organ failure, etc. Patients with Renal transplant or any organ transplants in general may have severe complications due to these

12. Clinical Information about Human Herpes Virus Signs and Symptoms include: Rash or roseola, and chronic fatigue syndrome Roseola infantum � the patient may not have any noticable symptoms If the patient develops encephalitis (maybe they are immunocompromised) they may become symptomatic the day after the disease is gone

13. Lymphoma Code Changes Lymphomas have been named by their discoverer, or by some difference in their activity, related to their diseases or manifestations Recently these were divided in to 4 categories: Hodgkin�s High-Grade Intermediate Grade And Low Grade Non-Hodgkin�s Lymphoma World Health Organization (WHO) has standardized the nomenclature proposed by the Revised European-American Lymphoma classification (REAL) Lymphoma is a type of cancer involving cells of the immune system called lymphocytes. Approximately 35 different types of lymphomas fall into 2 major categories: Hodgkins lymphoma 2. All other types of lymphomas (also known as non-hodgkins lymphomas or NHL�s) The NHL�s can be further broken down into aggressive (fastgrowing) or indolent (slow growing) types and classified as either B cell or T cell NHL�s There are 54 new codes in these categories we are about to discuss. Lymphoma is a type of cancer involving cells of the immune system called lymphocytes. Approximately 35 different types of lymphomas fall into 2 major categories: Hodgkins lymphoma 2. All other types of lymphomas (also known as non-hodgkins lymphomas or NHL�s) The NHL�s can be further broken down into aggressive (fastgrowing) or indolent (slow growing) types and classified as either B cell or T cell NHL�s There are 54 new codes in these categories we are about to discuss.

14. Clinical Aspects of REAL First classified by cell type � the cell which, if it is normal, most closely looks like the tumor cell B-cell tumors T-cell tumors Natural killer cell tumors And other minor tumors Revised European-American Lymphoma classification (REAL) We need a breakdown of all of the Non-Hodgkins�. Hodgkins is Hodgkins. All of the others are non-Hodgkins lymphoma. These are broken down by malignancy. WHO wants to have better ICD-9 codes. Revised European-American Lymphoma classification (REAL) We need a breakdown of all of the Non-Hodgkins�. Hodgkins is Hodgkins. All of the others are non-Hodgkins lymphoma. These are broken down by malignancy. WHO wants to have better ICD-9 codes.

15. Mature B-Cell Tumors (NHL) Chronic lymphocytic leukemia/small lymphocytic lymphoma B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia Splenic marginal zone lymphoma Plasma cell neoplasms � plasma cell myeloma, plasmacytoma, heavy chain diseases, monoclonal deposit disease Extranodal marginal zone B cell lymphoma (mucosa associated lymphoid tissue, MALT lymphoma) Nodal marginal zone B cell lymphoma Follicular lymphoma Mantle cell lymphoma Diffuse large B cell lymphoma Mediastinal (thymic) large B cell lymphoma Intravascular large B cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukemia Lymphomatoid granulomatosis The Burkitt lymphoma/leukemia was discovered by the same physician who discovered that with eating raw bran and putting it in your cereal it would lower your colon CA risk. The Burkitt lymphoma/leukemia was discovered by the same physician who discovered that with eating raw bran and putting it in your cereal it would lower your colon CA risk.

16. Mature T-Cell and Natural Killer Cell Tumors (NHL) T cell prolymphocytic leukemia T cell large granular lymphocytic leukemia Aggressive NK cell leukemia Adult T cell leukemia/lymphoma Extranodal NK/T cell lymphoma, nasal type Enteropathy-type T cell lymphoma Hepatosplenic T cell lymphoma Blastic NK cell lymphoma Mycosis fungoides/Sezary syndrome Primary cutaneous CD30-positive T cell lymphoproliferative disorders Primary cutaneous anaplastic large cell lymphoma Lymphomatoid Papulosis Angioimmunoblastic T cell lymphoma Peripheral T cell lymphoma, unspecified Anaplastic large cell lymphoma

17. Hodgkin�s Lymphoma Nodular lymphocyte-predominant Hodgkin lymphoma Classical Hodgkin lymphoma Nodular sclerosis Mixed cellularity Lymphocyte-rich Lymphocyte depleted or not depleted The Reed Stenberg Cell � as seen on this slide is a massive cell. Usually larger than 10 cells together. The Reed Stenberg Cell � as seen on this slide is a massive cell. Usually larger than 10 cells together.

18. Immunodeficiency-Associated Lymphoproliferative Disorders Associated with a primary immune disorder Associated with the Human Immunodeficiency Virus (HIV) Post-transplant Associated with Methotrexate therapy

19. Histiocytic and Dendritic Cell Neoplasms (CNS) Histiocytic sarcoma Langerhans cell histiocytosis Langerhans cell sarcoma Interdigititating dendritic cell sarcoma/tumor Follicular dendritic cell sarcoma/tumor Dendritic cell sarcoma, unspecified

20. Classification by Immunologic Subtype and Aggressiveness B Cell Small lymphocytic Lymphoplasmacytic Follicular Marginal zone, MALT Marginal zone, nodal Mantle cell Diffuse large B cell Primary mediastinal large B cell Burkitt�s like T Cell Peripheral T�cell Anaplastic large T/null cell lymphoblastic They added new cell types that complete cell types. In the first column these are so namedThey added new cell types that complete cell types. In the first column these are so named

21. Revision to Code 200 Revise 200 Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue Underlined text is changedUnderlined text is changed

22. Our New Subdivisions for Lymphomas 200.3X Marginal zone 200.4X Mantle zone 200.5X Primary CNS 200.6X Anaplastic large cell 200.7X Large cell Lymphoma 200.8X Peripheral T-cell .X0 Unspecified site .X1 Head, face, neck nodes .X2 Intrathoracic nodes .X3 Intra-abdominal nodes .X4 Nodes axilla, upper limb .X5 Inguinal, lower limb .X6 Pelvic nodes .X7 Spleen .X8 Multiple Sites We now have a larger breakdown than we had prior. The right hand column is the actual site. You will need to have your physician give you this information. The .X8 is actually seen quite frequently for example: inquinal and spleen, etc. We now have a larger breakdown than we had prior. The right hand column is the actual site. You will need to have your physician give you this information. The .X8 is actually seen quite frequently for example: inquinal and spleen, etc.

23. Further Breakdown of These Codes 200.3X Marginal Zone Lymphoma � typically indolent and accounts for approx. 10% of all lymphomas 200.4X Mantle Cell Lymphoma � aggressive tumor type and represents about 6% of all lymphomas Typically described as incurable with traditional tx but stem cell transplant may be provided 200.5X Primary CNS Lymphoma � also aggressive type but only accounts for about 1-2% of all cases Requires different chemo options than other NHL�s and in many cases also requires radiation to brain. 200.3X � Marginal Zone � are B cell lymphomas. Involve the lymph nodes they are called �nodal marginal zone B-Cell lymphoas. If outside of the lymph nodes then they are �mucosa assoc lymphatic tissue lymphomas� or MALT. 200.4X � Mantle cell aggressive type of B-cell NHL. Marked by small to medium sized ca cells that may be in the lymph nodes, spleen, bone marrow, blood or GI system. 200.5x = Primary Central Nerv System � Younger pts may have brain dysfunction, while older pts may present with NHL related dementia. Malignant ca cells form in the lymph tissue of the brain and/or spinal cord. Because the eye is so close to the brain, primary CNS can also start in the eye (called ocular lymphoma). Primary CNS lymphoma MAY occur in pts who have AIDS or other disorders of the immune system OR who have had an organ transplant and are immunocompromised. 200.3X � Marginal Zone � are B cell lymphomas. Involve the lymph nodes they are called �nodal marginal zone B-Cell lymphoas. If outside of the lymph nodes then they are �mucosa assoc lymphatic tissue lymphomas� or MALT. 200.4X � Mantle cell aggressive type of B-cell NHL. Marked by small to medium sized ca cells that may be in the lymph nodes, spleen, bone marrow, blood or GI system. 200.5x = Primary Central Nerv System � Younger pts may have brain dysfunction, while older pts may present with NHL related dementia. Malignant ca cells form in the lymph tissue of the brain and/or spinal cord. Because the eye is so close to the brain, primary CNS can also start in the eye (called ocular lymphoma). Primary CNS lymphoma MAY occur in pts who have AIDS or other disorders of the immune system OR who have had an organ transplant and are immunocompromised.

24. More Information 200.6X Anaplastic Large Cell Lymphoma � also aggressive and accounts for 2% of all lymphomas. Pts are tested for ALK-1 which is fusion protein. 200.7X Large Cell Lymphoma � considered very aggressive, grows extremely quickly and accounts for approximately 20-30% of all lymphomas Metastatic lymph node tumors are classified to category 196.X (Secondary and unspecified malignant neoplasm of lymph node) 200.6X � If the protein is positive ALK-1+ there is a direct correlation to younger age and better prognosis. Usually a T cell type of lymphoma. Usually appears in the lymph nodes, skin, bones, soft tissue, lungs or liver. 200.7X � Large Cell are most common type comprising 20-30% of all NHL�s. 200.6X � If the protein is positive ALK-1+ there is a direct correlation to younger age and better prognosis. Usually a T cell type of lymphoma. Usually appears in the lymph nodes, skin, bones, soft tissue, lungs or liver. 200.7X � Large Cell are most common type comprising 20-30% of all NHL�s.

25. Peripheral T-Cell Lymphoma New code 202.7X Peripheral T-cell lymphoma .X0 Unspecified site .X1 Head, face, neck nodes .X2 Intrathoracic nodes .X3 Intra-abdominal nodes .X4 Nodes axilla, upper limb .X5 Inguinal, lower limb .X6 Pelvic nodes .X7 Spleen .X8 Multiple Sites Peripheral T cell is also classified as aggressive and begins in mature T lymphocytes, usually occurs in approx 7% of all lymphomas. Tumor type carries the worst prognosis of all lymphomas and typically is assoc. with extranodal presentation which means that the tumor is involving organs in addition to lymph nodes. Also called Mature T cell lymphoma Peripheral T cell is also classified as aggressive and begins in mature T lymphocytes, usually occurs in approx 7% of all lymphomas. Tumor type carries the worst prognosis of all lymphomas and typically is assoc. with extranodal presentation which means that the tumor is involving organs in addition to lymph nodes. Also called Mature T cell lymphoma

26. Carcinoma In-Situ (CIS) Deleted 233.3 � other and unspecified- greater specificity desired with HPV connection with CIS New code 233.30 Unspecified female genital organ New code 233.31 Vagina Severe dysplasia of vagina Vaginal intraepithelial neoplasia III [VAIN III] New code 233.32 Vulva Severe dysplasia of vulva Vulvar intraepithelial neoplasia III [VIN III] New code 233.39 Other female genital organ Again this year as there was in 2005, numerous changes to the female reproductive health codes. You can look these up in the alphabetic index using Neoplasm, by site, malignant CA insitu. Again this year as there was in 2005, numerous changes to the female reproductive health codes. You can look these up in the alphabetic index using Neoplasm, by site, malignant CA insitu.

27. Endocrine Specific Codes Deleted 255.4 Corticoadrenal insufficiency which included both glucocorticoid (cortisone, etc.) and mineralocorticoid (aldosterone, etc.) problems New code 255.41 Glucocorticoid deficiency Addisonian crisis Addison�s disease NOS Adrenal atrophy (autoimmune) Adrenal calcification Adrenal crisis Adrenal hemorrhage Adrenal infarction Adrenal insufficiency NOS Combined glucocorticoid and mineralocorticoid deficiency Corticoadrenal insufficiency NOS New code 255.42 Mineralocorticoid deficiency Hypoaldosteronism Excludes: combined glucocorticoid and mineralocorticoid deficiency (255.41) These are used generally for the patients who have death after these insufficiencies or deficienciesThese are used generally for the patients who have death after these insufficiencies or deficiencies

28. Clinical Perspective of Endocrine Changes The adrenal cortex produces 50 hormones including 98% of the corticosteroids (mostly cortisone) and mineralcorticoids (mostly aldosterone) Adrenal medulla produces adrenaline (epi and norepi) Primary adrenal insufficiency includes lack of production of both cortisones (corticosteroids) and mineralcorticoids Secondary retains production of mineralcorticoids Patients with heart failure. Patients with heart failure.

29. Clinical Aspects of Hormones Effects of corticosteroids Stimulates production of glucose from protein (glucogenesis) and decreases cellular glucose usage Mobilizes amino acids Increases pts red cell and platelet counts Inhibits effects of insulin Massive effects in inflammation to fight SIRS Effects of aldosterone Responds to renin angiotensin cycle in maintenance of blood pressure Effect on kidneys, intestines, sweat glands to maintain electrolyte balance Excesses of aldosterone result in picture of sodium retention, hypokalemia and alkalosis Systemic inflamatory response If you can process these you are ok � When you have insufficiency you can die. Systemic inflamatory response If you can process these you are ok � When you have insufficiency you can die.

30. 2 types of Adrenal Insufficiency Primary Adrenal Insufficiency Reduction of both aldosterone and cortisol Results from destruction of adrenal glands (TB, fungal replacement, hemorrhage, malignancy) May result from congenital hypoplasia or from toxicity to adrenal glands Secondary Adrenal Insufficiency Pituitary tumors, not stimulating adrenals to produce the hormones Long term usage of steroids clinically as in chemo, COPD, allergic dx and autoimmune dz Caused by some other problem in body Caused by some other problem in body

31. Acute Adrenal Insufficiency Can result in shock and possible rapid death May result from rapid cessation of long term steroid usage Can result from sepsis or surgical stresses Most common known cause of hemorrhage is Waterhouse Friedrichsen syndrome � bilateral adrenal hemorrhages from menigococcemia Autoimmmune adrenal insufficiency likely will have its own breakdown of polyglandular autoimmune disorders (PGA�s) codes in future Waterhouse Friedrichsen � hemorrhage into adrenal glands. Waterhouse Friedrichsen � hemorrhage into adrenal glands.

32. Actual Codes New code 255.41 Glucocorticoid deficiency Addisonian crisis Addison�s disease NOS Adrenal atrophy (autoimmune) Adrenal calcification Adrenal crisis Adrenal hemorrhage Adrenal infarction Adrenal insufficiency NOS Combined glucocorticoid and mineralocorticoid deficiency Corticoadrenal insufficiency NOS New code 255.42 Mineralocorticoid deficiency Hypoaldosteronism Excludes: combined glucocorticoid and mineralocorticoid deficiency (255.41) Pay attention to all of the notes listed below! Pay attention to all of the notes listed below!

33. A Few Good MEN New code 258.01 Multiple endocrine neoplasia [MEN] type I Wermer�s syndrome New code 258.02 Multiple endocrine neoplasia [MEN] type IIA Sipple�s syndrome New code 258.03 Multiple endocrine neoplasia [MEN] type IIB Use additional codes to identify any malignancies and other conditions associated with the syndromes You may also see this as MEA � Adenoma or Adenomatosis Use add�l note in ICD-9 and applicable to all the codes in that category You may also see this as MEA � Adenoma or Adenomatosis Use add�l note in ICD-9 and applicable to all the codes in that category

34. MEN May be in Women Long known groupings of endocrine tumors with genetic cause MEN I � parathyroid adenomas causing hyperparathyroidism, kidney stones, pancreatic adenomas, anterior pituitary tumors and skin tumors Mostly benign but can have malignancy We never had a way of reporting these in the past. Typically going to be seen by endocrinologists. If not chronic kidney dz physicians will continue looking. May be ulcers that won�t heal for example. We never had a way of reporting these in the past. Typically going to be seen by endocrinologists. If not chronic kidney dz physicians will continue looking. May be ulcers that won�t heal for example.

35. MEN May be in Women cont. MEN II � Medullary carcinoma of thyroid [bad acting thyroid cancer, worse than papillary or follicular], pheochromocytoma [excessive adrenaline and dangerous hypertension] of adrenal gland IIA may also have hyperparathyroidism [with kidney stones] due to parathyroid adenoma IIB won�t Most include medullary malignancy. Highest mortality rate. May have extremely high B/P. Hyperchromatosis Most include medullary malignancy. Highest mortality rate. May have extremely high B/P. Hyperchromatosis

36. New Anemia Codes New code 284.81 Red cell aplasia (acquired) (adult) (with thymoma) Red cell aplasia NOS New code 284.89 Other specified aplastic anemias Aplastic anemia (due to): chronic systemic disease drugs infection radiation toxic (paralytic) Use additional E code to identify cause They have now expanded these codes out to the 5 digit level to show what types of aplasia and aplastic anemias. Pay attn to the note about the additional E code for drugs, radiation, or an infection,etc if know. They have now expanded these codes out to the 5 digit level to show what types of aplasia and aplastic anemias. Pay attn to the note about the additional E code for drugs, radiation, or an infection,etc if know.

37. One solo Code New code 288.66 Bandemia Bandemia without diagnosis of specific infection Excludes: confirmed infection � code to infection leukemia (204.00-208.9) Use only if unknown � probably while they are trying to determine cause. Use only if unknown � probably while they are trying to determine cause.

38. Developmental Delays New code 315.34 Speech and language developmental delay due to hearing loss Use additional code to identify type of hearing loss (389.00-389.9)

39. Hydrocephalus Code New code 331.5 Idiopathic normal pressure hydrocephalus (INPH) Normal pressure hydrocephalus NOS Excludes: congenital hydrocephalus (742.3) secondary normal pressure hydrocephalus (331.3) spina bifida with hydrocephalus (741.0)

40. Myotonic Conditions New code 359.21 Myotonic muscular dystrophy Dystrophia myotonica Myotonia atrophica Myotonic dystrophy Proximal myotonic myopathy (PROMM) Steinert�s disease New code 359.22 Myotonia congenita Acetazolamide responsive myotonia congenita Dominant form (Thomsen�s disease) Recessive form (Becker�s disease) New code 359.23 Myotonic chondrodystrophy Congenital myotonic chondrodystrophy Schwartz-Jampel disease New code 359.24 Drug-induced myotonia Use additional E code to identify drug New code 359.29 Other specified myotonic disorder Myotonia fluctuans Myotonia levior Myotonia permanens Paramyotonia congenita (of von Eulenburg) These are muscular dystrophy codes. The only one of these that is reversable is the drug induce 359.24. Some are congenital, some are acquired. Herpes may cause some of these. These are muscular dystrophy codes. The only one of these that is reversable is the drug induce 359.24. Some are congenital, some are acquired. Herpes may cause some of these.

41. Clinical Perspective Excessive tone or spasms to muscles, impairs movements Myotonic muscular dystrophy is most common form of adult onset MD � high risk during and after anesthesia Drug induced known adverse effect of Lasix (furosemide) and Atromid-S (clofibrate) The Lasix may actually cause myotonic contractions. The Lasix may actually cause myotonic contractions.

42. Floppy Iris Syndrome Variant of small pupil syndrome A complication of TV ads � telling men to ask their physicians for drugs Alpha-1 blocking agents are present in some antihypertensives and is present as Flomax Patients undergoing cataract surgery by phacoemulsification are in danger of permanent small pupils because of flaccid iris and drugs usually used in surgery Can be prevented (if known) with iris hooks and dilators This is also know as the IFIS � Intraoperative Floppy Iris Syndrome Ads have now been changed to have patients tell their phyisicians, etc. This is also know as the IFIS � Intraoperative Floppy Iris Syndrome Ads have now been changed to have patients tell their phyisicians, etc.

43. Eye Codes New code 364.81 Floppy iris syndrome Intraoperative floppy iris syndrome (IFIS) Use additional E code to identify cause, such as: sympatholytics [antiadrenergics] causing adverse effect in therapeutic use (E941.3) New code 364.89 Other disorders of iris and ciliary body Prolapse of iris NOS Excludes: prolapse of iris in recent wound (871.1)

44. Hearing Codes New code 388.45 Acquired auditory processing disorder Auditory processing disorder NOS Excludes: central auditory processing disorder (315.32) New code 389.05 Conductive hearing loss, unilateral New code 389.06 Conductive hearing loss, bilateral New code 389.13 Neural hearing loss, unilateral New code 389.17 Sensory hearing loss, unilateral

45. More Hearing Codes New code 389.20 Mixed hearing loss, unspecified New code 389.21 Mixed hearing loss, unilateral New code 389.22 Mixed hearing loss, bilateral

46. Cardiac Codes New Code 414.2 Chronic total occlusion of coronary artery Complete occlusion of coronary artery Total occlusion of coronary artery Code first coronary atherosclerosis (414.00-414.07) Excludes: acute coronary occlusion with myocardial infarction (410.00-410.92) acute coronary occlusion without myocardial infarction (411.81)

47. Septic Embolism Septic embolism is a venous blood clot that can be present because of stasis from prolonged occlusion, inflammation (phlebitis) or infection. A venous clot in the peripheral circulation can embolize to the lungs A clot in the left side of the heart or originating from an infected mitral or aortic valve can embolize to the arteries in the periphery (legs, organs, brain, etc) Such an infected clot is a septic embolus. If it goes to the brain � stroke, if leg- causes dead leg.

48. Septic Embolism Codes New code 415.12 Septic pulmonary embolism Septic embolism NOS Code first underlying infection, such as: septicemia (038.0-038.9) Excludes: septic arterial embolism (449) New code 449 Septic arterial embolism Code first underlying infection, such as: infective endocarditis (421.0), lung abscess (513.0) Use additional code to identify the site of the embolism (433.0-433.9, 444.0-444.9) Excludes: septic pulmonary embolism (415.12) Please note that the second code on this slide is out of order due to the significance that it has to the other code. Please note that the second code on this slide is out of order due to the significance that it has to the other code.

49. Septic Embolism 415.12 is septic pulmonary embolism � from peripheral venous circulatory system, usually related to an indwelling venous access device, through the right heart to the lungs 449 is septic arterial embolism, from the left side of heart OR heart valves from endocarditis, through the aorta � even more rare would be an infected venous clot going through an atrial septal defect Any embolisms in peripheral system can go to the lungs. These may result from an old infected IV site. Cellulitis can cause the clot to travel to the heart. Look for infective endocarditis. Atrial may cause arterial embolism 449 � It causes lung abscesses and/or empyema. Just remember the circulation. If the septic clot ends in an artery, it�s from the left heart � look for a valve. If the septic clot ends in the lungs, it�s probably related to a venous catheter infection. Look for a reason! In documentation you may see septic embolism and lung abscess � these conditions may not be related. Only when result is linked. Any embolisms in peripheral system can go to the lungs. These may result from an old infected IV site. Cellulitis can cause the clot to travel to the heart. Look for infective endocarditis. Atrial may cause arterial embolism 449 � It causes lung abscesses and/or empyema. Just remember the circulation. If the septic clot ends in an artery, it�s from the left heart � look for a valve. If the septic clot ends in the lungs, it�s probably related to a venous catheter infection. Look for a reason! In documentation you may see septic embolism and lung abscess � these conditions may not be related. Only when result is linked.

50. More Heart Codes New code 423.3 Cardiac tamponade Code first the underlying cause New code 440.4 Chronic total occlusion of artery of the extremities Complete occlusion of artery of the extremities Total occlusion of artery of the extremities Code first atherosclerosis of arteries of the extremities (440.20-440.29, 440.30-440.32) Excludes: acute occlusion of artery of extremity (444.21- 444.22) Differentiate acute vs. Chronic occlusion. Acute have their own set of codes. 444.21-444.22. That is why they are listed in the excludes notes. Occlusions of the extremities! Differentiate acute vs. Chronic occlusion. Acute have their own set of codes. 444.21-444.22. That is why they are listed in the excludes notes. Occlusions of the extremities!

51. Influenza New code 488 Influenza due to identified avian influenza virus Note: Influenza caused by influenza viruses that normally infect only birds and, less commonly, other animals Excludes: influenza caused by other influenza viruses (487) Bird flu infection when it is caused by avian influenza virus Bird flu infection when it is caused by avian influenza virus

52. Dental Codes New code 525.71 Osseointegration failure of dental implant Hemorrhagic complications of dental implant placement Iatrogenic osseointegration failure of dental implant Osseointegration failure of dental implant due to complications of systemic disease Osseointegration failure of dental implant due to poor bone quality Pre-integration failure of dental implant NOS Pre-osseointegration failure of dental implant New code 525.72 Post-osseointegration biological failure of dental implant Failure of dental implant due to lack of attached gingiva Failure of dental implant due to occlusal trauma (caused by poor prosthetic design) Failure of dental implant due to parafunctional habits Failure of dental implant due to periodontal infection (peri-implantitis) Failure of dental implant due to poor oral hygiene Iatrogenic post-osseointegration failure of dental implant Post-osseointegration failure of dental implant due to complications of systemic disease

53. More Dental Codes New code 525.73 Post-osseointegration mechanical failure of dental implant Failure of dental prosthesis causing loss of dental implant Fracture of dental implant Excludes: cracked tooth (521.81) fractured dental restorative material with loss of material (525.64) fractured dental restorative material without loss of material (525.63) fractured tooth (873.63, 873.73) New code 525.79 Other endosseous dental implant failure Dental implant failure NOS

54. Anal Sphincter Tear New code 569.43 Anal sphincter tear (healed) (old) Tear of anus, nontraumatic Use additional code for any associated fecal incontinence (787.6) Excludes: anal fissure (565.0) anal sphincter tear (healed) (old) complicating delivery (654.8) To show med necess For those pts who now have to have tx for the fecal incontnence, etc. To show med necess For those pts who now have to have tx for the fecal incontnence, etc.

55. VIN and CIN are NOT the same New code 624.01 Vulvar intraepithelial neoplasia I [VIN I] Mild dysplasia of vulva New code 624.02 Vulvar intraepithelial neoplasia II [VIN II] Moderate dysplasia of vulva New code 624.09 Other dystrophy of vulva Kraurosis of vulva Leukoplakia of vulva 624.0 is deleted Dystrophy of vulva which specifically EXCLUDES CIN of the vulva. VIN of the vulva is not the same as CIN of the vulva 233.32 � but they can be mistaken. 624.0 is deleted Dystrophy of vulva which specifically EXCLUDES CIN of the vulva. VIN of the vulva is not the same as CIN of the vulva 233.32 � but they can be mistaken.

56. Anal Sphincter Tear w/ Pregnancy New code 664.6X Anal sphincter tear complicating delivery, not associated with third-degree perineal laceration [0,1,4] Excludes: third-degree perineal laceration (664.2) Must assign 5th digit dependant upon if patient has delivered, still pregnant or unknown

57. Aseptic Necrosis of Bone New code 733.45 Aseptic Necrosis of Bone, Jaw Use additional E code to identify drug, if drug-induced Excludes: osteoradionecrosis of jaw (526.89)

58. Hard to Swallow Codes New code 787.20 Dysphagia, unspecified Difficulty in swallowing NOS New code 787.21 Dysphagia, oral phase New code 787.22 Dysphagia, oropharyngeal phase New code 787.23 Dysphagia, pharyngeal phase New code 787.24 Dysphagia, pharyngoesophageal phase New code 787.29 Other dysphagia Cervical dysphagia Neurogenic dysphagia Identify what are the issues being assisted Must have code clinical documentation. Must have code clinical documentation.

59. Greater Definition of Dysphagias 787.21 Oral Phase Impaired structure/physiology of palate, tongue, lips, cheeks 787.22 Oropharyngeal Phase Impaired structure/physiology of tongue base and pharyngeal walls 787.23 Pharyngeal Phase Impaired structure/physiology of pharynx and larynx 787.24 Pharyngoesophageal Phase Impaired structure/physiology of upper esophageal sphincter 787.25 Dysphagia, unspecified � became 787.20 A question was posed whether or not a speech therapist could provide the type of dysphagia in order to have the greatest specificity of the code. The Physician ordering the therapy really needs to provide specificity. A question was posed whether or not a speech therapist could provide the type of dysphagia in order to have the greatest specificity of the code. The Physician ordering the therapy really needs to provide specificity.

60. Implications of Dysphagia Phases Some implications of dysphagia Aspiration (pneumonia, bronchitis, pneumonitis) Dehydration Malnutrition Diseases cause various phases to be affected Treatments differ, dependent on phase affected

61. Expansion of Ascites Code 789.5 Ascites has been deleted New code 789.51 Malignant ascites Code first malignancy, such as: malignant neoplasm of ovary (183.0) secondary malignant neoplasm of retroperitoneum and peritoneum (197.6) New code 789.59 Other ascites Right heart failure, cirrhosis, renal failure, hypothyroidism, peritoneal infections, hypoproteinemia from any source, pancreatitis, congenital deformities of portal vein, liver, heart

62. Clinical Aspect Malignant Ascites Adenocarcinoma deposits on the peritoneum which cause leakage of fluid Colon ca, pancreatic ca, liver ca, ovarian ca May be active Clear, yellow fluid Reaction of infection, outpouring of fluid

63. V Codes New code V12.53 Sudden cardiac arrest Sudden cardiac death successfully resuscitated New code V12.54 Transient ischemic attack (TIA), and cerebral infarction without residual deficits Prolonged reversible ischemic neurological deficit (PRIND) Reversible ischemic neurologic deficit (RIND) Stroke NOS without residual deficits Excludes: late effects of cerebrovascular disease (438.0-438.9) V12.53 � this code may be very useful in those pts who have an automatic defibrillator implanted. One of the covered indications for an implantable auto defibrillator is a �documented episode of cardiac arrest due to ventricular fibrillation VF not due to a transient or reversible cause� according to the NCD 20.4 effective January 27, 2005. This code could be used to show that this pt really meets this indication. V12.53 � this code may be very useful in those pts who have an automatic defibrillator implanted. One of the covered indications for an implantable auto defibrillator is a �documented episode of cardiac arrest due to ventricular fibrillation VF not due to a transient or reversible cause� according to the NCD 20.4 effective January 27, 2005. This code could be used to show that this pt really meets this indication.

64. OB V Code New code V13.22 Personal history of cervical dysplasia Personal history of conditions classifiable to 622.10-622.12 Excludes: personal history of malignant neoplasm of cervix uteri (V10.41)

65. More Family Hx V Codes! Revise Family history of condition classifiable to 188�189 New code V16.52 Bladder New code V17.41 Family history of sudden cardiac death (SCD) Excludes: family history of ischemic heart disease (V17.3) family history of myocardial infarction (V17.3) New code V17.49 Family history of other cardiovascular diseases Family history of cardiovascular disease NOS

66. Endrocrine V Codes New code V18.11 Multiple endocrine neoplasia [MEN] syndrome New code V18.19 Other endocrine and metabolic diseases

67. Contraception and Procreative Mgmt New code V25.04 Counseling and instruction in natural family planning to avoid pregnancy New code V26.41 Procreative counseling and advice using natural family planning New code V26.49 Other procreative management counseling and advice New code V26.81 Encounter for assisted reproductive fertility procedure cycle Patient undergoing in vitro fertilization cycle Use additional code to identify the type of infertility Excludes: pre-cycle diagnosis and testing � code to reason for encounter New code V26.89 Other specified procreative mgmt

68. More V Codes! New code V49.85 Dual sensory impairment Blindness with deafness Combined visual hearing impairment Code first: hearing impairment (389.00-389.9) visual impairment (369.00-369.9) Revised V58.69 Long-term (current) use of other medications Other hHigh-risk medications

69. Disability Evals/Exams New code V68.01 Disability examination Use additional code(s) to identify: specific examination(s), screening and testing performed (V72.0-V82.9) New code V68.09 Other issue of medical certificates

70. Misc V Codes New code V72.12 Encounter for hearing conservation and treatment New code V73.81 Human papillomavirus (HPV)

71. Genetic Susceptibility V Codes New code V84.81 Genetic susceptibility to multiple endocrine neoplasia [MEN] New code V84.89 Genetic susceptibility to other disease

72. New E Codes!!!!! New code E928.6 Environmental exposure to harmful algae and toxins Includes: Algae bloom NOS Blue-green algae bloom Brown tide Cyanobacteria bloom Florida red tide Harmful algae bloom Pfisteria piscicida Red tide Has anyone been to Lake Manona or Lake Mendota? Unfortunately, many of the lakes in WI are infected with these algaes. Interesting, it must not just be WI that is dealing with this. Has anyone been to Lake Manona or Lake Mendota? Unfortunately, many of the lakes in WI are infected with these algaes. Interesting, it must not just be WI that is dealing with this.

73. E code for Bisphosphonates E933 Primarily systemic agents New code E933.6 Oral bisphosphonates New code E933.7 Intravenous bisphosphonates

74. Case Scenarios

75. Case Scenario # 1 A 58 year old female patient is seen for biopsy of masses found in both the chest and her groin lymph nodes. The pathology report comes back as nodal marginal zone B-cell lymphoma. What would the appropriate diagnosis be for this patient? A. 200.38 B. 195.1, 200.35 C. 200.23, 200.35 D. 200.83 A is the correct answer. According to the Coding Clinic 2nd quarter 1993 pp 3-4 If lymph nodes in more than one region of the body (eg head and thorax, neck and abdomen, axilla and lower limb and pelvis) are involved, the fifth digit �8� should be assigned. 200.38 should be assigned because this is the Marginal zone lymphoma of specific sites. A is the correct answer. According to the Coding Clinic 2nd quarter 1993 pp 3-4 If lymph nodes in more than one region of the body (eg head and thorax, neck and abdomen, axilla and lower limb and pelvis) are involved, the fifth digit �8� should be assigned. 200.38 should be assigned because this is the Marginal zone lymphoma of specific sites.

76. Case Scenario # 2 Patient is admitted to the Emergency Room after having spent the day at the beach. Family members stated that they told him to stay out of the water due to the blue green algae that had been reported at the lake. What is the appropriate E code to use for the ER visit? A. E926.0 B. E928.6 C. E999 D. E927 B is the correct answer B is the correct answer

77. Case Scenario # 3 45 year old patient presents to the clinic for a work-up of left lower quadrant abdominal pain. He has Peripheral T-Cell lymphoma of the axilla, in remission. At the beginning of the encounter (before any radiology findings are available from the hospital radiology department) what would the diagnosis code be for this encounter? 202.74, 789.04 789.00, 202.70 789.04, V10.79 789.04, 202.74 D is the correct answer as the patient came in for abdominal pain and we have no radiology findings at this time. According to the Coding Clinic, 2nd quarter 1992, pp 3-4 Lymphoma pts who are in remission are still considered to have lymphoma and should be assigned the appropriate codes from categories 200-202. Code 202.74 should be assigned to represent Peripheral T cell lymphoma of the axillary region lymph nodes. D is the correct answer as the patient came in for abdominal pain and we have no radiology findings at this time. According to the Coding Clinic, 2nd quarter 1992, pp 3-4 Lymphoma pts who are in remission are still considered to have lymphoma and should be assigned the appropriate codes from categories 200-202. Code 202.74 should be assigned to represent Peripheral T cell lymphoma of the axillary region lymph nodes.

78. Resources ICD-9-CM Book 2008 published by Ingenix http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdtab_addenda08.pdf HcPro Audioconference �The Impact of the New and Revised 2008 ICD-9-CM Diagnosis and Procedure Codes� 8.24.07 Advance Magazine 7.16.07 issue Coding for Non-Hodgkin�s Lymphoma AAPC Coding Edge August 2007 issue �What�s Your ICD-9 Game Plan� by Catherine Gray, RHIT, CCS, CPC, CPC-CS

79. That�s it�.now everyone can relax and enjoy the rest of their day. Thank you for coming to this session�.I hope you have walked away with a better understanding of E/M coding.That�s it�.now everyone can relax and enjoy the rest of their day. Thank you for coming to this session�.I hope you have walked away with a better understanding of E/M coding.