ICD-9-CM Update

1. ICD-9-CM Update ION SEPTEMBER, 2008

2. Disclaimer • This presentation is an abbreviated seminar for practices. Other codes may apply. Please review a complete list at • Please get a new code book each year to allow for reference. • This presentation is good for the date of the presentation only. Typos may be evidenced herein. It is not coding or legal advice. • All code changes can be found at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/

3. Oncology ICD-9-CM Introduction (AMA CC) • Chapter 2 of the ICD-9-CM contains the code for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. Malignant is generally the only one paid for chemo. • If malignant, any secondary (metastatic) sites should also be determined.The Neoplasm Table in the Alphabetic Index should be referenced first. If the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column is appropriate. For example, if the documentation indicates Adenoma,refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to see also neoplasm, by site, benign. • The Table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the Table that corresponds to the type listed in the record.

4. ICD-9-CM for Cancer • The Neoplasm Table from AHA(Cont’d) • The tabular should then be referenced to verify that the correct code has been selected and that a more specific site code does not exist. • If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. • When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present. • Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines: • 1. When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy. • 2. When the admission/encounter is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by the appropriate code(s) for the malignancy. • 3. When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy. • 4. When the admission/encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy,the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.

5. Issues in ICD-9-CM • History of • When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code. (Effective 12/01/05)

6. ICD-9-CM Issues • Admissions/Encounters involving chemotherapy and radiation therapy • When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by chemotherapy or radiation treatment, the neoplasm code should be assigned as principal or first-listed diagnosis. • When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal or first- listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series. • If a patient admission/encounter is solely for the administration of chemotherapy or radiation therapy code V58.0, Encounter for radiation therapy, or V58.1, Encounter for chemotherapy, should be the first-listed or principal diagnosis. If a patient receives both chemotherapy and radiation therapy both codes should be listed, in either order of sequence

7. ICD-9-CM Issues • Rule Out Diagnoses (“Rule Out Lung Cancer”) • Never code this as definitive, unless you have clinical evidence. • Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-defined conditions (codes 780.0 - 799.9) contain many, but not all codes for symptoms.

8. ICD-9-CM Guidelines NCHS • Coding and sequencing of complications Coding and sequencing of complications associated with the malignancies or with the therapy: 1) Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code 285.22, Anemia in neoplastic disease) is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy. Code 285.22 may also be used as a secondary code if the patient suffers from anemia and is being treated for the malignancy. ICD-9-CM Official Guidelines for Coding and Reporting Effective December 1, 2005 Page 18 of 77 2)Anemia associated with chemotherapy, immunotherapy and radiation therapy When the admission/encounter is for management of an anemia associated with chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by code E933.1. The appropriate neoplasm code should be assigned as an additional code. 3) Management of dehydration due to the malignancy When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy. 4)Treatment of a complication resulting from a surgical procedure When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.

9. ICD-9-CM Guidelines 12/10/05 from NCDVS • Code Sequencing • V58.0, Radiotherapy, and codes from subcategory V58.1x, Encounter for chemotherapyand immunotherapy for neoplastic conditions. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1x may be used together on a record with either one being sequenced first.

10. V58.1x • Here is the scoop from the ICD-9-CM Maintenance Committee. V58.11 Encounter for antineoplastic chemotherapy V58.12 Encounter for immunotherapy for neoplastic condition “ Immunotherapy also called immune therapy and biologic therapy is a treatment that stimulates the body’s immune defense system to fight infection and disease. It is not classified as chemotherapy. Unlike traditional cytotoxic chemotherapies that attack cancer cells themselves, immunotherapy is designed to enhance the body’s defenses by mimicking the way natural substances activate the immune system.  These can stimulate the growth and activity of cancer-killing cells, e.g.interleukin used in the treatment of malignant melanoma and renal cell carcinoma.”

11. ICD-9-CM Changes • What drugs are immunotherapy? • This is as follows: "The Food and Drug Administration has approved several immunotherapies for use against specific cancer, including Bacille Calmette-Guerin (BCG), interferon-alfa (IFN-alfa), interleukin-2 (IL-2), and other monoclonal antibodies."

12. V58.1x • Monoclonal Antibodies in Cancer • Rituxan (Rituximab) • Herceptin (Transtuzumab) • Mylotarg (Gemtuzumab ozogamicin) • Campath (Alemtuzumab) • Zevalin (Ibritumomab tiuxetan) • Bexxar (Tositumomab) • Erbitux (Cetuximab) • Avastin (Bevacizumab) • Vectibix (Panitumumab)

13. Non-Hodgkin’s Lymphoma • The main cell found in lymphoid tissue is the lymphocyte, an infection-fighting white blood cell, of which there are two main types, B lymphocytes (B cells) and T lymphocytes (T cells). B cell lymphomas account for 85% of the non-Hodgkin's lymphoma cases in the United States. There is no known cause for non-Hodgkin's lymphoma but there may be a relationship between the condition and bacterial or viral infection • Treatment generally depends on the behavior of the disease (indolent, aggressive, or very aggressive). There are thirty (30) subtypes of Non-Hodgkin's lymphoma. Source: AHA Coding Clinic

14. Non-Hodgkin’s Lymphoma • Marginal zone lymphomas (200.3) are slow growing B cell tumors that are categorized based on whether they occur outside the lymph nodes or within the lymph node. Mucosa-associated lymphoid tissue (MALT) lymphomas for example, are extra-nodal marginal zone lymphomas that occur in the gastrointestinal tract, eyes, thyroid, salivary glands, lungs, and skin. Nodal marginal zone B cell lymphomas involve the lymph nodes but are uncommon. Splenic marginal lymphomas involve the spleen, bone marrow and blood. Treatment for marginal zone lymphomas depends on type, location and presentation. • Mantle cell lymphoma (200.4) is an aggressive Non-Hodgkin's B cell lymphoma that accounts for about 6% of all Non-Hodgkin's lymphoma cases in the United States. It is frequently diagnosed as a stage 4 disease found in the gastrointestinal tract, bone marrow, and the lymph nodes above and below the diaphragm. The chemotherapeutic approach using R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) is a common treatment. Mantle cell lymphoma is difficult to treat but combinations of chemotherapy, biological therapies and other regimens show promise in improving survival. Source: AHA Coding Clinic Third Quarter, 2007

15. Non-Hodgkin’s Lymphoma • Primary central nervous system (CNS) lymphoma (200.5) is found in the brain and spinal cord. A weakened immune system increases the risk for this aggressive lymphoma. It is common in patients with acquired immunodeficiency syndrome (AIDS), history of kidney transplant and other immunocompromised conditions. Tumors are usually limited to the cranial-spinal axis and to the eye without systemic involvement. Radiation therapy has been the standard treatment due to the diffuse nature of this lymphoma. • Large cell lymphomas (200.7) are the most common type of Non-Hodgkin's lymphoma. They are aggressive and occur in the lymph node and extranodal sites such as the gastrointestinal tract, testes, thyroid, skin, breast, central nervous system and bone. Large cell lymphomas comprise 20% to 25% of childhood lymphomas. High-dose chemotherapy and stem cell/bone marrow transplant have increased survival rates. • Anaplastic large T cell lymphoma (200.6) and peripheral T cell lymphoma (202.7) are common T cell lymphomas. Anaplastic large T cell lymphomas can be cutaneous or systemic. Cutaneous anaplastic large cell lymphomas appear on the skin and grow slowly. They respond well to radiation and surgery. Chemotherapy is used occasionally. Systemic anaplastic large cell lymphoma may appear throughout the body and frequently affect the skin, bone, soft tissue and lung. Although aggressive, these lymphomas respond to chemotherapy. Peripheral T cell lymphomas represent a diverse group of lymphomas that are aggressive. They often require salvage treatment and transplant, yet respond well to treatment.

16. Cancer ICD-9-CM Codes 10/1/08 • 199.2 Malignant neoplasm associated with transplant organ • 203.02 Multiple myeloma, in relapse • 203.12 Plasma cell leukemia, in relapse • 203.82 Other immunoproliferative neoplasms, in relapse • 204.02 Acute lymphoid leukemia, in relapse • 204.12 Chronic lymphoid leukemia, in relapse • 204.22 Subacute lymphoid leukemia, in relapse • 204.82 Other lymphoid leukemia, in relapse • 204.92 Unspecified lymphoid leukemia, in relapse • 205.02 Acute myeloid leukemia, in relapse • 205.12 Chronic myeloid leukemia, in relapse • 205.22 Subacute myeloid leukemia, in relapse • 205.32 Myeloid sarcoma, in relapse • 205.82 Other myeloid leukemia, in relapse • 205.92 Unspecified myeloid leukemia, in relapse • 206.02 Acute monocytic leukemia, in relapse • 206.12 Chronic monocytic leukemia, in relapse • 206.22 Subacute monocytic leukemia, in relapse • 206.82 Other monocytic leukemia, in relapse • 206.92 Unspecified monocytic leukemia

17. Cancer ICD-9-CM Codes 10/1/08 • 207.02 Acute erythremia and erythroleukemia, in relapse • 207.12 Chronic erythremia, in relapse • 207.22 Megakaryocytic leukemia, in relapse • 207.82 Other specified leukemia, in relapse • 208.02 Acute leukemia of unspecified cell type, in relapse • 208.12 Chronic leukemia of unspecified cell type, in relapse • 208.22 Subacute leukemia of unspecified cell type, in relapse • 208.82 Other leukemia of unspecified cell type, in relapse • 208.92 Unspecified leukemia, in relapse

18. Cancer ICD-9-CM Codes 10/1/2008 • 209.00 Malignant carcinoid tumor of the small intestine, unspecified portion • 209.01 Malignant carcinoid tumor of the duodenum • 209.02 Malignant carcinoid tumor of the jejunum • 209.03 Malignant carcinoid tumor of the ileum • 209.10 Malignant carcinoid tumor of the large intestine, unspecified portion • 209.11 Malignant carcinoid tumor of the appendix • 209.12 Malignant carcinoid tumor of the cecum • 209.13 Malignant carcinoid tumor of the ascending colon • 209.14 Malignant carcinoid tumor of the transverse colon • 209.15 Malignant carcinoid tumor of the descending colon • 209.16 Malignant carcinoid tumor of the sigmoid colon • 209.17 Malignant carcinoid tumor of the rectum • 209.20 Malignant carcinoid tumor of unknown primary site • 209.21 Malignant carcinoid tumor of the bronchus and lung • 209.22 Malignant carcinoid tumor of the thymus • 209.23 Malignant carcinoid tumor of the stomach • 209.24 Malignant carcinoid tumor of the kidney • 209.25 Malignant carcinoid tumor of foregut, not otherwise specified • 209.26 Malignant carcinoid tumor of midgut, not otherwise specified • 209.27 Malignant carcinoid tumor of hindgut, not otherwise specified • 209.29 Malignant carcinoid tumor of other sites

19. New Cancer ICD-9 Codes 10/1/2008 • 209.30 Malignant poorly differentiated neuroendocrine carcinoma, any site • 238.77 Post-transplant lymphoproliferative disorder (PTLD) • 289.84 Heparin-induced thrombocytopenia (HIT) • 999.81 Extravasation of vesicant chemotherapy • 999.82 Extravasation of other vesicant agent • 999.88 Other infusion reaction • 999.89 Other transfusion reaction • V07.51 Prophylactic use of selective estrogen receptor modulators (SERMs) • V07.52 Prophylactic use of aromatase inhibitors • V07.59 Prophylactic use of other agents affecting estrogen receptors and estrogen levels • V13.51 Personal history of pathologic fracture • V87.41 Personal history of antineoplastic chemotherapy • V87.42 Personal history of monoclonal drug therapy • V87.49 Personal history of other drug therapy • And, there may be more…

20. Other ICD-9-CM Changes • Secondary Diabetes Mellitus (249.xx) • New types of headaches (339.xx) • A gaggle of new PAP and anal smear codes (795.xx-796.xx) • V87.xx for exposure to toxic (and potentially carcinogenic) substances

21. Funniest 2009 ICD-9-CM Codes • 339.43 Primary Thunderclap Headache • 339.82 Headache Associated With Sexual Activity • 339.85 Primary Stabbing Headache • 372.74 Pingueculitis • 611.81 Ptosis of Breast • 796.77 Satisfactory Anal Smear, But Lacking Transformation Zone

22. Changed Codes of Note • 203.00 Multiple myeloma, without mention of having achieved remission • 203.10 Plasma cell leukemia, without mention of having achieved remission • 203.80 Other immunoproliferative neoplasms, without mention of having achieved • remission • 204.00 Acute lymphoid leukemia, without mention of having achieved remission • 204.10 Chronic lymphoid leukemia, without mention of having achieved remission • 204.20 Subacute lymphoid leukemia, without mention of having achieved remission • 204.80 Other lymphoid leukemia, without mention of having achieved remission • 204.90 Unspecified lymphoid leukemia, without mention of having achieved remission • 205.00 Acute myeloid leukemia, without mention of having achieved remission • 205.10 Chronic myeloid leukemia, without mention of having achieved remission • 205.20 Subacute myeloid leukemia, without mention of having achieved remission • 205.30 Myeloid sarcoma, without mention of having achieved remission • 205.80 Other myeloid leukemia, without mention of having achieved remission • 205.90 Unspecified myeloid leukemia, without mention of having achieved remission

23. Changed Codes of Note (2009) • 206.00 Acute monocytic leukemia, without mention of having achieved remission • 206.10 Chronic monocytic leukemia, without mention of having achieved remission • 206.20 Subacute monocytic leukemia, without mention of having achieved remission • 206.80 Other monocytic leukemia, without mention of having achieved remission • 206.90 Unspecified monocytic leukemia, without mention of having achieved remission • 207.00 Acute erythremia and erythroleukemia, without mention of having achieved • remission • 207.10 Chronic erythremia, without mention of having achieved remission • 207.20 Megakaryocytic leukemia, without mention of having achieved remission • 207.80 Other specified leukemia, without mention of having achieved remission • 207.20 Megakaryocytic leukemia, without mention of having achieved remission • 207.80 Other specified leukemia, without mention of having achieved remission \ • 208.00 Acute leukemia of unspecified cell type, without mention of having achieved remission • 208.10 Chronic leukemia of unspecified cell type, without mention of having achieved remission • 208.20 Subacute leukemia of unspecified cell type, without mention of having achieved remission • 208.80 Other leukemia of unspecified cell type, without mention of having achieved remission • 208.90 Unspecified leukemia, without mention of having achieved remission • V45.71 Acquired absence of breast and nipple

24. ICD-10-CM • The Department of Health and Human Services (HHS) announced a long-awaited proposed regulation that would replace the ICD-9-CM code sets now used to report health care diagnoses and procedures with greatly expanded ICD-10 code sets, effective October 1, 2011. In a separate proposed regulation, HHS has proposed adopting the updated X12 standard, Version 5010, and the National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions, such as health care claims. Version 5010 is essential to use of the ICD-10 codes. • In 2000, under authority provided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the ICD-9-CM code sets were adopted for use in the administrative transactions by both the public and private sectors to report diagnoses and inpatient hospital procedures. Covered entities required to use the ICD-9-CM code sets include health plans, health care clearinghouses, and health care providers who transmit any electronic health information in connection with a transaction for which a standard has been adopted by HHS.

25. Overview of ICD-10 • International Classification of Diseases and Related Health Problems, the 10th Edition • Maintained by the World Health Organization • Classifies the causes of disease morbidity and mortality • Contains diseases, symptoms, etiologies, and injuries • Official Site: • http://www.who.int/whosis/icd10/

26. History of ICD • Origin (1893) • International List of Causes of Death • International Statistical Institute (ISI) • WHO (1946) • Morbidity and mortality • Revised every 10 years • ICD-10 (1994)

27. ICD Revisions Mortality ISI WHO Mortality Morbidity

28. Purpose of ICD-10 • WHO: • Statistically oriented classification system for health census and statistics • To permit the systematic analysis, interpretation and comparison of mortality and morbidity data collected in different countries or areas, at different times

29. Updates of ICD-10 • Must through a local Collaborating Centre • E.g, US: National Center for Health Statistics (NCHS) • Submit to WHO 3 to 6 months before Heads of Centres annual meeting • Present in Heads of Centres meeting in October • Updates: • Publish no later than 15 months after each Centre Heads meeting • Latest update available: 1999 (http://www.who.int/whosis/icd10/corr-eng.htm)

30. Content of ICD-10 • Volume 1: • Tabular List • Cause-of-death titles and codes • Classification at 3- and 4-character levels • Volume 2: • Instruction Manual • Description, guidelines, and coding rules • Volume 3: • Alphabetical Index to diseases and nature of injury, external causes of injury • Table of drugs and chemicals

31. ICD-10: The Code • Core code: • 3 character (1 letter + 2 digits) • A00 • Up to 2,600 categories • Mandatory for reporting at the international level • Extended code: • the 4th digit following a decimal point • A00.0 • Up to 26,000 categories • Recommended not required by WHO

32. ICD-10: The Classification • Two types of classification: • Main classification • diagnoses and health status • E11 = Non-insulin dependent diabetes mellitus • Supplementary classification • generally outside the formal diagnoses but related to health care • Z83.3 = Family history of diabetes mellitus

33. ICD-10 Hierarchy for Classification • 9,275 codes used in US • ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10/ • 3 level hierarchy • Level 1: the 21 chapters • 21 categories • Level 2: the 1st – 3rd characters (A00) • 1643 categories • Level 3: the 1st – 4th characters (A00.0) • 7611 categories • Site for browsing the hierarchy and searching diseases: • http://www.med-ia.ch/bolinosmed/codifications/icd10/

34. Most Important Coding Rules of ICD-10 1— Highest Level of Specificity 2— Daggers (†) and asterisks (*) are coded together, daggers first 3— Principal disease: one disease of major medical cost

35. 1. Highest Level of Specificity • As specific as possible • Patient: • Type 2 diabetes mellitus with renal complications • Code: • E11.2 = Type 2 diabetes mellitus with renal complications • Not E11 = Type 2 diabetes mellitus

36. 2. Dagger and Asterisk • For a disease encoded by two codes • Dagger represents etiological aspects. • Asterisk refers to anatomical location • Example: • For Renal tuberculosis: A18.1† urogenital tuberculosis N29.1* infectious disease of kidney and ureter classified elsewhere . .

37. 174 malig neo female breast 1740 malig neo nipple 1741 mal neo breast-central 1742 mal neo breast up-inner 1743 mal neo breast low-inner 1744 mal neo breast up-outer 1745 mal neo breast low-outer 1746 mal neo breast-axillary 1748 malign neopl breast nec 1749 malign neopl breast nos 175 malig neo male breast 1750 mal neo male nipple 1759 mal neo male breast nec C50011 Malignant neoplasm of nipple and areola, right female breast C50012 Malignant neoplasm of nipple and areola, left female breast C50019 Malignant neoplasm of nipple and areola, unspecified female breast C50021 Malignant neoplasm of nipple and areola, right male breast C50022 Malignant neoplasm of nipple and areola, left male breast C50029 Malignant neoplasm of nipple and areola, unspecified male breast C50111 Malignant neoplasm of central portion of right female breast C50112 Malignant neoplasm of central portion of left female breast C50119 Malignant neoplasm of central portion of unspecified female breast C50121 Malignant neoplasm of central portion of right male breast C50122 Malignant neoplasm of central portion of left male breast C50129 Malignant neoplasm of central portion of unspecified male breast C50211 Malignant neoplasm of upper-inner quadrant of right female breast C50212 Malignant neoplasm of upper-inner quadrant of left female breast C50219 Malignant neoplasm of upper-inner quadrant of unspecified female breast C50221 Malignant neoplasm of upper-inner quadrant of right male breast C50222 Malignant neoplasm of upper-inner quadrant of left male breast C50229 Malignant neoplasm of upper-inner quadrant of unspecified male breast C50311 Malignant neoplasm of lower-inner quadrant of right female breast C50312 Malignant neoplasm of lower-inner quadrant of left female breast C50319 Malignant neoplasm of lower-inner quadrant of unspecified female breast C50321 Malignant neoplasm of lower-inner quadrant of right male breast C50322 Malignant neoplasm of lower-inner quadrant of left male breast C50329 Malignant neoplasm of lower-inner quadrant of unspecified male breast C50411 Malignant neoplasm of upper-outer quadrant of right female breast C50412 Malignant neoplasm of upper-outer quadrant of left female breast C50419 Malignant neoplasm of upper-outer quadrant of unspecified female breast C50421 Malignant neoplasm of upper-outer quadrant of right male breast C50422 Malignant neoplasm of upper-outer quadrant of left male breast C50429 Malignant neoplasm of upper-outer quadrant of unspecified male breast C50511 Malignant neoplasm of lower-outer quadrant of right female breast C50512 Malignant neoplasm of lower-outer quadrant of left female breast Differences between ICD-9 & ICD-10 : Breast Cancer (Partial List)

38. References • World Health Organization (WHO)http://www.who.int • WHO statistical informationhttp://www.who.int/whosis/icd10/ • Centers for Disease Control (CDC) National Center for Health Statistics (NCHS) • http://www.cdc.gov/nchs • http://www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm • http://www.cdc.gov/nchs/about/major/dvs/icd10des.htm

39. Get Ready for October 1 • Check codes against the full list of codes that you use and make sure that nurses and doctors are updated on the coding possibilities. • Spot check your PM system to make sure additions and changes are in your billing and EMR systems. • Update Superbill or EMR Problem List as necessary. • Educate billers and coders.