Coding corner

Coding corner: ICD-9 changes take effect.


Every summer, the CDC's National Center for Health Statistics announces changes to the ICD-9-CM that take effect Oct. 1. In the past, CMS allowed physicians to use both the old and new diagnosis codes for the first three months of implementation, but that has not been the case for a number of years. Physicians must now discontinue use of deleted codes and begin using new codes every October. Many private insurers follow the same rules, so if you have not already updated your ICD-9 coding material, it is time to do so.

Q: What changes have the biggest impact on internists?

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A: There were several hundred changes to the ICD-9 codes for this year. Many of the codes are not commonly used by most general internists.

Still, it is important to remember that physicians are required to use the most specific code or codes possible when assigning diagnoses on a claim form. ICD-9 codes are used to determine appropriate payment for services and make coverage decisions, and they also can be an important tracking tool for public health statistics. ICD-9 code assignment is also important for physicians who plan to participate in Medicare's Physician Quality Reporting Initiative (PQRI), because the diagnosis determines which patients require quality reporting codes.

The following changes will go into effect on Oct. 1. Some codes were deleted in favor of more specific five-digit ICD-9-CM codes.

Deleted 599.7 Hematuria

Replaced with 599.70 Hematuria, unspecified 599.71 Gross hematuria 599.72 Microscopic hematuria

Deleted 780.6 Fever

Replaced with 780.60 Fever, unspecified 780.61 Fever presenting with conditions classified elsewhere 780.62 Postprocedural fever 780.63 Postvaccination fever 780.64 Chills (without fever) 780.65 Hypothermia not associated with low environmental temperature

As usual, a long list of ICD-9 diagnosis codes has been added. A significant number of codes were added in the areas of leukemia (204.xx), carcinoid tumors (209.xx), secondary diabetes mellitus (249.xx), migraine (346.xx), and erythema (695.xx). The full list of added, deleted and revised codes is online.

Q: I got paid for PQRI reporting for 2008, but I never received my results to see how I did on the measures. How do I get these?

A: CMS announced that physicians who successfully participated in the PQRI would receive bonus payments in July 2008. So if you reported successfully, you will have received an electronic funds transfer to the corporation to which you reassign your payments.

If you participated and did not receive a bonus or if you want to review your statistics as a quality review project, CMS has made the results available for physicians on the Web. The PQRI data is not available to the general public and each participating physician controls access to his or her data.

Because of access control, the process of reviewing the results is somewhat cumbersome and requires the cooperation of physicians and staff. CMS has created a program called the Individuals Authorized Access to CMS Services (IACS) that is intended to allow physicians and practices to access data. This data will not be limited to PQRI data but for most physicians it will be their entry into using the system.

For any physician who practices in a group, the group must first be registered in the system, followed by the registration of individual physicians. Practices should register by visiting the CMS Web site.

Q: What are the new conditions on Medicare's “do not pay” list?

A: Effective Oct. 1, Medicare has added three new conditions for which it will not reimburse a hospital when the patient acquires one of them during a stay:

  • surgical site infections following certain elective procedures such as orthopedic surgeries and weight reduction surgery;
  • extreme blood sugar derangement; and
  • deep vein thrombosis/pulmonary embolism following total knee replacement and hip replacement procedures.

Medicare will pay the hospital in these cases as if the diagnosis representing each of the above did not exist. Congress mandated that CMS implement this policy to avoid paying for preventable ill-effects to the patient and to encourage quality. ACP supports reducing the incidence of avoidable hospital-acquired conditions but has expressed concern to CMS that not all of the conditions to which the policy applies are entirely preventable.

Q: How does Medicare know when to apply this policy so as to avoid paying the hospital for these conditions?

A: CMS requires hospitals to clearly indicate the conditions with which the patient is afflicted at the time of admission, referred to as present on admission (POA). Conditions developed/ present during an outpatient encounter, including in the emergency department or observation area, that lead to an admission are considered POA.

The hospital will determine the diagnosis code(s) that pertain to each patient based on the clinical documentation provided by the physician and others related to the admission. The hospital then assigns a POA indicator to each diagnosis code it assigns to support payment, selecting from a list that stipulates each of the following:

  • A diagnosis was present at the time of admission;
  • A diagnosis was not present;
  • The documentation is insufficient to determine if it was present; and
  • The physician was unable to determine if the condition was present.

Each POA indicator has a payment implication.

Q: Is Medicare considering a dramatic change that would increase the number of ICD-9 codes?

A: CMS published a proposal in August 2008 that would require the use of a new version of diagnosis codes, called ICD- 10, that would greatly expand the number of available diagnosis codes from the approximately 17,000 in ICD-9 to more than 155,000 in ICD-10. CMS proposes that this new, more granular and detailed diagnosis code set take effect October 2011. In ICD-10, codes will contain up to seven alphanumeric digits as opposed to up to five primarily numeric digits in ICD-9. Diabetes mellitus codes are also expanded to include the classification of diabetes and the manifestation.

ACP has opposed the switch to ICD-10 because of concern over the cost and administrative burden that would accompany such a dramatic change. CMS believes that the more voluminous set of diagnosis codes will allow more precise reporting that will aid pay-for-performance efforts and biosurveillance. The agency will make a final decision after considering public comments and will provide a significant transition period if it decides to move forward with its proposal.

Q: Does ACP offer any resources that help with diagnosis coding?

A: The College makes a list of the ICD codes most commonly used by internists available (and free for ACP members) online. The College plans to provide members assistance in transitioning to ICD-10 if the government goes through with its recently proposed plan to implement this significantly more expansive diagnosis code set.