Health Information Management

2010 ICD-9-CM updates: Dealing with venous disease code changes

JustCoding News: Inpatient, October 28, 2009

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by Robert S. Gold, MD

If you didn’t participate in the August 26 audio conference titled, The Impact of the New and Revised 2010 ICD-9-CM Codes,” in which Gloryanne Bryant, RHIA, CCS, CCDS, and I spoke about the 2010 ICD-9-CM changes, this article is for you.

Let’s start with the concept of acute and chronic pulmonary embolism (PE) and thrombosis and embolism of the venous system. In spite of these titles being inappropriate, we must learn to analyze a medical record and frame a physician query so the medical staff won’t give you a “What are you, nuts?” response.

When a physician admits a patient to the hospital for the first time with either PE or a deep vein thrombosis (DVT) that wasn’t there earlier, it’s acute. But what if the physician didn’t document it as acute? Do you have to ask for ‘acute’ to get the right code sets? If you refer to the addenda of the final rule regarding the codes to see whether there’s a default code, you’ll find the code for unspecified deep vein thrombosis (code 453.40) is the code for acute.

Now here’s where you have to be very careful before assigning the code for acute PE (code 415.19) when the physician did not specify whether the condition actually was acute in the admission for PE or DVT. When the patient obviously was not on anticoagulants prior to admission and the physician starts the anticoagulants (e.g., heparin, Lovenox, coumadin—and not aspirin or Plavix) during this admission, then use of the default code is appropriate and ethical. On the other hand, when the patient was already on an anticoagulant coming through the door, you have some thinking to do.

If you see atrial fibrillation as one of the diagnoses or evidence that the patient has had a heart attack or some hypercoagulable state, the anticoagulant might be for that condition. So this might imply an acute condition despite being on apparent treatment already.

A physician will sometimes admit a patient currently on anticoagulants with a diagnosis of DVT or ‘recent pulmonary embolism’ for the purpose of installing an inferior vena cava umbrella (Greenfield filter) because the patient has problems with the anticoagulant he or she has been taking. In this instance, the patient’s condition is not acute.

In medical parlance, a ‘chronic pulmonary embolism’ doesn’t exist. It’s an acute event. It happens, and the patient survives or doesn’t survive. The physician will place the patient on long-term treatment—usually three to six months—to prevent further PE or to dissolve the clot that originated the PE, but there’s truly no chronic pulmonary embolism.

Coders must identify whether the condition is acute, permitting use of the default code for acute. When it’s not acute, the coder must determine whether it’s an old condition not under treatment, in which case, the coder should assign code V12.51 (venous thrombosis and embolism) for history of PE or DVT. When it is an old condition still under treatment, then it is chronic. Ask the physician whether it was acute and, if he or she validates that it wasn’t acute, assign the code for chronic when still under treatment or the V code if not under treatment.

Where you may need help is in specifying the vein with the DVT or superficial thrombosis because there are codes for various permutations of both.

The titles of most of these codes include the phrase ‘venous embolism and thrombosis.’ Arteries can be blocked because of local disease causing occlusion, and that’s called thrombosis. It’s usually instigated by atherosclerosis, so you should be using totally different codes. Arteries can be occluded because of embolism when a clot in a larger artery forms and travels to occlude smaller arteries. That’s an embolism. That doesn’t happen in veins. You simply don’t get a clot from a larger vein breaking off and flowing to occlude a smaller vein. Blood doesn’t flow in that direction. If any embolism will occur, it ends up in the lungs and not in any vein whatsoever, unless that larger vein is already occluded by a thrombus. All of these codes should be titled ‘venous thrombosis’—period.

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician programs in clinical documentation improvement. E-mail him at DCBAInc@cs.com.

This story was originally published in the October issue of Briefings on Coding Compliance Strategies.



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