Health Information Management

Q&A: Coding capillary leak syndrome secondary to biochemotherapy

HIM-HIPAA Insider, March 23, 2010

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Q: How should I code capillary leak syndrome secondary to biochemotherapy? Can you provide coding guidelines or a rationale for your answer?

A: Systemic capillary leak syndrome is difficult to diagnose, although it does typically have the following classic symptoms:
  • Nasal congestion
  • Runny nose
  • Cough
However, it’s important to note that each of these symptoms can be mistaken for an upper respiratory viral infection.
Mayo Clinic provides helpful information about capillary leak syndrome. To learn more, visit ICD-9-CM does not include a code for this syndrome, nor does Coding Clinic address how to code the condition.
Therefore, coders must report it as a capillary disease with the unspecified code 448.9 (other and unspecified capillary diseases).
Coders also should report E933.1 (adverse effect of antineoplastic and immunosuppressive drugs). The ICD-9-CM Official Guidelines for Coding and Reporting that became effective October 1, 2009, state in pertinent part that:
Codes from the E930–E949 series must be used to identify the causative substance for an adverse effect of drug, medicinal, and biological substances, correctly prescribed and properly administered. The effect, such as tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure, is coded and followed by the appropriate code from the E930–E949 series.
In this case, the biochemotherapy caused the systemic capillary leak. Thus, coders should report E933.1.
If the patient exhibits other symptoms, assign codes for them as well. For example, when a patient presents with malaise, report 780.79. When a patient presents with nausea, report 780.02. When a patient presents with lightheadedness, report 780.4. Report each of these codes in addition to 448.9.
Editor’s note: Sandra Sillman, RHIT, PAHM, DRG coordinator at Henry Ford Health System in Detroit, answered this question in the March 2010 issue of Briefings on Coding Compliance Strategies.

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