The ICD-9-CM Coordination and Maintenance Committee, cosponsored by the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS), met on October 7-8, 2004 in Baltimore, MD. Donna Pickett, RHIA, from NCHS, and Patricia Brooks, RHIA, from CMS, cochaired the meeting.
Proposed modifications to ICD-9-CM were presented and are summarized below. This summary does not include all of the details of the code proposals or all of the recommendations made at the meeting. For complete details, review the minutes and code proposals posted on the CMS and NCHS websites. Diagnostic code proposals and the minutes from the diagnosis portion of the meeting are posted on the NCHS website and can be accessed at the following link: www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm. Procedure code proposals and the minutes from the procedure portion of the meeting can be found at the CMS website and can be accessed at the following link: http://www.cms.hhs.gov/paymentsystems/icd9/.
None of the proposals discussed at the October meeting will go into effect April 1, 2005. Once they are approved by CMS and NCHS, these revisions will go into effect with discharges on or after October 1, 2005.
Suggestions for diagnosis code proposals for consideration at a future Coordination and Maintenance Committee may be emailed to Donna Pickett at email@example.com or mailed to: National Center for Health Statistics, ICD-9-CM Coordination and Maintenance Committee, 3311 Toledo Road, room 2402, Hyattsville, Maryland 20782.
Suggestions for procedure code proposals to be considered at a future Coordination and Maintenance Committee, may be emailed to Pat Brooks at PBrooks@cms.hhs.govor mailed to: Centers for Medicare & Medicaid Services, CMM, HAPG, Division of Acute Care, Mail Stop C4-08-06, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
The next meeting of the ICD-9-CM Coordination and Maintenance Committee is scheduled for March 31-April 1, 2005 and will be held at the CMS building in Baltimore, MD. New proposals for inclusion on this agenda must be received by January 31, 2005.
Refractory Anemia/Myelodysplastic Syndrome
The ICD-9-CM classifies refractory anemia as aplastic anemia. The ICD-10 and ICD-O-3 classify refractory anemia as myelodypsplastic syndrome. In ICD-O-3, myelodysplastic syndrome is classified as a malignancy. This discrepancy between the classifications creates a problem for statistical classification for both morbidity and mortality. It has been proposed that ICD-9-CM be modified to reflect the classification of refractory anemia to correspond to its classification in the ICD-10 and ICD-O-3. Refractory anemia and myelodysplastic syndrome would be classified to subcategory 202.9, Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue.
Secondary Diabetes Mellitus
Diabetes mellitus may develop as a consequence of another disorder, such as cystic fibrosis. A unique code for secondary diabetes mellitus has been requested in category 251, Other disorders of pancreatic internal secretion. The underlying disorder would be sequenced first. An audience member recommended that an instructional note be added indicating that an additional code should be assigned, if applicable, for long-term (current) insulin use (V58.67). It was suggested that a distinct code for diabetes due to a drug should be created. Public input is sought on whether the diabetic manifestation codes (such as code 583.81, Nephritis and nephropathy in diseases, not specified as acute or chronic, in diseases classified elsewhere) should be allowed with the secondary diabetes code.
Androgen Insensitivity Syndrome
Androgen insensitivity syndrome is the current preferred term for testicular feminization, also called Goldberg-Maxwell syndrome. Affected individuals generally develop as normal females through childhood and have a normal adult appearance. However, they actually have an XY chromosome genotype. Though a patient may have a vagina, she does not develop a uterus and she does not have menarche. This can be the first sign of this disorder. The patient does have undescended testicles, and is at risk for testicular cancer, so the testes must be surgically removed.
A new code has been proposed in category 259, Other endocrine disorders, for androgen insensitivity syndrome.
Volume Depletion, Dehydration, Hypovolemia
Volume depletion may refer to depletion of total body water (dehydration), or depletion of the blood volume (hypovolemia). Blood volume may be maintained despite dehydration, with fluid being pulled from other tissues. Conversely, hypovolemia may occur without dehydration, when “third-spacing” of fluids occurs (e.g., with significant edema or ascites). Treatment for these conditions is different. Therefore, an expansion of code 276.5, Volume depletion, has been requested in order to uniquely identify dehydration and hypovolemia. Depletion of volume of plasma or extracellular fluid, currently an inclusion term under code 276.5, will be indexed to the code for unspecified volume depletion.
Insomnia, Hypersomnia, and Sleep Apnea
The American Academy of Sleep Medicine has published “The International Classification of Sleep Disorders” that contains diagnostic, severity, and duration criteria to aid clinical diagnosis and treatment of sleep disorders. The Academy has been working with NCHS staff to bring the ICD up-to-date with the current classification of sleep disorders. As part of this endeavor, the following modifications have been proposed:
- New code for alcohol-induced sleep disorders (category 291)
- New code for drug-induced sleep disorders (category 292)
- New subcategory in category 349 for organic disorders of initiating and maintaining sleep which would include codes for:
- Organic insomnia, unspecified
- Insomnia due to non-mental health condition classified elsewhere
- Insomnia due to mental health condition
- Other organic insomnia
- New subcategory in category 349 for organic disorders of excessive somnolence which would include codes for:
- Organic hypersomnia, unspecified
- Recurrent hypersomnia
- Hypersomnia due to non-mental health condition classified elsewhere
- Hypersomnia due to mental health condition
- Other organic hypersomnia
- New subcategory in category 349 for organic sleep apnea which would include codes for:
- Organic sleep apnea, unspecified
- Primary central sleep apnea
- High-altitude periodic breathing
- Obstructive sleep apnea
- Idiopathic sleep-related non-obstructive alveolar hypoventilation
- Sleep-related hypoventilation/hypoxemia in conditions classifiable elsewhere
- Central sleep apnea in conditions classified elsewhere
- Other organic sleep apnea
- New code for behavioral insomnia of childhood (category V69)
An audience member commented that idiopathic and primary insomnia, which would be classified to the same code under this proposal, are not synonymous.
Diabetic Retinopathy, Diabetic Macular Edema, and Diabetic Peripheral Neuropathy
Diabetic retinopathy is a complication of diabetes that is caused by changes in the blood vessels of the eye. It is the third most common cause of blindness in the U.S. and the leading cause of blindness in individuals 20-74 years of age. When the blood vessels in the retina are damaged, they may leak fluid or blood and grow fragile, brush-like branches and scar tissue. This can blur or distort the images that the retina sends to the brain. In its earliest stages, diabetic retinopathy is called nonproliferative diabetic retinopathy and is characterized by retinal vascular abnormalities, including microaneurysms, intraretinal hemorrhages, and cotton-wool spots.
As diabetic retinopathy progresses, there is a gradual closure of retinal vessels, which results in impaired perfusion and retinal ischemia. Signs of increasing ischemia include venous abnormalities and more severe vascular leakage. When these signs progress past certain defined levels, moderate or severe non-proliferative diabetic retinopathy is diagnosed. According to the American Academy of Ophthalmology, mild non-proliferative diabetic retinopathy is characterized by microaneurysms only. Severe non-proliferative diabetic retinopathy is characterized by any of the following (and no signs of proliferative retinopathy): more than 20 intraretinal hemorrhages in each of 4 quadrants; definite beading in 2 or more quadrants; prominent intraretinal microvascular anomalies in 1 or more quadrants. Moderate non-proliferative diabetic retinopathy involves more abmormalities than just microaneurysms, but less than the severe form of the condition.
The more advanced stage, proliferative diabetic retinopathy, is characterized by the onset of neovascularization on the inner surface of the retina, induced by retinal ischemia. Treatment of diabetic retinopathy includes control of diabetes-associated metabolic abnormalities (e.g., hyperglycemia, hyperlipidemia, hypertension), laser photocoagulation, and vitrectomy.
Diabetic macular edema is swelling of the retina in diabetes mellitus due to leaking of fluid from blood vessels within the macula and cannot occur in the absence of diabetic retinopathy. As macular edema develops, blurring occurs in the middle or just to the side of the central visual field. Diabetic macular edema can occur in both the non-proliferative and proliferative stages of diabetic retinopathy.
Diabetic peripheral neuropathy is a serious and progressive complication of diabetes involving damage to or impairment of peripheral nerves and is associated with significant morbidity, loss of quality of life, and increases in costs. It affects limbs symmetrically and progresses from distal (toes) to proximal (knees) over time. Symptoms include numbness, tingling, and painful sensations. Diabetic peripheral neuropathy is a risk factor for ulcers and amputations.
New codes have been requested to identify the different stages (mild, moderate, severe) of nonproliferative diabetic retinopathy and the stages of diabetic peripheral neuropathy (asymptomatic, symptomatic, and disabling). A unique code for diabetic macular edema has also been requested. It was noted that either codes for unspecified nonproliferative diabetic retinopathy and unspecified diabetic peripheral neuropathy need to be included in the proposal, or default codes need to be identified for use when the stage is not documented in the medical record. A suggestion was made to change the “code first” note under proposed code 362.06, diabetic macular edema, to a “code also” note, since the diagnosis referenced can only be reported as a secondary diagnosis and coding conventions generally do not mandate sequencing of secondary diagnoses.
Concerns were expressed by audience members as to how clearly the stage of retinopathy or neuropathy would be documented in the medical record. The use of the term “disabling” peripheral neuropathy was also felt to be problematic, since this is a subjective term and it might be misinterpreted to mean that the patient qualified for medical disability. Audience members also felt that the proposed diabetic neuropathy code revisions should not be finalized until the American Academy of Neurology has completed the approval process for their guidelines for the diagnosis of neuropathy.
Acute Coronary Syndrome
A modification to category 410, Acute myocardial infarction, has been proposed to allow for the classification of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). Treatment is different for these distinct categories of myocardial infarction. The proposed modification would involve a revision of the code descriptions of subcategories 410.0-410.6 and 410.8 to specify ST-elevation myocardial infarction. The description of subcategory 410.7 would be modified to indicate non-ST-elevation myocardial infarction.
The audience expressed concerns that these modifications would result in myocardial infarctions that are not specified as ST-elevation or non-ST-elevation to be classified to subcategory 410.9, even when the specific site of the myocardial infarction is known. It was recommended that no changes be made to the code descriptions for subcategories 410.0-410.6 and 410.8 and that “non-ST-elevation myocardial infarction” be indexed to subcategory 410.7 and be added as an inclusion term under subcategory 410.7.
Long Q-T Syndrome
The long Q-T syndrome may be suspected in individuals with a prolonged Q-T interval on electrocardiogram. It is usually diagnosed in childhood and occurs most commonly in Asians. It is associated with recurrent syncope and sudden death. One form also involves congenital bilateral neural deafness (Romano-Ward syndrome). Some patients with the syndrome do not actually have a prolonged Q-T interval, but are still susceptible to syncope and suddent death. Genetic testing of family members is generally indicated. A number of specified genetic defects have been identified as causes of the long Q-T syndrome, most of which involve genes for ion channels that control repolarization of the heart. Treatment of long Q-T syndrome involves monitoring and potentially placement of an implantable cardioverter-defibrillator.
A new code for Long Q-T syndrome has been proposed in subcategory 426.8, Other specified conduction disorders. It was noted that one can have a prolonged Q-T interval without having this syndrome. A prolonged Q-T interval without the syndrome should continue to be classified to code 794.31, Abnormal electrocardiogram.
Other Specified Peritonitis
An expansion of code 567.2, Other suppurative peritonitis, has been proposed in order to create a unique code for spontaneous bacterial peritonitis. This change was requested to distinguish this type of bacterial peritonitis from other types, since the treatment differs.
An expansion of code 567.8, Other specified peritonitis, was also proposed in order to create distinct codes for choleperitonitis and sclerosing mesenteritis. Acute peritonitis may occur due to bile in the peritoneal cavity, referred to as choleperitonitis. Sclerosing mesenteritis is a broad category of inflammatory processes involving the mesenteric fat. It includes fat necrosis and fibrosis. Each of these conditions requires specific treatment. A meeting attendee noted that “chemical peritonitis” is classified to code 998.7, Acute reaction to foreign substance accidentally left during a procedure, and a note should be added under this code instructing to coders to assign an additional code for the specific type of peritonitis.
Chronic Kidney Disease
It has been requested that ICD-9-CM incorporate the clinical practice guidelines for chronic kidney disease published by the National Kidney Foundation. These guidelines have been accepted by the National Institutes for Health and are a major focus of the Department of Health and Human Services (HHS) Healthy People 2010.
Chronic renal failure and chronic renal insufficiency are imprecise terms. The proper term to be used is chronic kidney disease. Chronic kidney disease has five stages, based on the glomerular filtration rate. The degree of time, effort, and work that is involved in taking care of these various stages increases progressively. Care of stage 4 and 5 patients is intensive and complicated.
The proposed modifications include replacement of the term “chronic renal failure” with “chronic kidney disease” in category 403, Hypertensive renal disease, category 404, Hypertensive heart and renal disease, and code 585, Chronic renal failure. An expansion of code 585 has been proposed to uniquely identify the five stages of chronic kidney disease, as well as a specific code for end stage renal disease. Definitions of each of the stages would be given under each code. A note has been proposed under category 585 indicating that the codes in this category only apply to patients diagnosed with kidney disease for longer than 3 months. A note would be added under categories 403 and 404 to indicate that an additional code should be used to identify the stage of chronic kidney disease. A note would also be added under subcategory 250.4, Diabetes with renal manifestations, to indicate that an additional code should be used to identify a manifestation of chronic kidney disease.
Audience members were concerned that the 3-month time frame proposed for category 585 may not always be well-documented. Some audience members felt that changing the term “chronic renal failure” to “chronic kidney disease” could be confusing, since “chronic renal failure” is a commonly-documented diagnosis. Concerns were also expressed about incorporating the definitions of the various stages in the classification. According to the proposal, the definition of end stage renal disease is stage V chronic kidney disease with patient on dialysis, and some attendees felt that a diagnosis should not be defined by a procedure. It was noted that patients may refuse dialysis, yet still be in end stage renal disease.
Code 599.6, Urinary obstruction, unspecified, must currently be used even when the urinary obstruction is due to a specified cause. Therefore, it has been proposed that code 599.6 be expanded to create unique codes for “unspecified” and “other specified” urinary obstruction. Index changes have also been proposed to clarify that urinary obstruction and urinary retention due to benign prostatic hypertrophy are classified to the benign prostatic hypertrophy codes.
A number of substances are known to have effects on the development of the fetus when the mother is exposed to the substance during pregnancy. Some of these teratogens have been known for many years, but others have become known since the original creation of the ICD-9-CM. Unique codes for anti-infectives, anticonvulsants, and antimetabolic agents have been requested in subcategory 760.7, Noxious influences affecting fetus or newborn via placenta or breast milk.
The passage of meconium before birth is an indication of fetal distress. It is seen most commonly in infants small for gestational age, post dates, or those with cord complications, or other factors compromising placental circulation. Meconium aspiration is commonly defined as the presence of meconium below the vocal cords and occurs in up to 35% of live births with meconium staining.
Meconium aspiration syndrome occurs in about 4% of deliveries complicated by meconium stained fluid. Meconium aspiration syndrome occurs when meconium from amniotic fluid in the upper airway is inhaled into the lungs by the newborn with his/her first breath and it invokes an inflammatory reaction in the lungs. The ICD-9-CM has a single code for meconium aspiration syndrome (code 770.1). The use of this code for meconium staining and meconium aspiration is inappropriate. Unique codes for meconium staining and meconium aspiration have been requested. These codes would be created in subcategory 779.8, Other specified conditions originating in the perinatal period.
Excessive Crying in Child, Adolescent, or Adult
A unique code for “excessive crying of child, adolescent, or adult” has been proposed in subcategory 780.9, Other general symptoms. A code already exists for “excessive crying of infant (baby).”
Asphyxia and Hypoxemia
Asphyxia originally meant stopping of the pulse, but the term has come to be associated with hypoxia and hypercapnia. Hypoxia refers to a deficiency of oxygen reaching the tissues of the body, usually due to low inspired oxygen. Hypoxemia means deficient oxygenation of the blood. Hypercapnia refers to elevated levels of carbon dioxide in the arterial blood. Low oxygen levels can be present without asphyxiation.
To differentiate asphyxia from hypoxemia, an expansion of code 799.0, Asphyxia, has been requested. Hypercapnia would continue to be classified to code 786.09, Other respiratory abnormalities. Questions were raised as to the appropriate indexing of various causes of asphyxia, such as suffocation. The NCHS agreed to check into the indexing issues further.
Mechanical Complication of Joint Prosthesis
The vast majority of hip and knee replacements last for up to 15 to 20 years or more. However, after an extended period of in vivo use, hip and knee replacements can fail, necessitating revision surgery. Common reasons for revision joint replacement surgery include mechanical loosening of the prosthesis (also referred to as “aseptic loosening”); wear of the bearing surface, particularly common with polyethylene, causing resorption of the bone around the prosthesis; infection; dislocation of the prosthetic joint; fracture of the bone around the implant (also referred to as “peri-prosthetic fracture”); implant fracture; technical error; and pain. Early complications include dislocation, instability, and infection. Late (after 5 years) complications include articular bearing surface wear, osteolysis, and aseptic/mechanical loosening.
Currently, ICD-9-CM diagnosis codes do not differentiate the specific causes of failed hip or knee replacements. An expansion of code 996.4, Mechanical complication of internal orthopedic device, implant, and graft, has been proposed to capture more detail about the cause of a failed prosthetic joint. Specific codes have been proposed for: mechanical loosening; instability; implant failure; peri-prosthetic fracture; and articular bearing surface wear. An additional code from subcategory V43.6, Organ or tissue replaced by other means, would be assigned to indicate which joint is involved. Infections associated with a prosthetic joint would continue to be classified to code 996.66, Infection and inflammatory reaction due to internal joint prosthesis. A suggestion was made to add a “use additional code” note under existing code 996.66 to indicate that a code from subcategory V43.6 should also be assigned to identify the joint involved. It was also suggested that complications due to osteolysis should be included in the proposed codes, since that is the most common cause of aseptic loosening.
Mechanical Complication of Ventilator
Effective October 1, 2004, a new code,V46.12, was implemented for encounter for respirator dependence during power failure. There is no code which describes encounters or admissions due to general mechanical equipment failure. Mechanical ventilators are carefully designed so that no single point of failure can endanger the patient. They usually have manual backup mechanisms to enable hand-driven respiration, and some systems are equipped with methods to operate or call for help if they fail. There are times when a ventilator-dependent individual must be admitted to a facility and be connected to another ventilator until his or her ventilator is fixed or replaced.
An expansion of code 997.3 has been proposed to create a unique code for mechanical complications of respirator. It was suggested that subcategory V46.1, Other dependence on machines, Respirator, might be a more appropriate location for the new code, since the problem is a failure of the device, not a medical complication affecting the patient’s respiratory system. In fact, it was suggested that revising the title of code V46.12, Encounter for respirator dependence during power failure, to include all mechanical failures of respirators might be the best solution. Placing a code for complication of a respirator in subcategory 997.3 would make it appear as though a problem with the respirator has caused the patient to develop a respiratory condition.
History of Fall
A new code has been requested for history of fall. Falls are an important public health problem affecting about one third of adults over age 65. Approximately 20-30% of those who fall will suffer moderate to severe injuries, including hip fractures and head trauma. People who report they have fallen in the past year, or have a history of falls, are much more likely to have a fall resulting in serious injury. Other factors also affect the risk of falling, such as unsteady gait, dizziness, or use of certain medications. Knowing about a history of a fall helps to identify people at risk for fall-related injuries who don’t have other risk factors. Once patients with a history of falls or other risk factors are identified, interventions are effective in lowering the incidence of falls that result in serious injury.
The proposed code for history of fall would be created within subcategory V15.8, Other specified personal history presenting hazards to health. It was recommended that advice be provided as to whether this code can be a first-listed diagnosis only, secondary diagnosis only, or can be either a first-listed or secondary diagnosis, depending on the circumstances of the encounter.
Bed Confinement Status
Creation of a new code has been proposed for bed confinement status. While initially requested by the ambulance industry to identify patients who require ambulance transport because they are confined to bed, such a code would also be useful in other settings such as long-term care facilities, home health agencies, and skilled nursing facilitie to report the additional complexity involved with patients who are bed-confined. The proposed code would be created in subcategory V49.8, Other specified conditions influencing health status.
Suicidal ideation, or the thought of committing suicide, may be a problem even for people who have not been diagnosed with a mental or behavioral disorder. Suicidal ideation includes all thoughts of committing suicide, whether or not the thoughts include a plan to commit suicide. Though most patients who voice or admit to suicidal thoughts do not go on to commit suicide, some of these patients will commit, or attempt to commit, suicide. Thus, suicidal ideation warrants thorough evaluation.
A code for suicidal ideation has been proposed in subcategory V62.8, Other psychological or physical stress, not elsewhere classified. It was suggested that a unique code be created for suicidal tendencies as well. The term “suicidal tendencies” means that the patient has attempted suicide in the past, whereas “suicidal ideation” means the patient has had thoughts of suicide.
Proposed diagnosis addenda changes were reviewed. The proposed revisions include:
- Movement of inclusion term for “Hb-Bart’s disease” from under code 282.7, Other Hemoglobinopathies, to code 282.49, Other thalassemia;
- Addition of inclusion term for “infectious acute disseminated encephalomyelitis” under code 323.6, Postinfectious encephalitis;
- Addition of inclusion term for “noninfectious acute disseminated encephalomyelitis” under code 323.8, Other causes of encephalitis;
- Addition of inclusion term for “neuroleptic-induced Parkinsonism” under code 332.1, Secondary Parkinsonism;
- Addition of inclusion term for “medication-induced postural tremor” under code 333.1, Essential and other specified forms of tremor;
- Addition of inclusion term for “neuroleptic-induced acute dystonia” under code 333.7, Symptomatic torsion dystonia;
- Addition of inclusion term for “neuroleptic-induced tardive dyskinesia” under code 333.82, Orofacial dyskinesia;
- Addition of inclusion term for “medication-induced movement disorders NOS” under code 333.90, Unspecified extrapyramidal diseases and abnormal movement disorders;
- Addition of inclusion term for “neuroleptic-induced acute akathisia” under code 333.99, Other extrapyramidal diseases and abnormal movement disorders;
- Revised list of codes in note under category 402, Hypertensive heart disease, which states “use additional code to specify type of heart failure” (proposed change would replace the listed codes with the code range “428.0-428.9”);
- Addition of note under code 487.0, Influenza with pneumonia, indicating that an additional code should be used to identify the type of pneumonia;
- Addition of note under subcategory 648.8, Abnormal glucose tolerance, indicating that an additional code should be used, if applicable, to identify long-term [current] use of insulin (V58.67);
- Addition of note under subcategory 660.8, Other causes of obstructed labor, indicating that an additional code should be used to identify the condition;
- Addition of clarifying language in chapter 15 (Certain conditions originating in the perinatal period) to explain that the perinatal period includes the first 28 days after birth;
- Addition of inclusion terms for “borderline intellectual functioning” and “religious or spiritual problem” under code V62.89, Other psychological or physical stress, not elsewhere classified;
- Addition of Index entry for “newborn acrocyanosis, meaning transient blue hands and feet” (omit code);
- Addition of Index entry for newborn cardiomyopathy (425.4);
- Addition of Index entry for congenital newborn cardiomyopathy (425.3);
- Addition of Index entry for takotsubo cardiomyopathy (429.89);
- Addition of Index entry for central auditory processing disorder (315.32);
- Revision of Index entry for male erectile disorder (607.84 instead of 307.72);
- Addition of Index entry for dysplasia of the colon (211.3);
- Revision of Index entry for hyperglycemia (790.29 instead of 790.6);
- Revision of Index entry for Ebola infection (078.89 instead of 065.8);
- Addition of Index entry for transfusion-related lung injury (997.3);
- Addition of Index entries for history of hepatitis B and C (V12.09);
- Revision of Index entry for hyperkeratosis of the cervix (622.2 instead of 622.1);
- Revision of Index entry for neoplasm of the posterior fossa (191.9 instead of 191.6);
- Addition of Index entry for febrile seizure with status epilepticus (345.3);
- Addition of Index entry for apical ballooning syndrome (429.89);
- Addition of Index entry for AV nodal re-entry (re-entrant) tachycardia (427.89);
- Addition of Index entry for stasis ulcer with varicose veins (454.0);
- Addition of Namenda (drug used to treat Alzheimer’s disease) to the Table of Drugs and Chemicals.
Insertion of Multiple Stents
In the past, angioplasty and stents were largely focused on treating single, short obstructions. Long lesions, lesions in multiple vessels, and anatomically complex lesions, such as chronic total occlusions and those at bifurcations, generally were treated with coronary artery bypass grafts. With advances in technique and design, it has now become possible to insert stents in several different vessels during the same operative episode. It has also become feasible to treat longer lesions within the same vessel, as well as anatomically complex lesions, by inserting multiple adjoining or overlapping stents. Drug-eluting stents are more effective than bare metal stents in treating multi-vessel coronary disease. The insertion of multiple stents is also being done in peripheral vessels.
A series of new codes in a new subcategory, 00.4, Other vascular system procedures, has been proposed to identify the number of vessels and number of stents involved in vascular procedures. As part of this proposal, the description of code 36.01 would be changed to “Percutaneous transluminal coronary angioplasty” (language pertaining to “single vessel” and “without mention of thrombolytic agent” would be deleted). Codes 36.02, Single vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy with mention of thrombolytic agent, and 36.05, Multiple vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent, would be deleted. The number of vessels treated, number of stents inserted, and any injection or infusion of thrombolytic agent would be coded separately from the angioplasty. Consideration is also being given to creation of a unique code for insertion of bifurcated stent(s), but that option did not receive much support because there are currently no bifurcated stents on the market.
Cardiac Support Device
The CorCap™ Cardiac Support Device is a fundamentally new therapy for the treatment of heart failure that is specifically designed to reduce ventricular wall stress. This device is a single-use, permanent, biocompatible, textile mesh implant that is placed around the heart and adjusted to conform to the heart, supporting the heart without acutely changing hemodynamics. It is intended to reduce wall stress, reverse the remodeling process and prevent the progression of cardiac dilation associated with heart failure. As a consequence, patients may experience an improvement in symptoms and functional status. Approval by the U.S. Food and Drug Administration is anticipated in July 2005.
The cardiac support device can be implanted concomitant to mitral valve repair/replacement or as a stand-alone procedure. It is anticipated that it may also be placed concomitant to coronary bypass graft procedures in the future. The device is implanted as an inpatient procedure using a sternotomy approach. After sternotomy, the pericardium is opened to expose the heart. Baseline measurements of heart size are obtained by determining left ventricular end diastolic dimension using transesophageal echocardiography. The outside circumference and base-to-apex dimension of the heart is also measured. From these measurements, the appropriate device size is selected.
The cardiac support device is positioned around the ventricles and sutures are placed to secure the device to the heart. The device is custom fitted by gathering excess fabric toward the anterior seam using a specially designed clamp.
Creation of code 00.56, Implantation of prosthetic cardiac support device around the heart, has been proposed.
Revision of Total Hip and Knee Replacement
ICD-9-CM does not differentiate the type of revision hip or knee replacement procedure. Code 81.53 is used to capture all “partial” and “total” revision hip replacement procedures, and code 81.55 captures all revision knee replacement procedures. These two codes currently capture a wide variety of procedures that differ in their clinical indications, resource intensity, and clinical outcomes.
The vast majority of hip and knee replacements last for up to 15 to 20 years or more. However, after an extended period of time, hip and knee replacements can fail, necessitating revision surgery. Common reasons for revision surgery include: mechanical loosening of the prosthesis (also referred to as “aseptic loosening”); wear of the bearing surface, particularly common with polyethylene, causing resorption of the bone around the prosthesis; infection; dislocation of the prosthetic joint; fracture of the bone around the implant (also referred to as “peri-prosthetic fracture”); implant fracture; technical error; and pain.
All hip and knee replacements have an articular bearing surface that is subject to wear (the acetabular bearing surface in the hip and the tibial bearing surface in the knee). Wear of the articular bearing surface occurs over time, and has been found to be related to many factors, including the age and activity level of the patient. In some cases, wear of the articular bearing surface can produce debris particles, which can cause peri-prosthetic bone resorption (also known as osteolysis) and mechanical loosening of the prosthesis. Wear of the bearing surface can also lead to instability and/or prosthetic dislocation, and is a common cause of revision hip or knee replacement surgery.
The most common cause of long-term failure of hip and knee replacement surgery is mechanical loosening of the implants, also referred to as “aseptic loosening.” Aseptic loosening can occur as a result of breakdown of the cement mantle with cemented implants or failure of bony ingrowth with cementless implants. It is also often associated with particular wear debris from the joint replacement bearing surface, leading to peri-prosthetic bone resorption.
“Osteolysis” refers to peri-prosthetic bone resorption that occurs in response to particulate wear debris that is generated at the joint replacement bearing surface. This progessive bone loss can lead to pain, loss of fixation and mechanical loosening of the implants, or peri-prosthetic fracture. Bearing surface wear and osteolysis are related to patient activity level and are more common in younger, more active patients. Osteolysis is more common following hip replacement than knee replacement surgery.
Infection is an infrequent but devastating complication of joint replacement surgery. Depending on the organism, superficial infections that occur during the peri-operative period can often be treated with local surgical debridement, antibiotics, and retention of the implants. Deep infections that occur more than three months following surgery often require removal of the implants (frequently associated with extensive bone loss), implantation of a temporary antibiotic-impregnated cement spacer, a prolonged period of intravenous antibiotics, followed by delayed reinsertion of the implants. Common causes of deep infection following total joint replacement include contamination of the wound at the time of surgery, contiguous spread from an infection near the joint, or blood-borne spread from an invasive procedure such as dental work or colonoscopy. The results of revision joint replacement following infection have not been as successful as the results following primary total joint replacement or revision joint replacement for other causes.
Instability (e.g., subluxation or dislocation) of the prosthetic joint is a more common problem leading to failure and revision surgery in hip replacement than in knee replacement. Patients who are older than age 70, female, or have a diagnosis of inflammatory arthritis, osteonecrosis of the hip, or hip fracture all have a higher risk of prosthetic hip dislocation. First time dislocations can often be treated with closed reduction of the hip and bracing. Recurrent dislocation significantly impairs the patient’s quality of life and necessitates revision hip replacement surgery.
A peri-prosthetic fracture, or fracture of the bone around the prosthesis, can occur as a result of abnormal bone quality (such as osteoporosis or osteolysis) or supra-physiologic loading (e.g., a mechanical fall or motor vehicle collision). Treatment options include fixation of the bone around the prosthesis or revision total joint replacement with or without reconstruction of associated bony defects.
A rare cause of failed total joint replacement is failure or breakage of the implants. Implant failures have been reported with both hip replacement implants (fracture of the polyethylene or ceramic bearing surface or the femoral stem) and knee replacement implants (fracture of the polyethylene tibial insert).
Revision hip replacement can involve replacing any or all of the implants, including the femoral component, the acetabular component, and the bearing surface (the femoral head and acebular liner), and, at times, involves major reconstruction of the bones and soft tissues around the hip. Exchange of the modular femoral head and acetabular liner is one of the most common revision hip replacement procedures performed. The most frequent indications for this type of revision surgery are wear of the polyethylene bearing surface or recurrent dislocation of the prosthetic hip.
Revision of the acetabular component involves removal and exchange of the entire acetabular component, including both the metal shell and the polyethylene, ceramic, or metal modular bearing surface. Common indications for this type of revision surgery are wear of the modular bearing surface, aseptic loosening, malposition of the component, or infection.
Revision of the femoral component involves removal of the implant and the surrounding cement. Long-stemmed, specialized revision implants are often required, with or without bone allograft, depending on the amount of bone loss and the quality of the remaining host bone. Recovery times following femoral component revision tend to be longer than with isolated acetabular component revision, due to the need for protected weight bearing to allow the bone to heal to the prosthesis in many cases. Common indications for isolated femoral component revision include aseptic loosening, malpositioning of the components, infection, or peri-prosthetic fracture.
Revision of both the acetabular and femoral components may be required when both implants fail. This type of surgery is the most labor- and resource-intensive and is associated with the highest complication rate of all revision hip replacement procedures. Extensive surgical exposure, specialized revision hip implants, and specialized techniques for reconstruction of extensive bony defects are often required.
In cases of deep infection of a prosthetic hip, removal of the implants with insertion of an antibiotic-impregnated cement spacer, followed by six weeks of intravenous antibiotics is often required in order to clear the infection. Revision hip replacement in these cases often involves complex bony reconstruction due to extensive bone loss that occurs as a result of the infection and removal of the often well-fixed implants.
Revision hip replacement for peri-prosthetic fracture is frequently performed as an urgent procedure. These patients are often older and sicker (e.g., have multiple associated medical comorbidities) than other hip replacement patients, and their bone quality tends to be poor. These procedures often require extensive bony reconstruction and the use of specialized implants. They are associated with higher complication rates, a higher risk of peri-operative mortality, and longer recovery times than other revision hip replacement procedures.
One type of revision knee replacement surgery is isolated modular tibial insert exchange, which involves replacing the modular polyethylene bearing surface without removing the femoral, tibial, or patellar implants. Indications for this procedure include wear of the polyethylene bearing surface or instability of the prosthetic knee joint.
Revision of the tibial component involves removal and exchange of the entire tibial component, including both the metal base plate and the modular polyethylene bearing surface. Indications include wear of the modular bearing surface, aseptic loosening, or infection.
Revision of the femoral component in revision knee replacement surgery involves removal and exchange of the metal implant that covers the end of the distal femur. Indications include infection or aseptic loosening with or without associated osteolysis/bone loss.
Revision of the patellar component may be required due to failure of the implant, maltracking of the patella in the femoral groove leading to wear and breakage of the implant, fracture of the patella with or without loosening of the patellar implant, rupture of the quadriceps or patellar tendon, and infection.
The most common type of revision knee replacement procedure is a complete total knee revision. A complete revision of all implants is more common in knee replacement than in hip replacement because the implants used in knee replacement are not compatible across vendors or types of prostheses. So, even if only one of the implants is loose or broken, a complete revision of all components is often required in order to ensure that the implants are compatible.
In cases of deep infection of a prosthetic knee, removal of the implants with insertion of an antibiotic-impregnated cement spacer, followed by 6 weeks of intravenous antibiotics, is often required in order to clear the infection. Revision knee replacement from an antibiotic impregnated cement spacer often involves complex bony reconstruction due to extensive bone loss that occurs as a result of the infection and removal of the often well-fixed implants.
The MEDPAR database provides a rich source of data for epidemiological studies related to hip and knee replacement procedures. This data has been used by many clinical investigators to study the epidemiology of primary and revision total joint replacement procedures, including how clinical, demographic, surgeon, and hospital characteristics impact results in terms of complications and hospital readmission rates. However, efforts to use this database to study factors related to implant longevity and specific failure mechanisms is currently limited by the ICD-9-CM coding system, since this system does not capture the type of revision joint replacement procedure performed.
The American Joint Registry Project is a project sponsored by the National Institutes of Health that is intended to capture relevant information related to total joint replacement procedures that are performed in the U.S., including factors related to the patient, the surgeon, the hospital, the implants used, and the procedure. This information could be extremely valuable in evaluating the quality, clinical outcomes, and cost-effectiveness of total joint replacement implants and procedures. More specific procedure codes could dramatically improve the quality of the data available for use in the American Joint Registry Project to study failure mechanisms related to specific implants and surgical techniques.
A series of new procedure codes has been proposed to capture information on revision hip and knee replacement procedures. A new subcategory, 00.7, would be created for “other hip procedures.” Within this new subcategory, new codes for revision of the acetabular component of a hip replacement, femoral component, and both components would be created. In addition, new codes for insertion and removal of (cement) spacer would be created in subcategory 84.5, Implantation of other musculoskeletal devices and substances. Consideration is also being given to a code for revision of hip replacement involving only the acetabular line and/or femoral head. Coders had expressed some concern that the medical record documentation might not clearly differentiate between procedures on the acetabular component versus the liner.
To address revision knee replacement procedures, creation of subcategory 00.8, Other knee procedures, has been proposed. New codes for revision of the tibial component of a knee replacement, femoral component, and patellar component would be created in this new subcategory. Consideration is also being given to creating a new code for revision of just the tibial insert. However, documentation may not always support differentiation between procedures on the tibial insert and the tibial component.
There was some discussion as to whether the existing codes for revision hip and knee replacement, codes 81.53 and 81.55, should be revised to represent a total revision (all components) or an “unspecified” revision. The audience generally felt that the existing code for revision of hip replacement should be used for unspecified revisions and a new code should be created for revision of a total hip replacement in order to maintain comparability with past data. Unlike hip revision surgery, the vast majority (85%) of knee replacements are total, so revising existing code 81.55, Revision of knee replacement, to specify revision of a total knee replacement, and classifying unspecified knee replacement revisions to this code, would seem to be appropriate.
Revision or Relocation of Defibrillator Pocket
A revision of code 37.79, Revision or relocation of pacemaker pocket, has been proposed so that this code can be assigned for any revision or relocation of a pocket containing the pulse generator component of any type of cardiac device.
Insertion of Rechargeable Neurostimulator Pulse Generator
Neurostimulator pulse generators currently in use have an average life span of approximately three years. However, this varies considerably depending on the severity of each patient’s symptoms and their individual needs. Generator life span can be as low as six months for patients who require high-energy output to manage their symptoms. In order to extend battery life, sub-optimal electrical settings are often chosen, resulting in reduced efficacy of the therapy. Patients must undergo repeated surgeries to replace the pulse generator when it reaches end-of-life.
To provide consistent relief and reduce the need for repeated surgeries, rechargeable pulse generators have recently been developed. Although they also eventually reach end-of-life, the ability to recharge the battery allows for higher output over a much longer life span of up to 8 or 9 years. The new rechargeable systems expand the number of available electrodes in an implanted system. They are capable of handling 16 electrodes over 2 leads, versus current devices with 8 electrodes over 2 leads. The increased number of electrodes provides broader coverage on the spinal column, and gives the physician much greater programming flexibility.
Current ICD-9-CM procedure codes do not distinguish between rechargeable and nonrechargeable neurostimulator pulse generators. Two new codes have been proposed in subcategory 86.9, Other operations on skin and subcutaneous tissue, for insertion and replacement of single array and dual array rechargeable neurostimulator pulse generator. Pulse generators that are not specified as rechargeable would be classified to the existing codes. Code 86.96, Insertion or replacement of other neurostimulator pulse generator, will continue to be used when the number of arrays is not known. Code 86.05, Incision with removal of foreign body or device from skin and subcutaneous tissue, will continue to be used for removal of any type of pulse generator. Some participants questioned whether new codes are necessary if rechargeable pulse generators might ultimately become the standard of care. Others felt that new codes are necessary so that the use of this new technology and patient outcomes can be tracked.
Infusion of Liquid Radioisotope
Iotrex™ is an organically bound liquid form of Iodine-125 used in intracavitary brachytherapy with the GliaSite® Radiation Therapy System. After the malignant brain tumor has been resected, a balloon catheter is implanted temporarily inside the cavity. The patient is discharged from the hospital and readmitted a few days or weeks later to have Iotrex™ infused via the catheter and intracavitary radiation is delivered to the target area. The emitted gamma radiation from Iotrex™ is delivered directly to the margins of the tumor bed. Because the radiation dose rapidly decreases beyond the tumor site, there is minimal damage to surrounding healthy tissue. This approach allows the physician to maximize total radiation to the target area. After 3-7 days, the liquid Iotrex™ is removed under local anesthesia. Under general anesthesia, the catheter is removed. Catheter removal involves an incision in the scalp, removal of the screws in order to remove the port, and pulling the balloon end of the catheter out through the burr hole.
A unique procedure code for infusion of liquid radioisotope has been requested. CMS recommended, and the audience generally concurred, that this procedure should continue to be classified to code 92.28, Injection or instillation of radioisotopes. CMS also recommended that code 86.09, Other incision of skin and subcutaneous tissue, continue to be assigned for the removal of the catheter. However, participants did not feel that code 86.09 adequately captured the procedure involved in removing the catheter. It was suggested that unique codes be created for both the removal of the liquid radioisotope and the catheter.
Proposed procedure addenda changes were reviewed. The proposed revisions include:
- Addition of Index entries for debridement of bursa (83.5) and debridement of fascia (83.39);
- Revision of Index entry for “Latzko operation, colpocleisis” (70.8 instead of 70.4);
- Revisions in Tabular List and Index to allow use of the “total system” codes for implantation of cardiac resynchronization pacemakers and defibrillators when the pulse generator and one or more leads are implanted;
- Addition of “code also” note under codes for implantation of cardiac resynchronization pacemakers and defibrillators indicating that a code for electrophysiologic (EPS) studies should also be assigned (some concerns were expressed by the audience as to whether all EPS studies should be separately coded and suggested that it would be preferable to consider EPS studies part of the implantation procedure).
An update on ICD-10-PCS was provided by staff from 3M Health Information Systems. Changes that have been made for 2005 include:
- Minor revisions were made to the definitions of the root operations “extraction,” “fragmentation,” and “reattachment;”
- Two new approaches were defined and added to the system (“via indwelling device” and “open with endoscopic assistance”);
- Scope of the root operations “division” and “removal” was modified so that their application is limited to body parts and devices that can actually be divided and removed;
- Laboratory section was deleted;
- Old training manual will be replaced by a new reference manual that will include definitions of the ICD-10-PCS terms, root operations and approaches and the draft ICD-10-PCS coding guidelines.
The updated version of ICD-10-PCS will be posted on the CMS website at the following link: http://www.cms.hhs.gov/paymentsystems/icd9/icd10.asp.
|Source: AHIMA Web Site (November 2004)|