by Lou Ann Schraffenberger, MBA, RHIA, CCS, CCS-P, FAHIMA
The new ICD-9-CM diagnosis codes for fiscal year 2010 go into effect October 1, 2009. This article outlines the changes in the ICD-9-CM diagnosis codes. The 2009 addenda with all the changes to the ICD-9-CM tabular and alphabetic index (volumes 1 and 2) is located on the National Center for Health Statistics Web site at www.cdc.gov/nchs/datawh/ftpserv/ftpICD9/ftpICD9.htm. The ICD-9-CM procedure changes are outlined in the accompanying article “New ICD-9-CM Procedure Codes for FY 2010.”
Merkel Cell Carcinoma and Other Neuroendocrine Tumors
New codes (209.31–36 and 209.75) were added to describe Merkel cell carcinoma, a lethal skin cancer with a 33 percent mortality rate. The codes describe the location of the neuroendocrine malignancy and include the face, scalp, neck, upper and lower limbs, and trunk, with a code for an unknown primary site.
New codes were added to fully classify secondary neuroendocrine tumors and personal history of neuroendocrine tumors. Codes 209.70–79 identify secondary neuroendocrine tumors of unspecified site, distant lymph nodes, liver, bone, peritoneum, and other sites. Code V10.91 reports a personal history of a malignant neuroendocrine tumor. Use of these codes follows the same guidelines as those for all malignant neoplasms.
Retina and Choroid Neoplasms
The new code, 239.81, Neoplasm of unspecified nature of the retina and choroid, was created to track patients who may have a suspected melanoma of the retina or suspected choroid tumor. Because it is very difficult to biopsy the retina there is generally no tissue sample to confirm this diagnosis.
Gout is a disorder in which uric acid crystals are deposited in joints and soft tissue with accompanying inflammation and degenerative changes. Revised and new codes were created to identify an acute attack of gout or acute gouty arthropathy (274.01), chronic gouty arthropathy without tophus (274.02), and chronic gouty arthropathy with tophus (274.03). An unspecified code (274.00) is used to code an unspecified gouty arthropathy. Trophus, a deposit of uric acid crystals that forms a chalky mass on the bones at the joints, most commonly occurs in the large joint of the big toe, producing pain and swelling.
Tumor Lysis Syndrome
A new code, 277.88, for tumor lysis syndrome describes a group of metabolic complications that can occur after treatment of cancer, usually lymphomas and leukemias. Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalemia, and acute renal failure are caused by the breakdown products of dying cancer cells, which can occur even without cancer treatment. This condition can cause acute renal failure, cardiac arrhythmia, and metabolic acidosis, which can in turn result in mortality and morbidity.
Autoimmune Lymphoproliferative Syndrome
New code 279.41 describes autoimmune lymphoproliferative syndrome (ALPS), which is an inherited disorder of the immune system that affects both children and adults. In ALPS, unusually high numbers of white blood cells (lymphocytes) accumulate in the lymph nodes, liver, and spleen, which can lead to enlargement of these organs. ALPS can cause problems such as anemia, thrombocytopenia, and neutropenia. It may be diagnosed in early childhood. Patients are treated with steroid therapy. However, patients have a greater risk of developing lymphoma as they get older.
Antineoplastic Chemotherapy-Induced Anemia
Anemia acquired as the result of the administration of antineoplastic chemotherapy is a common side effect of cancer treatment. Not a truly aplastic form of anemia that reduces the bone marrow cellularity to aplasia, this type of anemia has a reduction in the supply of red blood cells that produces fatigue and weakness in the patient. The anemia is treatable and usually short term. No external cause code for the antineoplastic drug is required, as new code 285.3 identifies this drug as the cause of the anemia.
The new code for temporal sclerosis, 348.81, includes mesial temporal and hippocampal sclerosis terminology. Mesial temporal sclerosis usually results in partial (focal) or temporal lobe epilepsy. The sclerosis is the loss of neurons and scarring of the temporal lobe associated with certain brain injuries. This seizure disorder can cause symptoms such as strange sensations, changes in behavior or emotions, muscle spasms, or convulsions. The changes associated with mesial temporal sclerosis are easily identifiable on a magnetic resonance imaging (MRI) scan. The condition can be corrected by a temporal lobectomy of the brain to remove the part of the brain where the sclerosis exists.
Inclusion Body Myositis
A new code, 359.71, was created to identify inclusion body myositis (IBM), one of a group of muscle diseases known as the inflammatory myopathies that are characterized by chronic muscle inflammation accompanied by muscle weakness. The onset of muscle weakness is generally gradual over months or years and affects both proximal and distal muscles. Muscle weakness may affect only one side of the body. Falling and tripping are usually the first noticeable symptoms of IBM.
For some individuals, the disorder begins with weakness in the wrists and fingers that causes difficulty with pinching, buttoning, and gripping objects. Difficulty swallowing occurs in approximately half of IBM cases. Symptoms of the disease usually begin after the age of 50, although the disease can occur earlier. IBM occurs more frequently in men than in women. There is no cure for IBM, nor is there a standard course of treatment.
Acute Chemical Conjunctivitis
Acute chemical conjunctivitis is the result of irritating substances entering the eye. The substances may be household cleaners, sprays, smoke, smog, industrial pollutants, or chlorine from swimming pools. A new code, 372.06, for acute chemical or acute toxic conjunctivitis was requested to better track this condition, which places a patient’s vision at significant risk if not treated.
Venous Thrombosis and Embolism and Pulmonary Emboli
Venous thrombosis and embolism, or VTE, can occur in veins of the upper and lower extremities as well as the thorax and neck. An “acute” VTE is a new thrombosis that requires the initiation of anticoagulant therapy. The term “chronic” in reference to these conditions is meant to describe an old or previously diagnosed thrombus that requires continuation of established anticoagulation therapy.
ICD-9-CM codes were revised and created to allow for better reporting and tracking of the conditions, also known as DVTs or deep vein thrombosis, as well as a code for a VTE occurring in superficial veins.
Codes 453.40–42 were revised to add the word “acute” to the venous embolism and thrombosis of deep vessels in the proximal and distal as well as unspecified deep vessels of the lower extremity.
A new set of codes, 453.81–89, were added to describe “acute” venous embolism and thrombosis of the upper extremity veins such as the antecubital, basilic, cephalic, brachial, radial, ulnar, axillary, subclavian, internal jugular, and other thoracic and unspecified veins.
New codes 453.50–52 were added to identify “chronic” venous embolisms and thrombosis of deep vessels in the proximal and distal as well as unspecified deep vessels in the lower extremity. An additional code for associated long-term (current) use of anticoagulants, V58.61, is used with these codes if applicable.
New codes 453.71–79 were added to describe “chronic” venous embolism and thrombosis of the upper extremity veins such as the antecubital, basilic, cephalic, brachial, radial, ulnar, axillary, subclavian, internal jugular, and other thoracic and unspecified veins. Code V58.61 for associated long-term (current) use of anticoagulants is used as well if applicable.
In addition, a new code, 453.6, was created to identify venous embolism and thrombosis of superficial vessels of the lower extremity, such as the lesser or greater saphenous veins.
Finally, new code 416.2 was added to identify a chronic pulmonary embolism. Again, code V58.61 is used with this code if applicable.
An excludes note follows all the new codes for the chronic VTEs to note these conditions are not the same as a personal history of venous thrombosis and embolism or pulmonary embolism reported with code V12.51. A personal history code is intended to describe a condition that is no longer under treatment. The chronic conditions in this section are usually under long-term anticoagulation therapy.
Avian and Novel Influenza Virus
Category 488 has been retitled “Influenza due to certain identified influenza viruses.” New code 488.0 is used to code bird flu, or more specifically influenza due to identified avian influenza virus. A second new code was added to identify swine flu, or more specifically influenza due to identified novel H1N1 influenza virus (488.1).
A new code, 569.71, was created for pouchitis. Pouchitis is a nonspecific inflammation of an internal ileoanal pouch, which was created following a proctocolectomy with ileal pouch anal anastomosis. An internal ileoanal pouch is created to treat ulcerative colitis or familial adenomatous polyposis. Creating the pouch means the patient does not need a permanent ileostomy and has preserved continence. A common complication of the pouch is pouchitis, which is usually treated successfully with antibiotics.
Two new codes were created to describe specific forms of vomiting: 569.87 for vomiting of fecal matter and 787.04 for bilious vomiting or emesis. Both conditions can be indicative of a serious condition that requires an evaluation.
Two additional codes were created for bilious emesis or vomiting in a newborn (779.32) and other vomiting in newborn (779.33). Both conditions are included under the subcategory 779.3, disorder of stomach function and feeding problems in the newborn. Two other new codes under this subcategory were created to describe feeding problems in the newborn (779.31) and failure to thrive in the newborn (779.34).
Two new codes were added to the subcategory 621.3, Endometrial hyperplasia, to distinguish between benign endometrial hyperplasia (621.34) and endometrial intraepithelial neoplasia or endometrial intraepithelial neoplasia (621.35). Benign endometrial hyperplasia is the result of the benign hormonal effects of unopposed estrogens on the uterus. Patients with endometrial hyperplasia commonly present with abnormal bleeding. This may be menorrhagia, metrorrhagia, menometorrhagia, or postmenopausal bleeding. Endometrial cancer must be ruled out, particularly in patients older than 35 years of age who present with these conditions. The most common method used to diagnose hyperplasia and cancer is endometrial aspiration, also known as an endometrial biopsy.
Endometrial intraepithelial neoplasia (EIN) is a premalignant lesion of the uterine lining that confers an elevated risk for the woman to develop the most common form of uterine cancer. It is composed of a collection of abnormal endometrial cells, arising from the glands that line the uterus, which have a tendency over time to progress to endometrial adenocarcinoma, endometrioid type. EIN is treated with surgery or hormonal therapy.
Category 670, Major puerperal infection, was expanded to describe serious infections that can arise during a woman’s postpartum period. Each new code requires a fifth digit of 0, 2, or 4 to identify the episode of care in which the condition was established.
The codes for 670.1 identify puerperal endometritis. Pueperal sepsis is now coded to 670.2. Pueperal septic thrombophlebitis (new code 670.3) is an inflammatory condition that affects the adnexa of the pelvis. It differs from postpartum deep vein thrombosis, which is identified with code 671.4. Other major pueperal infections are coded to 670.8.
Omphalocele and Gastroschisis
Two congenital conditions are now better identified with new ICD-9-CM codes. Omphalocele (756.72) is a ventral wall defect in patients whose intestines are covered by a membranous sac with the possible exposure of the intestine if the sac ruptures. It occurs in one to two babies per 10,000 births and is more common in infants of mothers age 35 or older. It is associated with other structural and chromosomal anomalies in the infant.
Gastroschisis (756.73) is a congenital ventral wall defect, usually to the right of the umbilical cord insertion that results from the failure of the developing abdominal wall to completely close. The fetal intestines will extrude through the defect and are exposed to the amniotic fluid. This produces an inflamed, thick, swollen intestine. If identified before birth, mothers need special monitoring. Plans are made for careful delivery and immediate management of the problem after birth.
Treatment for gastroschisis is surgery. A surgeon will put the bowel back into the abdomen and close the defect, if possible. If the abdominal cavity is too small, a mesh sack is stitched around the borders of the defect and the edges of the defect are pulled up. Over time, the herniated intestine falls back into the abdominal cavity, and the defect can be closed.
Other treatments for the baby include nutrients by IV and antibiotics to prevent infection. The baby’s temperature must be carefully controlled, since the exposed intestine allows significant body heat to escape. It occurs in two to five babies per 10,000 births, with increasing prevalence and a high incidence in younger mothers.
A code for hypoxic-ischemic encephalopathy (768.7) was added in 2006, but fifth digits were added this year (768.70–3) to accommodate the well-defined clinical definitions of mild, moderate, and severe forms of the newborn condition based on clinical presentations and imaging findings. Stages I, II, and III correlate with the descriptions of mild, moderate, and severe encephalopathy. Because of the varying degrees of severity of this illness and the treatment required, distinct codes were added this year at the request of the American Academy of Pediatrics.
Code 784.42 was created to identify dysphonia or hoarseness of speech. Dysphonia may be a symptom of a laryngeal disorder affecting the structure or function of the larynx. Impairments of resonance and nasal air flow include hypernasality (new code 784.43) and hyponasality (new code 784.44). These conditions are usually the result of impairments affecting the structure or function of the oral cavity, nasal airway, or the velopharyngeal port.
New code 784.51 was created for dysarthria or slow, distorted speech that results from the inability to control or coordinate the muscles used for speech. The new code 438.13 is used to identify dysarthria as a late effect of stroke.
Dysarthria can also result from traumatic brain injury, brain tumor, degenerative neurological conditions, and other conditions that cause facial paralysis. Other causes are the excessive use of alcohol and certain medications, such as sedatives and narcotics. Treatment is directed to the underlying cause, which may improve speech. Speech therapy is also used to regain normal speech. Dysarthria can be a sign of a serious underlying problem and should be investigated thoroughly.
Other speech disturbances of unknown origin will now be coded to the new symptom code 784.59, including dysphasia and slurred speech. New code 438.14 should be used to identify other fluency disorders due to a cerebrovascular accident, such as stuttering.
A specific code for colic, 789.7, was added. Colic is defined as crying for more than three hours a day, three days a week, or three weeks in an otherwise well-fed, healthy baby. The condition usually starts a few weeks after birth and improves by three months. Ninety percent of babies are rid of the condition by nine months. The cause of colic is unknown but may include allergies, lactose intolerance, and an immature digestive system.
Inconclusive Mammogram-Nonspecific Finding
A routine mammogram may be described as inconclusive due to radiologist documentation of “dense breasts.” This is not an abnormal breast condition but one that requires further testing to confirm that no malignant condition exists that cannot be noted on the mammogram. A new code, 793.82, was created to explain this finding and justify the need for further testing, such as an ultrasound study.
As part of this new code, the title of category 793 was changed to “Nonspecific (abnormal) findings on radiological and other examination of body structure.” The term “abnormal” is now a nonessential modifier to emphasize these findings are inconclusive and not necessarily abnormal.
Signs and Symptoms Involving Emotional State
Category 799.2 has been retitled “Signs and symptoms involving emotional state,” instead of the previous title of “Nervousness.” Five new codes were added to describe specific signs and symptoms of nervousness (799.21), irritability (799.22), impulsiveness (799.23), emotional lability (799.24), demoralization and apathy (799.25), as well as a code for other signs and symptoms of emotional state (799.29).
Apparent Life-Threatening Event in an Infant
New code 799.82, Apparent life-threatening event in an infant (ALTE), has been added to better track the incidence and provide a possible explanation of the event in infants. An ALTE has been defined by the National Institutes of Health as “an episode that is frightening to the observer and that is characterized by some combination of apnea, color change, marked change in muscle tone, choking or gagging. In some cases, the observer fears the infant has died.”
Previously used terms to describe this condition include aborted crib death or near-miss SIDS, even though there is no proven relationship between this conditions and sudden infant death syndrome (SIDS). It occurs in infants born at greater than 37 weeks gestational age and can occur during sleep, wakefulness, or feeding. Cyanosis and apnea are the predominant presenting symptoms. The true incidence of ALTE is unknown as it is a clinical syndrome and probably has been coded a variety of ways.
Two new codes have been added for torus or buckle fracture of the ulna (813.46) and radius and ulna (813.47). This type of fracture is most common in children and generally occurs after a fall on an outstretched arm. A revision to the alphabetic index for FY 2010 will lead the coder to code 812.49 for a torus fracture of the humerus.
Code 832.2 was created to identify nursemaid’s elbow, a subluxation of the radial head commonly seen in children under the age of five years. Prior to the creation of the new code, the condition was coded dislocation of the elbow. Also called a radial head dislocation, a nursemaid’s elbow is a partial dislocation of the elbow, which occurs when the forearm slips out of its normal position at the elbow joint. The injury occurs when a child is pulled up too hard by the hand or wrist, especially by one arm. The partial dislocation can be reduced by a doctor with a fairly simple maneuver.
Poisoning by Antidepressants and Psychostimulants
Category code 969, Poisoning by psychotropic agents, includes code 969.0 for poisoning by antidepressant drugs. New codes were added for the seven current classes of antidepressants. Codes were created for unspecified antidepressants (969.00), monoamine oxidase inhibitors (969.01), selective serotonin and norepinephrine reuptake inhibitors (969.02), selective serotonin reuptake reuptake inhibitors (969.03), tetracyclic antidepressants (969.04), tricyclic antidepressants (969.05), and other antidepressants (969.09).
Similarly, code 969.7 was expanded to allow for the separation of caffeine from other psychostimulants. New codes include poisoning by unspecified psychostimulant (969.70), caffeine (969.71), amphetamines (969.72), methylphenidate (969.73), and other psychostimulants (969.79.)
A new code, 995.24, was created to describe instances of failed sedation. Moderate (conscious) sedation by nonanesthesia providers usually provides safe pain relief and amnesia to patients undergoing noxious procedures that do not require general anesthesia.
However, a failed sedation procedure can occur when the patient remains inadequately sedated, exhibits idiosyncratic responses to medications, fails to maintain a patent airway, and usually requires the services of an anesthesiologist to administer deep sedation or anesthesia to complete the procedure.
Once this event has occurred, it is important to acknowledge it during future procedures that require moderate sedation. A new V code was also created, V15.80, personal history of failed moderate sedation, to explain the caution in using moderate sedation again, possibly with an anesthesia provider present.
Traumatic Brain Injury
Two new V codes were created to describe a patient with a history of traumatic brain injury (V15.52) and special screening for traumatic brain injury (V80.01).
New V code, V15.83, describes underimmunization status or delinquent immunization status. The code indicates the status of a person who is at risk of disease due to being behind schedule on a recommended immunization schedule.
Newborn Post-Discharge Health Check
Many healthy newborns are discharged from the hospital less than 48 hours after delivery. When this occurs, pediatricians recommend the baby be examined by their primary care providers within two days of the discharge date. This is a special visit to assess the health and well being of the infant and reinforce family education.
Based on American Academy of Pediatrics guidelines, two new V codes were created for posthospital newborn care after vaginal and cesarean deliveries. Code V20.31 is for health supervision for newborn under age eight days. Code V20.32 is for health supervision for newborn eight to 28 days old.
Other New V Codes
A variety of new V codes were created to describe special patient circumstances:
- V26.42, Encounter for fertility preservation counseling
- V26.82, Encounter for fertility preservation procedure
- V53.50, Fitting and adjustment of intestinal appliance and device
- V53.51, Fitting and adjustment of gastric lap band
- V53.59, Fitting and adjustment of other gastrointestinal appliance and device
- V60.81, Foster care (status)
- V60.89, Other specified housing or economic circumstances
- V61.07, Family disruption due to death of family member
- V61.08, Family disruption due to other extended absence of family member
- V61.23, Counseling for parent-biological child problem
- V61.24, Counseling for parent-adopted child problem
- V61.25, Counseling for parent (guardian)-foster child problem
- V61.42, Substance abuse in family
- V72.60, Laboratory examination, unspecified
- V72.61, Antibody response examination
- V72.62, Laboratory examination ordered as part of a routine general medical examination
- V72.63, Preprocedural laboratory examination
- V72.69, Other laboratory examination
- V80.01, Special screening for traumatic brain injury
- V80.09, Special screening for other neurological conditions
- V87.32, Contact with and (suspected) exposure to algae bloom
- V87.43, Personal history of estrogen therapy
- V87.44, Personal history of inhaled steroid therapy
- V87.45, Personal history of systemic steroid therapy
- V87.46, Personal history of immunosuppressive therapy
External Cause of Injury (E) Codes for Never Events
Wrong surgery, wrong patient, and wrong site events are among the list of 28 “never events” on the National Quality Forum’s endorsed list of adverse events of concern to the public and healthcare providers. The Joint Commission, the Agency for Healthcare Research and Quality, and state governments use never events as quality indicators.
Beginning with fiscal year 2010, ICD-9-CM has one revised and two new external cause of injury codes to identify three of the never events:
- E876.5, Performance of wrong operation (procedure) on correct patient
- E876.6, Performance of operation (procedure) on patient not scheduled for surgery
- E876.7, Performance of correct operation (procedure) on wrong side/body part
External Cause of Injury (E) Codes for Activity Status
New codes from category E000 should be used in conjunction with the external cause code(s) assigned to a record to indicate the status of the person at the time the event occurred. A single code from category E000 should be assigned for an encounter as follows:
- E000.0, Civilian activity done for income or pay
- E000.1, Military activity
- E000.8, Other external cause status, such as leisure, recreation, sport, student, or volunteer activities
- E000.9, Unspecified external cause status
External Cause of Injury (E) Codes for Activity
Categories E001–E030 were created to indicate the activity of the person seeking healthcare for an injury or health condition, such as a heart attack while shoveling snow, which resulted from or contributed to the activity. These codes are appropriate for use for both acute injuries and conditions that are due to the long-term, cumulative effects of an activity. They are also appropriate for use with external cause codes for cause and intent if identifying the activity provides additional information on the event. These codes should be used in conjunction with other external cause codes for the external cause status (E000) and place of occurrence (E849).
This section contains the following broad activity categories:
- E001, Activities involving walking and running
- E002, Activities involving water and water craft
- E003, Activities involving ice and snow
- E004, Activities involving climbing, rappelling, and jumping off
- E005, Activities involving dancing and other rhythmic movement
- E006, Activities involving other sports and athletics played individually
- E007, Activities involving other sports and athletics played as a team or group
- E008, Activities involving other specified sports and athletics
- E009, Activity involving other cardiorespiratory exercise
- E010, Activity involving other muscle strengthening exercises
- E011, Activities involving computer technology and electronic devices
- E012, Activities involving arts and handcrafts
- E013, Activities involving personal hygiene and household maintenance
- E014, Activities involving person providing caregiving
- E015, Activities involving food preparation, cooking, and grilling
- E016, Activities involving property and land maintenance, building, and construction
- E017, Activities involving roller coasters and other types of external motion
- E018, Activities involving playing musical instrument
- E019, Activities involving animal care
- E029, Other activity
- E030, Unspecified activity
External Cause Codes for Military Operations
At the request of the Department of Defense, new external cause codes were created to better identify the causes of injury among military personnel. A new fourth-digit subdivision of .7 was created for water transport accidents, categories E830–E838, to identify an occupant of a military watercraft. Code E928.7 was created to identify mechanical malfunction of a firearm or air gun as the cause of an injury.
A full expansion of codes under categories E990-E999, Injuries resulting from operations of war, was made to identify specific causes of war injuries. For example, code E991.6 indentifies an injury caused by fragments from a vehicle-borne improvised explosive device, sustained during war operations.
Lou Ann Schraffenberger (firstname.lastname@example.org) is manager of clinical data, Center for Health Information Services at Advocate Health Care, Oak Brook, IL.
Schraffenberger, Lou Ann.
"New ICD-9-CM Diagnosis Codes for FY 2010"
Journal of AHIMA
[expanded online version].