AHIMA Comments on the Proposed Diagnosis Code Modifications Presented at the October ICD-9-CM Coordination and Maintenance Committee Meeting

January 4, 2005

Donna Pickett, MPH, RHIA
Medical Classification Administrator
National Center for Health Statistics
3311 Toledo Road
Room 2402
Hyattsville, Maryland 20782

Dear Donna:

The American Health Information Management Association (AHIMA) welcomes the opportunity to provide comments on the proposed diagnosis code modifications presented at the October ICD-9-CM Coordination and Maintenance Committee meeting.

Generally support code proposals, with additional comments or recommendations

Mechanical Complication of Joint Prosthesis
AHIMA supports the proposal for new codes for mechanical complications of joint prostheses. We agree with the recommendation that the title of proposed code 996.43 be changed from "fracture of prosthetic joint" to "failure of prosthetic joint." "Breakage of prosthetic joint" should still be listed as an inclusion term.

We recommend that an Excludes note be added under category 820, Fracture of neck of femur, for proposed code 996.44, Peri-prosthetic fracture around prosthetic joint. An Excludes note would remind coders that the new complication code, and not an acute injury code, should be assigned for a peri-prosthetic fracture.

History of Fall
While we support the proposed code for history of fall, it would be helpful to include some notes in the classification that would prevent the overuse or misuse of the code. While the narrative background in the Coordination & Maintenance Committee materials makes the intended purpose of this code clear, the code title by itself could be misconstrued. For example, should this code be used in conjunction with a follow-up code to describe the reason for follow-up after completion of treatment for an acute injury (e.g., follow-up visit after fractured wrist due to fall on ice has healed)? Also, should this code be used to identify a single past incident, or only when there has been more than one fall? For example, a 25-year-old healthy woman who tripped and fell down her basement stairs last year is not in the same risk category as an elderly patient who has experienced several falls in the past. Yet both technically have a history of a fall.

Once this code is implemented, it would be helpful to provide a few scenarios demonstrating the proper use of this code, including an explanation of whether this code may be assigned as a first-listed diagnosis, in Coding Clinic for ICD-9-CM.

Long Q-T Syndrome
Index entries and instructional notes will need to make it very clear that a prolonged Q-T without the syndrome should be assigned code 794.31, not the new code for long Q-T syndrome.

Secondary Diabetes
AHIMA supports the suggestion to create a specific code for diabetes due to a drug in addition to the proposed code for secondary diabetes mellitus. We also agree that an instructional note is needed to indicate that code V58.67 should be assigned for insulin use.

The diabetic manifestation codes should be allowed with the proposed code for secondary diabetes. Since patients with secondary diabetes can develop the same manifestations as patients with primary diabetes, it makes sense that the diabetic manifestation codes should be used with either type of diabetes.

Suicidal Ideation
We support the suggestion that a new code for "suicidal tendencies" be created in addition to the proposed code for "suicidal ideation."

Excessive Crying in Child, Adolescent, or Adult
Direction needs to be provided in instructional notes as to the time frame for using code 780.92 vs. the proposed new code. When is a patient no longer an infant and the proposed code for excessive crying of child, adolescent, or adult should be used instead of code 780.92?

Urinary Obstruction/Retention
In addition to the proposed Index entries, it would be helpful to add Excludes notes under proposed code 599.69 and subcategory 788.2 indicating that these codes should not be used if the urinary obstruction or retention is due to benign prostatic hypertrophy.

Insomnia, Hypersomnia, and Sleep Apnea
AHIMA supports the revisions to the proposal recommended by the American Academy of Neurology during the Coordination and Maintenance Committee meeting.

Refractory Anemia/Myelodysplastic Syndrome
We agree with the recommendation that an Excludes note be added under the codes that have been assigned for myelodysplastic syndrome and refractory anemia in the past.

Input from additional groups is needed before finalizing code proposal

Diabetic Retinopathy and Diabetic Macular Edema
AHIMA recommends that the American Academy of Ophthalmology be consulted regarding the proposed codes for diabetic retinopathy and diabetic macular edema prior to finalizing this proposal. Since they represent major providers of care for patients with these disorders, their concurrence on the proposed codes and their titles is extremely important to ensure that the codes reflect current medical practice and thinking.

AHIMA is concerned that medical record documentation will often lack information regarding whether nonproliferative diabetic retinopathy is mild, moderate, and severe. We recommend that an additional code be created for "unspecified nonproliferative diabetic retinopathy." We believe this approach would be preferable to designating the mild form as the default, since assigning the code for "mild" when the retinopathy is really unspecified would result in patients being inappropriately classified as having the mild form of the condition.

The "code first" note under proposed code 362.06 should be changed to a "code also" note since the listed codes are manifestation codes that can never be sequenced first.

Diabetic Peripheral Neuropathy
AHIMA recommends that input from key professional organizations, including the American Medical Association, American Academy of Family Physicians, American Academy of Neurology, and American Diabetes Association, should be obtained before finalizing this proposal. Additionally, finalization of these proposed new codes should wait until the American Academy of Neurology has completed its guidelines for the diagnosis of neuropathy to ensure that these guidelines and the new codes are consistent.

We are concerned that diabetic neuropathy will not be documented in the medical record as "asymptomatic," "symptomatic," or "disabling." We are particularly concerned about the term "disabling," since this a very subjective term and has a variety of different meanings.

Support code proposals as presented, with no additional comments

Bed confinement status

Androgen insensitivity syndrome

Volume depletion, dehydration, hypovolemia

Asphyxia and hypoxemia



Meconium staining

Do not support code proposals as presented

Acute Coronary Syndrome
AHIMA believes that the proposal is very confusing and will result in most myocardial infarctions being assigned the unspecified code because it appears as though a myocardial infarction must be specifically documented as an ST-elevation or non-ST elevation myocardial infarction. A preferable, and much simpler, approach would be to maintain the current code titles and just add non-ST-elevation myocardial infarction to the Index and as an inclusion term under subcategory 410.7x. This approach would achieve the same end result, which is to ensure that non-ST-elevation myocardial infarctions are classified to subcategory 410.7x.

Chronic Kidney Disease
AHIMA does not believe the proposal for chronic kidney disease should be implemented as presented. The term "chronic renal failure" is still commonly used in medical record documentation, so changing this term to "chronic kidney disease" in ICD-9-CM could lead to confusion. We are concerned about limiting the use of the proposed codes to patients diagnosed with kidney disease for longer than 3 months, since it may be difficult, if not impossible, for coders to determine whether a patient meets this definition. Also, as has been reiterated numerous times in Coding Clinic for ICD-9-CM and the ICD-9-CM Official Guidelines for Coding and Reporting, determination of the patient's diagnoses is the responsibility of the patient's physician. Therefore, coders should not be using the length of time the patient has had kidney disease as the determining factor for whether or not to assign a code for chronic kidney disease.

We are also concerned that physicians may not document the stage of the chronic kidney disease, or they may apply a different definition than the ones stated under the proposed codes. Typically, criteria defining a clinical condition are considered outside the scope of ICD-9-CM. Therefore, it does not seem appropriate to include the definition of each stage under the codes. Also, inclusion of these definitions may mislead coders into thinking they can determine the stage of chronic kidney damage based on laboratory values, without specific physician documentation.

We do not believe it is appropriate to limit the use of the proposed code for end stage renal disease to those stage V patients who are on dialysis. A diagnosis should not be linked to the performance of a procedure. There may be valid reasons why an end stage renal disease patient is not on dialysis. For example, the patient may have refused dialysis.

On a related issue, I noticed that although the Index directs you to code 593.9 for "disease, renal, chronic," there is an Excludes note under code 593.9 for "renal disease, chronic" that directs you to the code range 582.0-582.9. This is the code category for chronic glomerulonephritis.

Mechanical Complication of Ventilator
AHIMA does not agree with the proposed location of a new code for mechanical complication of a ventilator. Mechanical failure of a ventilator should not be classified to category 997. This category is for complications of body systems, not device failure. Placing the new code in this category indicates that the ventilator failure has caused the patient to develop a respiratory complication, which is not the case.

A new code for mechanical failure of a respiratory failure should be created in subcategory V46.1, which is where the code for "encounter for respirator dependence during power failure" is located. Alternatively, the title of code V46.12 could be expanded to cover both power and mechanical failure.


We do not support the proposed new Index entries for Sepsis. Since sepsis is defined as a systemic infection with SIRS, and therefore it is not possible to have sepsis without an infectious process, it is confusing to have Index entries for sepsis due to noninfectious process or trauma. Whenever the term "sepsis" is used, we recommend that only codes 995.91 and 995.92 can be assigned - not codes 995.93 or 995.94.

Under categories 402 and 404, it is not necessary to include code 428.9 in the range of codes for specifying the type of heart failure. Since code 428.9 is assigned for unspecified heart failure, this code does not add any information. The fifth digits in categories 402 and 404 already indicate the presence of heart failure.

The Includes note under "Certain Conditions Originating in the Perinatal Period" should be reworded to state "through the first 28 days after birth" (rather than "until the first 28 days after birth").

We support the other proposed addenda revisions.

Thank you for the opportunity to comment on the proposed diagnosis code revisions. If you have any questions, please feel free to contact me at (312) 233-1115 or sue.bowman@ahima.org.


Sue Bowman, RHIA, CCS
Director, Coding Policy and Compliance