1. ICD-9-CM Update
ION
SEPTEMBER, 2008

2. Disclaimer
This presentation is an abbreviated seminar for practices. Other codes may apply. Please review a complete list at
Please get a new code book each year to allow for reference.
This presentation is good for the date of the presentation only. Typos may be evidenced herein. It is not coding or legal advice.
All code changes can be found at

3. Oncology ICD-9-CM Introduction (AMA CC)
Chapter 2 of the ICD-9-CM contains the code for most benign and all malignant neoplasms. Certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters. To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. Malignant is generally the only one paid for chemo.
If malignant, any secondary (metastatic) sites should also be determined.The Neoplasm Table in the Alphabetic Index should be referenced first. If the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column is appropriate. For example, if the documentation indicates Adenoma,refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to see also neoplasm, by site, benign.
The Table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the Table that corresponds to the type listed in the record.

4. ICD-9-CM for Cancer The Neoplasm Table from AHA(Cont’d)
The tabular should then be referenced to verify that the correct code has been selected and that a more specific site code does not exist.
If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines:
1. When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated at the principal diagnosis and is followed by the appropriate code(s) for the malignancy.
2. When the admission/encounter is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by the appropriate code(s) for the malignancy.
3. When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
4. When the admission/encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy, the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.

5. Issues in ICD-9-CM History of
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code. (Effective 12/01/05)

6. ICD-9-CM Issues
Admissions/Encounters involving chemotherapy and radiation therapy
When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by chemotherapy or radiation treatment, the neoplasm code should be assigned as principal or first-listed diagnosis.
When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal or first- listed diagnosis, using codes in the series or where appropriate in the series.
If a patient admission/encounter is solely for the administration of chemotherapy or radiation therapy code V58.0, Encounter for radiation therapy, or V58.1, Encounter for chemotherapy, should be the first-listed or principal diagnosis. If a patient receives both chemotherapy and radiation therapy both codes should be listed, in either order of sequence

7. ICD-9-CM Issues Rule Out Diagnoses (“Rule Out Lung Cancer”)
Never code this as definitive, unless you have clinical evidence.
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Ill-defined conditions (codes ) contain many, but not all codes for symptoms.

8. ICD-9-CM Guidelines NCHS
Coding and sequencing of complications Coding and sequencing of complications associated with the malignancies or with the therapy:
1) Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code , Anemia in neoplastic disease) is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy. Code may also be used as a secondary code if the patient suffers from anemia and is being treated for the malignancy. ICD-9-CM Official Guidelines for Coding and Reporting Effective December 1, 2005 Page 18 of 77
2) Anemia associated with chemotherapy, immunotherapy and radiation therapy When the admission/encounter is for management of an anemia associated with chemotherapy, immunotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by code E The appropriate neoplasm code should be assigned as an additional code.
3) Management of dehydration due to the malignancy When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
4) Treatment of a complication resulting from a surgical procedure When the admission/encounter is for treatment of a complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.

9. ICD-9-CM Guidelines 12/10/05 from NCDVS
Code Sequencing
V58.0, Radiotherapy, and codes from subcategory V58.1x, Encounter for chemotherapy and immunotherapy for neoplastic conditions. These codes are to be first listed, followed by the diagnosis code when a patient’s encounter is solely to receive radiation therapy or chemotherapy for the treatment of a neoplasm. Should a patient receive both chemotherapy and radiation therapy during the same encounter code V58.0 and V58.1x may be used together on a record with either one being sequenced first.

10. V58.1x Here is the scoop from the ICD-9-CM Maintenance Committee.
V58.11 Encounter for antineoplastic chemotherapy
V58.12 Encounter for immunotherapy for neoplastic condition
“ Immunotherapy also called immune therapy and biologic therapy is a treatment that stimulates the body’s immune defense system to fight infection and disease. It is not classified as chemotherapy. Unlike traditional cytotoxic chemotherapies that attack cancer cells themselves, immunotherapy is designed to enhance the body’s defenses by mimicking the way natural substances activate the immune system.  These can stimulate the growth and activity of cancer-killing cells, e.g.interleukin used in the treatment of malignant melanoma and renal cell carcinoma.”

11. ICD-9-CM Changes What drugs are immunotherapy?
This is as follows: "The Food and Drug Administration has approved several immunotherapies for use against specific cancer, including Bacille Calmette-Guerin (BCG), interferon-alfa (IFN-alfa), interleukin-2 (IL-2), and other monoclonal antibodies."

12. V58.1x Monoclonal Antibodies in Cancer Rituxan (Rituximab)
Herceptin (Transtuzumab)
Mylotarg (Gemtuzumab ozogamicin)
Campath (Alemtuzumab)
Zevalin (Ibritumomab tiuxetan)
Bexxar (Tositumomab)
Erbitux (Cetuximab)
Avastin (Bevacizumab)
Vectibix (Panitumumab)

13. Non-Hodgkin’s Lymphoma
The main cell found in lymphoid tissue is the lymphocyte, an infection-fighting white blood cell, of which there are two main types, B lymphocytes (B cells) and T lymphocytes (T cells). B cell lymphomas account for 85% of the non-Hodgkin's lymphoma cases in the United States. There is no known cause for non-Hodgkin's lymphoma but there may be a relationship between the condition and bacterial or viral infection
Treatment generally depends on the behavior of the disease (indolent, aggressive, or very aggressive). There are thirty (30) subtypes of Non-Hodgkin's lymphoma.
Source: AHA Coding Clinic

14. Non-Hodgkin’s Lymphoma
Marginal zone lymphomas (200.3) are slow growing B cell tumors that are categorized based on whether they occur outside the lymph nodes or within the lymph node. Mucosa-associated lymphoid tissue (MALT) lymphomas for example, are extra-nodal marginal zone lymphomas that occur in the gastrointestinal tract, eyes, thyroid, salivary glands, lungs, and skin. Nodal marginal zone B cell lymphomas involve the lymph nodes but are uncommon. Splenic marginal lymphomas involve the spleen, bone marrow and blood. Treatment for marginal zone lymphomas depends on type, location and presentation.
Mantle cell lymphoma (200.4) is an aggressive Non-Hodgkin's B cell lymphoma that accounts for about 6% of all Non-Hodgkin's lymphoma cases in the United States. It is frequently diagnosed as a stage 4 disease found in the gastrointestinal tract, bone marrow, and the lymph nodes above and below the diaphragm. The chemotherapeutic approach using R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) is a common treatment. Mantle cell lymphoma is difficult to treat but combinations of chemotherapy, biological therapies and other regimens show promise in improving survival.
Source: AHA Coding Clinic
Third Quarter, 2007

15. Non-Hodgkin’s Lymphoma
Primary central nervous system (CNS) lymphoma (200.5) is found in the brain and spinal cord. A weakened immune system increases the risk for this aggressive lymphoma. It is common in patients with acquired immunodeficiency syndrome (AIDS), history of kidney transplant and other immunocompromised conditions. Tumors are usually limited to the cranial-spinal axis and to the eye without systemic involvement. Radiation therapy has been the standard treatment due to the diffuse nature of this lymphoma.
Large cell lymphomas (200.7) are the most common type of Non-Hodgkin's lymphoma. They are aggressive and occur in the lymph node and extranodal sites such as the gastrointestinal tract, testes, thyroid, skin, breast, central nervous system and bone. Large cell lymphomas comprise 20% to 25% of childhood lymphomas. High-dose chemotherapy and stem cell/bone marrow transplant have increased survival rates.
Anaplastic large T cell lymphoma (200.6) and peripheral T cell lymphoma (202.7) are common T cell lymphomas. Anaplastic large T cell lymphomas can be cutaneous or systemic. Cutaneous anaplastic large cell lymphomas appear on the skin and grow slowly. They respond well to radiation and surgery. Chemotherapy is used occasionally. Systemic anaplastic large cell lymphoma may appear throughout the body and frequently affect the skin, bone, soft tissue and lung. Although aggressive, these lymphomas respond to chemotherapy. Peripheral T cell lymphomas represent a diverse group of lymphomas that are aggressive. They often require salvage treatment and transplant, yet respond well to treatment.

16. Cancer ICD-9-CM Codes 10/1/08
199.2 Malignant neoplasm associated with transplant organ
Multiple myeloma, in relapse
Plasma cell leukemia, in relapse
Other immunoproliferative neoplasms, in relapse
Acute lymphoid leukemia, in relapse
Chronic lymphoid leukemia, in relapse
Subacute lymphoid leukemia, in relapse
Other lymphoid leukemia, in relapse
Unspecified lymphoid leukemia, in relapse
Acute myeloid leukemia, in relapse
Chronic myeloid leukemia, in relapse
Subacute myeloid leukemia, in relapse
Myeloid sarcoma, in relapse
Other myeloid leukemia, in relapse
Unspecified myeloid leukemia, in relapse
Acute monocytic leukemia, in relapse
Chronic monocytic leukemia, in relapse
Subacute monocytic leukemia, in relapse
Other monocytic leukemia, in relapse
Unspecified monocytic leukemia

17. Cancer ICD-9-CM Codes 10/1/08
Acute erythremia and erythroleukemia, in relapse
Chronic erythremia, in relapse
Megakaryocytic leukemia, in relapse
Other specified leukemia, in relapse
Acute leukemia of unspecified cell type, in relapse
Chronic leukemia of unspecified cell type, in relapse
Subacute leukemia of unspecified cell type, in relapse
Other leukemia of unspecified cell type, in relapse
Unspecified leukemia, in relapse

18. Cancer ICD-9-CM Codes 10/1/2008
Malignant carcinoid tumor of the small intestine, unspecified portion
Malignant carcinoid tumor of the duodenum
Malignant carcinoid tumor of the jejunum
Malignant carcinoid tumor of the ileum
Malignant carcinoid tumor of the large intestine, unspecified portion
Malignant carcinoid tumor of the appendix
Malignant carcinoid tumor of the cecum
Malignant carcinoid tumor of the ascending colon
Malignant carcinoid tumor of the transverse colon
Malignant carcinoid tumor of the descending colon
Malignant carcinoid tumor of the sigmoid colon
Malignant carcinoid tumor of the rectum
Malignant carcinoid tumor of unknown primary site
Malignant carcinoid tumor of the bronchus and lung
Malignant carcinoid tumor of the thymus
Malignant carcinoid tumor of the stomach
Malignant carcinoid tumor of the kidney
Malignant carcinoid tumor of foregut, not otherwise specified
Malignant carcinoid tumor of midgut, not otherwise specified
Malignant carcinoid tumor of hindgut, not otherwise specified
Malignant carcinoid tumor of other sites

19. New Cancer ICD-9 Codes 10/1/2008
Malignant poorly differentiated neuroendocrine carcinoma, any site
Post-transplant lymphoproliferative disorder (PTLD)
Heparin-induced thrombocytopenia (HIT)
Extravasation of vesicant chemotherapy
Extravasation of other vesicant agent
Other infusion reaction
Other transfusion reaction
V07.51 Prophylactic use of selective estrogen receptor modulators (SERMs)
V07.52 Prophylactic use of aromatase inhibitors
V07.59 Prophylactic use of other agents affecting estrogen receptors and estrogen levels
V13.51 Personal history of pathologic fracture
V87.41 Personal history of antineoplastic chemotherapy
V87.42 Personal history of monoclonal drug therapy
V87.49 Personal history of other drug therapy
And, there may be more…

20. Other ICD-9-CM Changes Secondary Diabetes Mellitus (249.xx)
New types of headaches (339.xx)
A gaggle of new PAP and anal smear codes (795.xx-796.xx)
V87.xx for exposure to toxic (and potentially carcinogenic) substances

21. Funniest 2009 ICD-9-CM Codes
Primary Thunderclap Headache
Headache Associated With Sexual Activity
Primary Stabbing Headache
Pingueculitis
Ptosis of Breast
Satisfactory Anal Smear, But Lacking Transformation Zone

22. Changed Codes of Note
Multiple myeloma, without mention of having achieved remission
Plasma cell leukemia, without mention of having achieved remission
Other immunoproliferative neoplasms, without mention of having achieved
remission
Acute lymphoid leukemia, without mention of having achieved remission
Chronic lymphoid leukemia, without mention of having achieved remission
Subacute lymphoid leukemia, without mention of having achieved remission
Other lymphoid leukemia, without mention of having achieved remission
Unspecified lymphoid leukemia, without mention of having achieved remission
Acute myeloid leukemia, without mention of having achieved remission
Chronic myeloid leukemia, without mention of having achieved remission
Subacute myeloid leukemia, without mention of having achieved remission
Myeloid sarcoma, without mention of having achieved remission
Other myeloid leukemia, without mention of having achieved remission
Unspecified myeloid leukemia, without mention of having achieved remission

23. Changed Codes of Note (2009)
Acute monocytic leukemia, without mention of having achieved remission
Chronic monocytic leukemia, without mention of having achieved remission
Subacute monocytic leukemia, without mention of having achieved remission
Other monocytic leukemia, without mention of having achieved remission
Unspecified monocytic leukemia, without mention of having achieved remission
Acute erythremia and erythroleukemia, without mention of having achieved
remission
Chronic erythremia, without mention of having achieved remission
Megakaryocytic leukemia, without mention of having achieved remission
Other specified leukemia, without mention of having achieved remission
Other specified leukemia, without mention of having achieved remission \
Acute leukemia of unspecified cell type, without mention of having achieved remission
Chronic leukemia of unspecified cell type, without mention of having achieved remission
Subacute leukemia of unspecified cell type, without mention of having achieved remission
Other leukemia of unspecified cell type, without mention of having achieved remission
Unspecified leukemia, without mention of having achieved remission
V45.71 Acquired absence of breast and nipple

24. ICD-10-CM
The Department of Health and Human Services (HHS) announced a long-awaited proposed regulation that would replace the ICD-9-CM code sets now used to report health care diagnoses and procedures with greatly expanded ICD-10 code sets, effective October 1, In a separate proposed regulation, HHS has proposed adopting the updated X12 standard, Version 5010, and the National Council for Prescription Drug Programs standard, Version D.0, for electronic transactions, such as health care claims. Version 5010 is essential to use of the ICD-10 codes.
In 2000, under authority provided by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the ICD-9-CM code sets were adopted for use in the administrative transactions by both the public and private sectors to report diagnoses and inpatient hospital procedures. Covered entities required to use the ICD-9-CM code sets include health plans, health care clearinghouses, and health care providers who transmit any electronic health information in connection with a transaction for which a standard has been adopted by HHS.

25. Overview of ICD-10
International Classification of Diseases and Related Health Problems, the 10th Edition
Maintained by the World Health Organization
Classifies the causes of disease morbidity and mortality
Contains diseases, symptoms, etiologies, and injuries
Official Site:

26. History of ICD Origin (1893) WHO (1946) Revised every 10 years
International List of Causes of Death
International Statistical Institute (ISI)
WHO (1946)
Morbidity and mortality
Revised every 10 years
ICD-10 (1994)

27. ICD Revisions Mortality ISI WHO Mortality Morbidity Revision
Implementation in US
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
1999-present
Mortality
ISI
WHO
Mortality
Morbidity

28. Purpose of ICD-10
WHO:
Statistically oriented classification system for health census and statistics
To permit the systematic analysis, interpretation and comparison of mortality and morbidity data collected in different countries or areas, at different times

29. Updates of ICD-10 Must through a local Collaborating Centre Updates:
E.g, US: National Center for Health Statistics (NCHS)
Submit to WHO 3 to 6 months before Heads of Centres annual meeting
Present in Heads of Centres meeting in October
Updates:
Publish no later than 15 months after each Centre Heads meeting
Latest update available: 1999 (

30. Content of ICD-10 Volume 1: Volume 2: Volume 3: Tabular List
Cause-of-death titles and codes
Classification at 3- and 4-character levels
Volume 2:
Instruction Manual
Description, guidelines, and coding rules
Volume 3:
Alphabetical Index to diseases and nature of injury, external causes of injury
Table of drugs and chemicals

31. ICD-10: The Code Core code: Extended code:
3 character (1 letter + 2 digits)
A00
Up to 2,600 categories
Mandatory for reporting at the international level
Extended code:
the 4th digit following a decimal point
A00.0
Up to 26,000 categories
Recommended not required by WHO

32. ICD-10: The Classification
Two types of classification:
Main classification
diagnoses and health status
E11 = Non-insulin dependent diabetes mellitus
Supplementary classification
generally outside the formal diagnoses but related to health care
Z83.3 = Family history of diabetes mellitus

33. ICD-10 Hierarchy for Classification
9,275 codes used in US
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10/
3 level hierarchy
Level 1: the 21 chapters
21 categories
Level 2: the 1st – 3rd characters (A00)
1643 categories
Level 3: the 1st – 4th characters (A00.0)
7611 categories
Site for browsing the hierarchy and searching diseases:

34. Most Important Coding Rules of ICD-10
1— Highest Level of Specificity
2— Daggers (†) and asterisks (*) are coded
together, daggers first
3— Principal disease: one disease of major
medical cost

35. 1. Highest Level of Specificity
As specific as possible
Patient:
Type 2 diabetes mellitus with renal complications
Code:
E11.2 = Type 2 diabetes mellitus with renal complications
Not E11 = Type 2 diabetes mellitus

36. 2. Dagger and Asterisk For a disease encoded by two codes Example:
Dagger represents etiological aspects.
Asterisk refers to anatomical location
Example:
For Renal tuberculosis:
A18.1† urogenital tuberculosis
N29.1* infectious disease of kidney and
ureter classified elsewhere
. .

37. Differences between ICD-9 & ICD-10 : Breast Cancer (Partial List)
174 malig neo female breast
1740 malig neo nipple
1741 mal neo breast-central
1742 mal neo breast up-inner
1743 mal neo breast low-inner
1744 mal neo breast up-outer
1745 mal neo breast low-outer
1746 mal neo breast-axillary
1748 malign neopl breast nec
1749 malign neopl breast nos
175 malig neo male breast
1750 mal neo male nipple
1759 mal neo male breast nec
C Malignant neoplasm of nipple and areola, right female breast
C Malignant neoplasm of nipple and areola, left female breast
C Malignant neoplasm of nipple and areola, unspecified female breast
C Malignant neoplasm of nipple and areola, right male breast
C Malignant neoplasm of nipple and areola, left male breast
C Malignant neoplasm of nipple and areola, unspecified male breast
C Malignant neoplasm of central portion of right female breast
C Malignant neoplasm of central portion of left female breast
C Malignant neoplasm of central portion of unspecified female breast
C Malignant neoplasm of central portion of right male breast
C Malignant neoplasm of central portion of left male breast
C Malignant neoplasm of central portion of unspecified male breast
C Malignant neoplasm of upper-inner quadrant of right female breast
C Malignant neoplasm of upper-inner quadrant of left female breast
C Malignant neoplasm of upper-inner quadrant of unspecified female breast
C Malignant neoplasm of upper-inner quadrant of right male breast
C Malignant neoplasm of upper-inner quadrant of left male breast
C Malignant neoplasm of upper-inner quadrant of unspecified male breast
C Malignant neoplasm of lower-inner quadrant of right female breast
C Malignant neoplasm of lower-inner quadrant of left female breast
C Malignant neoplasm of lower-inner quadrant of unspecified female breast
C Malignant neoplasm of lower-inner quadrant of right male breast
C Malignant neoplasm of lower-inner quadrant of left male breast
C Malignant neoplasm of lower-inner quadrant of unspecified male breast
C Malignant neoplasm of upper-outer quadrant of right female breast
C Malignant neoplasm of upper-outer quadrant of left female breast
C Malignant neoplasm of upper-outer quadrant of unspecified female breast
C Malignant neoplasm of upper-outer quadrant of right male breast
C Malignant neoplasm of upper-outer quadrant of left male breast
C Malignant neoplasm of upper-outer quadrant of unspecified male breast
C Malignant neoplasm of lower-outer quadrant of right female breast
C Malignant neoplasm of lower-outer quadrant of left female breast

38. References World Health Organization (WHO) http://www.who.int
WHO statistical information
Centers for Disease Control (CDC) National Center for Health Statistics (NCHS)
CMS is the Centers for Medicare and Medicaid Services (one of the largest payors in the US)

39. Get Ready for October 1
Check codes against the full list of codes that you use and make sure that nurses and doctors are updated on the coding possibilities.
Spot check your PM system to make sure additions and changes are in your billing and EMR systems.
Update Superbill or EMR Problem List as necessary.
Educate billers and coders.