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ICD-9-CM: Sequence and code your way to accurate claims

Editor’s note: This is the third part of a three-part series. This month’s article covers anemia, neoplasms, and overweight/obese conditions.

Coding conditions and symptoms such as anemia, neo- plasms, poisonings, and adverse affects using ICD-9-CM requires attention to detail and thorough documentation, says Deborah Grider, CPC, CPC-H, CPC-P, CCS-P, EMS, president of Medical Professionals, Inc., in Indianapolis. Be sure to keep official ICD-9-CM guidelines in mind when sequencing these diseases and their manifestations.

Anemia in chronic diseases

Patients with conditions such as chronic kidney disease (CKD) can suffer anemia as a result during dialysis. If you encounter this type of record and must code it, identify the type of anemia using the 285.x series of codes (revised December 1, 2005). These include

  • 285.2, -anemia in chronic illness
  • 285.21,- anemia in CKD
  • 285.22, anemia in neoplastic disease
  • 285.29, anemia of other chronic illness

    If the physician’s primary treatment is for anemia (e.g., a chemotherapy patient suffering from anemia), sequence anemia as the primary diagnosis and the malignancy as the secondary diagnosis.

    When an encounter is for management of an anemia associated with chemotherapy, immunotherapy, or radiotherapy, and the physician only treats the anemia, sequence the anemia as the primary diagnosis, followed by the appropriate neoplasm code, and then the E code (E933.1, Antineoplastic and immunosuppressive drugs).

    If an encounter is for management of dehydration due to a malignancy or the therapy, and the physician only rehydrates the patient, sequence dehydration first, followed by the malignancy diagnosis.

    Report it even if your fiscal intermediary (FI) does not pay for it, says Grider. “Many carriers won’t pay for this—they bundle the IV therapy into the chemo treatment and consider it incidental, but that’s a carrier issue, not a coding issue.”

    Don’t make the mistake of coding anemia as the primary reason for the encounter for a dialysis patient undergoing treatment. Report it as a secondary diagnosis. “Code the cause of the anemia [e.g., CKD] in the first position, and the anemia second,” Grider says. Only sequence the 285.x series first when the reason for the encounter is the anemia treatment.

    Coding example: A patient suffers from anemia in neoplastic disease due to primary carcinoma of the liver. List 285.22 first, followed by carcinoma of the liver primary site (155.2) as the secondary diagnosis.

    Overweight/obese conditions

    Code 278.0 (overweight and obesity) was recently revised to include fifth digits of specificity, and now also requires the use of a body mass index (BMI) V code, if known.

    It’s important to report this code because physicians performing procedures on morbidly obese patients often need more time and resources to complete the procedure (e.g., cholecystectomies). Also, reporting this code along with a proper BMI V code can help a claim meet national and local coverage determinations for medical necessity requirements for bariatric surgery. For example, a Medicare patient qualifies for bariatric surgery coverage if his or her BMI is 35 or over (morbid obesity). Report the V code as a secondary diagnosis.

    “Even though Medicare only looks at the first-listed diagnosis [on electronic claims], I can almost guarantee you that they will not pay the claim for bariatric surgery unless they see the BMI and the documentation,” Grider says.

    Coding example: Mr. Smith, a morbidly obese 50-year-old male with a BMI of 36.5 and obstructive sleep apena, reports for treatment. He is diagnosed with sleep apena. Code the encounter as follows:

  • 780.51 (sleep apnea)
  • 278.01 (morbid obesity)
  • V85.36 (BMI 36.0–36.9, adult)

    Note that code changes effective October 1 include new pediatric BMI V codes (V85.51–V85.54).


    Neoplasms are abnormal formations of tissue and can be benign or malignant. Some malignant neoplasms can be in situ localized, meaning that they do not invade surrounding tissues.

    When coding neoplasms, code the cancer’s origin as the primary site, and report the areas to which the cancer spreads as the secondary site. Use the index with the physician’s description of the neoplasm as the starting point (e.g., Disease, Bowen’s—see Neoplasm, skin in situ). Find it in the neoplasm table, verify it in the tabular list, and code it by anatomical site. Sometimes the pathology report does not define the type of neoplasm, and the patient must return for additional tests. If that’s the case, “Do not code a neoplasm as malignant without a definitive pathology report,” Grider says.

    Look carefully at the physician’s documentation when coding neoplasms, because certain anatomic terms can determine code assignments, such as

  • connective tissue—If the physician’s description does not include blood vessel, bursa, fascia, ligament, muscle, peripheral nerves, sympathetic and parasympathetic nerves and ganglia, synovia, tendon, use skin asthe anatomic site
  • bone—Consider carcinomas and adenocarcinomas of any type as metastatic from another site unless identified as intraosseous or odontogenic

    Neoplasm coding tips

  • Do not code neoplasms as active cancers after they have been eradicated through treatment. If the patient is no longer being treated for the neoplasm, code it as a “history of” using category V10, Personal history of malignant neoplasm.

    “A lot of medical societies recommend that you code these as active cancers for five years—some are even saying for seven years,” Grider says. But according to the official ICD-9-CM guidelines, when the patient is no longer being treated, or is simply being managed under evaluation and management guidelines, do not code it as an active cancer. “Many oncologists are still coding these as active diseases, but that’s something that [HIM professionals] have to work on diligently.”

  • If the patient receives ongoing drug therapy, and the malignancy is primary, code it as primary. For example, if a breast cancer patient takes Tamoxifen as part of ongoing therapy, and she does not have an existing neoplasm and has been cancer-free for three years, then code the malignancy as primary. If no personal history exists, but the patient has a family history of cancer, use the appropriate family history code.

    Neoplasm sequencing tips

    Keep the following in mind when sequencing neoplasms:

    1. If a patient is admitted to a hospital only for chemotherapy/immunotherapy/radiation therapy, code the treatment as primary using the V58 series. If a patient is having two types of treatment, the sequencing of codes does not matter. “[The treatments are] equal in complexity,” Grider says. Code the malignancy as secondary.

    2. If the patient is admitted to the hospital for treatment of the malignancy, and, once admitted, the physician decides to administer chemotherapy, code the chemotherapy as secondary.

    3. List the malignancy toward which the chemotherapy/other treatment is directed as the first-listed diagnosis. For example, if a breast cancer patient’s disease spreads to the gastrointestinal (GI) system and reports for treatment of the GI system, code that as the first-listed diagnosis/secondary site and the breast cancer as the primary site/secondary diagnosis. “It can get confusing, but always code where the [neoplasm] started, and also what you’re treating,” Grider says.

    4. If a patient is admitted, undergoes treatment, and experiences complications (e.g., nausea, vomiting, or dehydration) code the treatment as the principal diagnosis using V58.0, V58.11, or V58.12, and report the complication as secondary.

    5. If the reason for the admission is to determine the extent of the malignancy, list the primary malignancy or metastatic site as the principal or first-listed diagnosis—even if the physician provides chemotherapy on the same day.

    Note: Grider says some payers do not accept V codes in the mistaken belief that they represent preventive services. “That is not correct, there are many V codes that identify problems,” she says. Take proper steps to appeal these claims. Talk to your FI’s medical directors, medical societies, and state medical association and ask them to provide education.

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