April 16, 2013

A New Way of Thinking about the Index for ICD-10 Code Assignments

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Because there is not a simple crosswalk from ICD-9-CM to ICD-10-CM coding, coding professionals will need to change their way of thinking when looking up diagnostic terms in the I-10 index, which I discovered when trying to assign codes to the case below.

Inpatient Case Study

This 69-year-old female patient was admitted with complaints of progressive weakness and numbness in the right arm, as well as recent onset of expressive aphasia. The patient has also experienced a significant weight loss over the last six months, and is down to 90 pounds from her original weight of 140 pounds. The patient smokes two packs per day, with chronic obstructive pulmonary disease (COPD). The patient recently complained of neck pain, for which a cervical MRI was performed revealing old disc disease and moderate spondylytic changes, but nothing to explain the right-arm weakness. On admission, a non-contrast CT scan of the brain was obtained that was positive for metastatic disease.

IMPRESSION:  Metastatic disease to the brain, unknown primary; rule out lung

A CT scan of the chest was then performed showing a large right hilar mass extending into the anterior and subcarinal mediastinum completely obstructing the right middle lobe bronchus.  Enlarged pre-carinal lymph nodes were also noted on the CT scan.  A bronchoscopy was performed revealing a 75 percent occlusion of the right upper lobe; however, the washings taken from this mass were negative for malignant cells. A CT-guided needle biopsy was then performed of the right upper lobe that revealed well-differentiated adenocarcinoma. The patient refused treatment of complete brain radiation therapy with subsequent chemotherapy and was discharged to hospice.

DISCHARGE DIAGNOSES:

  • Brain metastasis from well-differentiated adenocarcinoma of the upper lobe, right lung
  • Expressive aphasia and right arm weakness
  • COPD, still smoking

Code Assignments

ICD-9-CM Diagnosis Codes

ICD-10-CM Diagnosis Codes

198.3  Secondary malignant neoplasm of brain and spinal cord

C79.31   Secondary malignant neoplasm of brain

162.3   Malignant neoplasm of upper lobe, bronchus or lung

C34.11   Malignant neoplasm, upper lobe, right bronchus or lung

784.3   Aphasia

R47.01   Aphasia

729.89  Other musculoskeletal symptoms referable to limbs, other

M62.81   Muscle weakness (generalized)

496  Chronic airway obstruction, not elsewhere classified

J44.9     COPD unspecified

305.1     Tobacco use disorder

Z72.0     Tobacco use

783.21   Abnormal loss of weight

R63.4     Abnormal weight loss

 


 

In the ICD-9-CM index, the Neoplasm Table is alphabetically indexed within the “N” section. In the ICD-10-CM index, the Neoplasm Table is situated immediately following the alphabetic index. While learning to use the ICD-10-CM, coding professionals must first locate the cancer or neoplasm type (i.e., adenoma, sarcoma) within the index before moving on to the Neoplasm Table. While the description in both I-9 and I-10 states “secondary” for metastatic, most of us have been trained to think of, or use, the term metastatic instead of secondary. The Neoplasm Table in both I-9 and I-10 uses the term “secondary” to identify a metastatic site of the malignant neoplasm.

Finding the correct code for the expressive aphasia was also a challenge.  In I-10, the term “expressive aphasia” falls under a developmental disorder category, which is not appropriate in this setting.  Code R47.01 is listed under the section of Signs and Symptoms Involving Speech.

ICD-9-CM Procedure Codes

ICD-10-PCS Codes

33.24   Closed [endoscopic] biopsy of bronchus

0BJ08ZZ Inspection, Respiratory System

33.26   Closed [percutaneous] [needle] biopsy of lung

0BBC3ZX Excision, Respiratory System

The washings that were taken during the bronchoscopy procedure do not appear to be considered a biopsy in ICD-10-PCS, as they are in ICD-9-CM.  The bronchoscopy procedure can be found under Inspection, Respiratory System in the index of ICD-10-PCS.  The characters of this code read:

  • 0 = Medical and surgical
  • B = Respiratory system
  • J = Inspection (visually and/or manually exploring a body part)
  • 0 = Tracheobronchial tree (body part)
  • 8 = Via natural or artificial opening endoscopic (approach)
  • Z = No device
  • Z = No qualifier

The needle biopsy of the lung mass includes the following characters:

  • 0 = Medical and surgical
  • B = Respiratory system
  • B = Excision (cutting out or off, without replacement, a portion of a body part)
  • C = Upper lung lobe, right (body part)
  • 3 = Percutaneous (approach)
  • Z = No device
  • X = Diagnostic (qualifier)

To ensure that the correct character is reported, watch for the use of the number 0 and the capital letter O. Obviously, using the incorrect character would change the whole intent of the code.

As you can see from the above example, the coder’s thought process for identifying the terms to begin the search for code assignment will change significantly. 

About the Author

Susan M. Howe is a senior healthcare consultant with Panacea Healthcare Solutions, Inc., St. Paul, MN.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.