Diagnosis coding confusion discussed at ICD-9-CM Coordination & Maintenance meeting

Editor’s note: This is the second article in a two-part series about topics discussed at the ICD-9-CM Coordination & Maintenance committee meeting March 9–10. Part one focused on procedure code proposals. Part two addresses potential diagnosis code revisions.

During the ICD-9-CM Coordination & Maintenance committee meeting March 9–10, a record number of diagnosis codes were addressed, including several compelling coding issues that have historically generated lively discussion among healthcare professionals and triggered confusion among coders. We’ll take a closer look at the discussions regarding coding for acute kidney diseases and related disorders, malnutrition, and infection due to central venous catheter.

Acute kidney diseases and related disorders

While the agenda for the discussion of diagnosis codes on March 10 included 22 ICD-9-CM diagnosis issues, one topic in particular kicked off significant discussion—coding for acute kidney diseases and related disorders.

The vibrant discussion surrounding coding and documentation for acute kidney disease highlighted the fact that coders and other healthcare professionals still struggle with various clinical definitions. Click here to access detailed agenda notes regarding this topic.

“I think it’s important to be able to distinguish levels of severity,” says Nelly Leon-Chisen, RHIA, director of coding and classification at the American Hospital Association (AHA) in Chicago.

How do you distinguish different levels?

“We’re interested that physicians are trying to come to a consensus,” says Leon-Chisen, who was present at the meeting, during which several physicians presented varying views on clinical definitions for acute kidney disease. “From a coding perspective, we have to rely on physician documentation. But it sounds like even among the physician community, they’re not all on the same page in terms of how the terminology should be used.”

Acute renal failure (code 584.9) used to be an MCC. However, CMS determined that based on the data it had gathered, the information that the code conveyed did not necessarily convey the patient severity or the amount of resources used to treat the patient. This is because coders would report this same code based on the documented diagnosis of acute renal failure. However, this diagnosis may be documented for a severely dehydrated patient who may have met criteria for reporting this code as well as for another patient whose condition is much more severe and requires dialysis and a longer hospitalization.

“Based on data they had, that code in terms of resources was behaving like other conditions that were CCs,” explains Leon-Chisen, discussing the background related to this code going from an MCC to a CC. “So I think for our hospital members, this is a big financial hit.”

There are tremendous challenges in adapting ICD-9-CM to the various stages of acute kidney injury and linking it to its underlying renal pathology, which is more problematic for physicians than stating its underlying cause, says James S. Kennedy, MD, CCS, managing director of FTI Healthcare’s clinical documentation improvement (CDI) practice based in Brentwood, TN, and Atlanta, who was also present at the meeting. “New terminology, such as acute kidney disease, was interspersed with acute kidney injury and the specified pathologies associated with acute renal failure under a proposed new title for category 584, Acute Kidney Disease and Disorders and Acute Tubular-Interstitial Diseases.”

Given that the Kidney Disease Improving Global Outcomes’ impending clinical practice guidelines for AKI will not be available until summer, some in the audience were not certain that physicians will embrace the concept of “acute kidney disease” as a clinical entity.

Also, as the saying goes, old habits die hard. For physicians who have been documenting the terminology “acute renal failure” for years, it may take time to get in the habit of instead documenting “acute kidney injury” to ensure proper coding, Leon-Chisen says.

“And even if they do use the AKI terminology but they don’t use the staging terminology, that same patient will be grouped with other patients who are documented as having acute renal insufficiency,” Leon-Chisen adds. “Whereas today, AKI is coded to acute renal failure.”

The agenda notes from the meeting states:

The current codes for acute renal failure (584) are primarily based on etiology and pathology. However, as described above, that is in contrast to clinical practice and recent clinical practice guidelines, and is a source of confusion. The National Kidney Foundation has proposed revisions to the ICD-9-CM classification system that reflect the current understanding and definitions of acute kidney disease (AKD) and acute kidney injury (AKI), as extensively reviewed and summarized in the Kidney Disease International Global Outcomes (KDIGO) evidence based guidelines on acute kidney injury (AKI).

Kennedy emphasizes that written comments must be received by April 1, 2011, given that these codes will be implemented immediately afterwards and published in the proposed rule for the inpatient prospective payment system to be released later that month. (Access an official summary of comments during the meeting on the CMS website.)


Malnutrition is another area where inconsistency in both coding and documentation have persisted over the years. The American Dietetic Association and the American Society for Parenteral and Enteral Nutrition requested what they believe is a much-needed update at the September 2010 ICD-9-CM Coordination & Maintenance Committee meeting. They proposed the creation of new codes and instructional notes to address their concerns.

The agenda notes for the March meeting states:

The existing ICD-9-CM codes for malnutrition are outdated and do not reflect the current standard of care or understanding of malnutrition-disease interaction. Thus, the existing ICD-9-CM malnutrition codes are inconsistently applied by clinicians and facilities across health care settings. Inconsistency in the recognition and documentation of malnutrition in adults is of concern and can significantly impact patient health, safety, quality of life, and health care costs.

Feedback from the associations as well as other submitted comments were taken into consideration when drafting the revisions to the malnutrition classification. Click here to access details regarding tabular and index revisions for this topic.

“A major issue related to coding for malnutrition is whether the cause and effect relationship need to be stated, or is the link assumed,” says Leon-Chisen, adding that the proposed revision aims to address this conundrum.

Another long-standing complication when coding malnutrition is that there are certain descriptors that when used in the medical record, default to relatively rare conditions. And these codes yield an MCC, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding for HCPro, Inc., in Danvers, MA.

A prime example of this is when providers identify “protein” malnutrition. This defaults to ICD-9-CM code 260 (Kwashiorkor). Further identification of “protein-calorie” defaults to code 263.9 (unspecified protein-calorie malnutrition), which is a CC.

Oddly, when the severity of protein calorie malnutrition is specified as mild or moderate (codes 263.0–263.1), this condition is not a CC, McCall explains.

“This seems to foster using less specific documentation,” McCall says. “The suggested revisions will certainly assist in remedying the issues stated above and hopefully bring this condition more in line with the clinical presentation of such a disease.”

Infection due to central venous catheter

Infections due to central venous catheters can lead to longer hospitalizations and could require greater use of resources. Coders currently report ICD-9-CM code 999.31 (infection due to central venous catheter) for this condition, but this code does not distinguish between infections that are local vs. systemic. And depending on the type of infection, there are very different clinical and epidemiologic implications.

Many in the healthcare community, including the AHA, are pleased that the proposed revisions discussed at the meeting aim to make this distinction clear. Click here to access details regarding tabular and index revisions for this topic.

“Primarily because they’re going to have separate codes for when it becomes a system infection versus a localized infection, where you just have skin redness around the tube,” says Leon-Chisen, who was pleased with the proposed revision. “To ensure patient safety and quality of care, it’s very important to distinguish those situations.”

Note, however, that the agenda did not address whether the proposed codes will retain the hospital-acquired condition designation, which ICD-9-CM code 999.31 currently does, McCall notes.

The agenda notes pertaining to this item state:

The primary target of current surveillance and prevention efforts is catheter-related bloodstream infection. However, use of the same code (999.31) for local catheter infections and bloodstream infections interferes with national and regional efforts to identify patients who experience central line-associated bloodstream infections, which are a particularly important complication of healthcare.

In addition, the current ICD-9-CM tabular language does not use the currently preferred term “central line- associated bloodstream infection.” This term has a broader, more surveillance-oriented meaning than previous terms. The surveillance definition includes all BSIs that occur in patients with CVCs, when other sites of infection have been excluded. This overestimates the true incidence of catheter-related BSI, because not all BSIs originate from a catheter.

No final decisions were made during the meeting, which was the last to address potential code updates before the partial code freeze is implemented. Any changes that are finalized will take effect October 1. Send your diagnosis code comments in writing to the following address by April 1:

Donna Pickett
3311 Toledo Road
Room 2402
Hyattsville, MD 20782

Editor’s note: E-mail your questions to Managing Editor Doreen V. Bentley, CPC-A.

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