January 12, 2009

Coding Headaches — Don’t Let New Rules Give You One
By G. John Verhovshek, MA, CPC
Radiology Today
Vol. 10 No. 1 P. 10

Most payers required the use of 2009 CPT codes beginning January 1. This article contains a summary of the most significant coding changes for radiology practices in the coming year.

CPT 2009 introduced the following three new codes to report brachytherapy services:

• 77785 — Remote afterloading high dose rate radionuclide brachytherapy; 1 channel;

• 77786 — 2-12 channels; and

• 77787 — more than 12 channels.

The new codes primarily reflect the changing nomenclature of radiation oncology rather than an essential shift in coding strategy. Although the CPT descriptors now specify high dose rate instead of high intensity, codes 77785 to 77787 represent the same brachytherapy services as their predecessors, 77781 to 77784, which CPT eliminated for this year.

The American Medical Association (AMA) has reduced the available number of high–dose-rate brachytherapy codes from four to three by revising the quantity of channels that each code describes. Prior to 2009, separate codes reported one to four, five to eight, nine to 12, and more than 12 source positions or catheters. The new codes report brachytherapy using a single channel, two to 12 channels, or more than 12 channels. Once again, the term channel replaced the previous source positions or catheters without altering the procedures the codes are meant to represent.

CPT 2009 also introduced new code 78808, Injection procedure for radiopharmaceutical localization by nonimaging probe study, intravenous (eg, parathyroid adenoma), to describe minimally invasive radioguided parathyroidectomy. During this procedure, the physician inserts a gamma probe into a small incision to identify the targeted tissue, which has been injected preoperatively with technetium-99m. Previously, you would have used unlisted code 78099, Unlisted endocrine procedure, diagnostic nuclear medicine, to report this procedure.

The updated code 74270, Radiologic examination, colon; contrast (eg, barium) enema, with or without KUB, added “contrast (eg, barium)” to its descriptor for 2009. The more inclusive language allows you to report 74270 accurately for a radiologic enema exam using a contrast other than barium.

Several dozen code descriptors in radiology’s portion of CPT additionally receive grammatical updates, but these minor changes do not affect code application.

Headache Diagnoses
ICD-9 contains a greater number of potentially significant changes for radiology practice. Primary among these is the following new code set to provide more precise headache diagnoses:

• 339.0x — Cluster headaches and other trigeminal autonomic cephalgias;

• 339.1x — Tension type headache (excludes tension headache NOS and tension headache related to psychological factors, 307.81);

• 339.2x — Post-traumatic headache;

• 339.3x — Drug induced headache, not elsewhere classified;

• 339.4x — Complicated headache syndromes; and

• 339.8x — Other specified headache syndromes.

Although the specifics of headaches can be clinically revealing, the reporting of headaches in ICD-9-CM has been limited to a signs and symptoms code, 784.0 Headache, codes for migraines (346.0 to 346.9), or for a psychologically induced tension headache (307.81). The new codes will allow for more accurate reporting and better data aggregation and may also provide more convincing medical justification for high-end imaging exams such as MRI. Note that 784.0 will still be used to classify headache as a symptom and without further specification.

Migraine codes also undergo the following revision with the addition of several fourth-digit categories:

• 346.3x — Hemiplegic migraine;

• 346.4x — Menstrual migraine;

• 346.5x — Persistent migraine aura without cerebral infarction;

• 346.6x — Persistent migraine aura with cerebral infarction; and

• 346.7x — Chronic migraine without aura.

Several specific clinical manifestations of migraine (hemiplegic, with aura, menstrual, persistent with infarction, and chronic) are now classified for the first time. Hemiplegic migraine had been an inclusion term under 346.8 but now has its own code. Ophthalmoplegic migraine now reports with 346.2x instead of 346.8x.

All migraine codes now require a fifth digit to indicate the presence of status migrainosus (severe migraine of more than 72 hours duration, which may increase the risk of stroke). The coding is as follows:

• 0 — Without mention of intractable migraine without mention of status migrainosus;

• 1 — With intractable migraine, so stated, without mention of status migrainosus;

• 2 — Without mention of intractable migraine with status migrainosus; and

• 3 — With intractable migraine, so stated, with status migrainosus.

Other ICD-9 Changes
ICD-9 2009 also introduces a new fifth-digit classification for leukemia codes: 203.xx to 208.xx.

A fifth digit of 2 to indicate “in relapse” for those patients who have had a lapsed remission and currently have active disease. Leukemia patients in relapse may require interventions and treatments different from when they are first diagnosed or in remission. Prior to this change, ICD-9 did not have a suitable method to identify patients in relapse.

A fifth digit of 0 with codes 203.xx to 208.xx now identifies patients with active disease and no history of remission. A fifth digit of 1 for leukemia patients currently in remission.

Also new this year is an entire category of codes—209.xx—to describe carcinoid tumors. Previously, neuroendocrine tumors would have been classified to site using normal neoplasm codes combined, with Chapter 3 codes to identify functional activity secondarily. The new codes are as follows:

• 209.0x — Malignant carcinoid tumors of the small intestine;

• 209.1x — Malignant carcinoid tumors of the appendix, large intestine, and rectum;

• 209.2x — Malignant carcinoid tumors of other and unspecified sites;

• 209.3x — Malignant poorly differentiated neuroendocrine carcinoma;

• 209.4x — Benign carcinoid tumors of the small intestine;

• 209.5x — Benign carcinoid tumor of the appendix, large intestine, and rectum; and

• 209.6x — Benign carcinoid tumors of other and unspecified sites.

When reporting 209.xx, code any multiple endocrine neoplasia syndrome (258.01 to 258.03) first, with associated multiple endocrine neoplasia syndromes (most commonly, carcinoid syndrome, 259.2) as additional diagnoses. Continue to classify pancreatic islet cell tumors by site, using 157.4.

Another new code, 199.2, Malignant neoplasm associated with transplant organ, helps report malignancy in a transplanted organ. The code applies whether the malignancy originated in the organ prior to transplant or had its genesis after transplant. Previously, no code was available to report malignancy in a transplanted organ.

Report 199.2 secondary to the code for complication of transplanted organ, with a third code to identify the site of the malignancy.

Finally, 2009 brings a new V-code series—V89.0x—to report suspected maternal and fetal conditions not found. The set is as follows:

• V89.01 — Suspected problem with amniotic cavity and membrane not found (Suspected oligohydramnios not found) (Suspected polyhydramnios not found);

• V89.02 — Suspected placental problem not found;

• V89.03 — Suspected fetal anomaly not found;

• V89.04 — Suspected problem with fetal growth not found;

• V89.05 — Suspected cervical shortening not found; and

• V89.09 — Other suspected maternal and fetal condition not found.

For example, these codes would be used if a patient shows no problem following a specialized ultrasound prompted by abnormal screening results. The appropriate V89.0x code, rather than signs and symptoms codes, can be used as a primary diagnosis to establish medical necessity for the more extensive exam with negative results.

— G. John Verhovshek, MA, CPC, is director of clinical coding communications for the American Academy of Professional Coders, the nation’s largest education and credentialing association for medical coders.