New ICD-9 codes are more specific, but will they mean more rejections?

More documentation will be required

Gather up all your ICD-9 cheat sheets, check your nurses’ clipboards for notes about codes, get your new coding books, and make sure your staff know that as of this month, there are changes to a number of ICD-9 codes commonly used in home health.

"We haven’t been using codes with this specificity and it is important for home health managers to make sure staff members understand that the new codes mean more documentation and more accurate diagnosis codes," says Prinny Rose Abraham, RHIT, a coding consultant with HIQM Consulting in Minneapolis. The new codes affect all health care providers, not just home health, and their development was driven by the need for more accurate data collected from diagnosis-related groups in hospitals, she explains.

The advantage of the new codes is the more specific, more accurate description of patients and their needs, says Lynda Dilts-Benson, RN, CRRN, CCM, CRNAC, clinical consultant for Reingruber & Co., a certified public accounting and health care consulting firm based in St. Petersburg, FL. Some of the codes may help justify the use of physical or occupational therapy for patients, she adds.

Although the implementation date for the new codes was Oct. 1, there is a three-month grace period during which you can submit claims with old codes and still receive payment, points out Claudia E. Reingruber, CPA, president of Reingruber & Co. This gives home health agencies that have not made the conversion to new codes some extra time to make sure coding cheat sheets, software programs, books, and other tools are updated and accurate, she adds.

Not only have some codes been deleted and additional digits added to other codes, but code titles have been changed as well, Abraham says. For this reason, it is not enough just to list the new codes without reviewing their proper application with staff members, she adds.

The key codes that will affect home health agencies are:

• Neuropathy. This new group of codes will affect clinical scores and prospective payment system reimbursement, Dilts-Benson says. These codes replace 357.8, which was used for other inflammatory and toxic neuropathy, and require more documentation, she adds. Chronic inflammatory demyelinating polyneuritis (357.81), critical illness polyneuropathy (357.82), and other inflammatory and toxic neuropathy (357.89) will help nurses more specifically describe the patient’s condition. Remember that "other" is not the same as "unspecified," Abraham says. Unspecified neuropathy still is coded as 357.9, she adds.

• Heart failure. "We have always used 428.0 for every case of congestive heart failure in the past, but 11 new codes will force us to be more specific about the type of heart failure that is diagnosed," Abraham says.

The new codes (428.20-428.43) now distinguish between systolic and diastolic heart failure, chronic and acute, and combined systolic and diastolic. This makes it important for the person accepting the referral or the admission nurse to check with the physician for a specific diagnosis if it is not clear in the medical record, she adds.

• Late effects of cerebrovascular accident (CVA). "Home health nurses don’t generally treat patients in the acute phase of CVA, but we’ve never had a code that accurately described what we do see," Dilts-Benson says. Now there are five codes that can be used more accurately: alterations of sensations (438.6), disturbance of vision (438.7), facial weakness (438.83), ataxia (438.84), and vertigo (438.85). "These codes will further support the presence of physical therapy and occupational therapy for the patient, although they don’t add extra reimbursement," she says.

• Post-phlebitic syndrome and venous hypertension. The previous code for post-phlebitic syndrome (459.1) now is invalid, and five new codes that subdivide the diagnosis category have been added, Abraham says.

"The new codes are all five digits and range from post-phlebitic syndrome without complications to post-phlebitic syndrome with ulcer, inflammation, and other complications," she says. New codes 459.30-459.39 also describe chronic venous hypertension in more detail.

• Torus fractures. Codes 813.45 (torus fracture of radius) and 823.40-.42 (torus fracture tibia alone, fibula alone, and fibula with tibia), require the nurse or staff member who is coding the claim to be sure that the correct part of the bone is identified, Abraham says.

"This requires specific documentation from the physician," she says. "In this instance, a coding book that includes pictures that clarify the location being coded may also be helpful."

• Disruption of wound. Codes 998.31 (disruption of internal operation wound) and 998.32 (disruption of external operation wound) replace 998.3, which was disruption of operation wound. "Once again, the home health nurse needs to be very specific and document carefully the basis for the code," Abraham explains.

• Pain. The code for generalized pain, 780.9, has been deleted. "Home health nurses now need to look up pain specific to the site or condition," she points out.

As you work your way through this coding change deadline, you also can start preparing for Oct. 1, 2003, when V-codes can be used as primary diagnoses, Dilts-Benson says. "You can use V-codes on the UB-92 and 485 Plan of Care now, but after Oct. 1, 2003, they’ll also be accepted on [Outcome and Assessment Information Set] forms and for reimbursement," she says.

Don’t assume that your software vendor already has updated codes in your system, Abraham says. "Coding updates come from third-party suppliers and are not always high on a software vendor’s priority list," she says. After you’ve bugged your software vendor, be sure to check all point-of-care devices, laptop programs, lists that sit on billing department desks, cheat sheets on nurses’ clipboards, and any other place where an employee may keep reminders, she says. "Make sure the complete set of up-to-date codes and descriptions are available and understood by everyone."

Once the three-month grace period is up, be sure to check your intermediary system frequently for on-line billing, Reingruber says.

"There are some agencies that are so focused on getting current claims filed that they forget to see what is happening with denials or down-coded claims," she says. "I suggest checking daily, so you can catch problems with the new codes in a timely manner to recoup lost reimbursement and prevent denials in the future."

[For more information about home health coding, contact:

  • Prinny Rose Abraham, CPHQ, RHIT, Health Information Consultant, HIQM Consulting, 5748 Russell Ave., Minneapolis, MN 55410. Telephone: (612) 927-9813. Fax: (612) 926-0342. E-mail:
  • Claudia E. Reingruber, CPA, President, Reingruber & Co., 100 Second Ave. S., Suite 1200, St. Peters-burg, FL 33701. Telephone: (727) 821-9200. Fax: (727) 820-0033. E-mail:
  • Lynda Dilts-Benson, RN, CRRN, CCM, CRNAC, Clinical Consultant, Reingruber & Co., 100 Second Ave. S., Suite 1200, St. Petersburg, FL 33701. Telephone: (727) 821-9200. Fax: (727) 820-0033.

For a list of the new codes, deleted codes, and description changes, go to:]