Audio Seminar/Webinar April 2, 2009 Practical Tools for Seminar Learning Copyright 2009 American Health Information Management Association. All rights reserved.
Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. CPT five digit codes, nomenclature, and other data are copyright 2009 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. As a provider of continuing education the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: (1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; (2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and (3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. The faculty has reported no vested interests or disclosures regarding this presentation. AHIMA 2009 Audio Seminar Series http://campus.ahima.org/audio American Health Information Management Association 233 N. Michigan Ave., 21 st Floor, Chicago, Illinois i
Faculty Robert S. Gold, MD Dr. Gold is founder and CEO of DCBA, Inc., a consulting firm that provides physician-to-physician clinical documentation improvement programs (CDIP), as well as audit and education services to healthcare organizations. Dr. Gold has over 42 years of experience as a physician, medical director, and consultant. He is also a frequent speaker on clinical data quality, coding, and compliance issues for AHIMA and other organizations. AHIMA 2009 Audio Seminar Series ii
Table of Contents Disclaimer... i Faculty... ii Objectives... 1 Agenda... 1 Concepts and Definitions Clinically Speaking Conundrum: Myel/Myelo-... 2 Blood Cell Lines... 2 Peripheral Blood and Bone Marrow Diagram... 3 Peripheral Blood and Bone Marrow... 3 Get to Know Your Blood Cells... 4 Hematology Tests: Reference Value Examples... 4 Get to Know Your Blood Cells... 5 WBC Differentials and Shifts... 5 Red Cells Common Anemia Codes... 6 Subcategory 285.2x, Anemia in Chronic Illnesses... 6 Anemia Designations... 7 Coding Clinic References... 7 Myelodysplastic Conditions Myeloproliferative Disorders... 8 Coding Perspective and DRG Assignment... 8-9 Blood Cell Lines... 9-10 Coding Perspective and DRG Assignment... 10-11 White Cells Blood Cell Lines... 11 Rationale & Clinical Insight... 12 Coding Perspective and DRG Assignment... 12 Blood Cell Lines... 13 Rationale & Clinical Insight... 13 Coding Perspective and DRG Assignment... 14 Neutropenias... 14 Blood Cell Lines... 15 Coding Perspective and DRG Assignment... 15 Leukemoid Reaction 288.62... 16 Other osis... 16 Blood Cell Lines... 17 Clinical Insight... 17 Platelets Primary Thrombocytopenia... 18 Thrombocytes (platelets)... 18 Rationale... 19 AHIMA 2009 Audio Seminar Series (CONTINUED)
Table of Contents Clinical Aspects Platelets and Platelet Deficiencies... 19 The Primary Thrombocytopenias... 20 Chapter 4 Diseases of the Blood and Blood-Forming Organs (280-289)... 21 Lymphomas Lymphoma Current Status... 22 Lymphatic Cell Lines... 22 Clinical Perspective REAL... 23 Mature B-Cell Tumors (NHL)... 23-24 Mature T-Cell and Natural Killer Cell Tumors (NHL)... 24-25 Hodgkin s Lymphoma... 25 Immunodeficiency-Associated Lymphoproliferative Disorders... 26 Histiocytic and Dendritic Cell Neoplasms (CNS)... 26 Classification by Immunologic Subtype and Aggressiveness... 27 Our Newer Subdivisions (2007)... 27 Leukemias Leukemias (204 208 series)... 28 Maturation in the Bone Marrow... 28 Leukemias... 29 Other Hematologic Conditions Code series 289.8x... 29 Hypercoagulable States... 30 Coding Primary Hypercoagulable State (289.81)... 30 Coding Secondary Hypercoagulable State (289.82)... 31 Coding HIT Heparin-Induced Thrombocytopenia (289.84)... 31 Coding Clinic Reference... 32 Bone Marrow Procedures Procedure Issues in Hematology... 32 CPT Assistant Reference... 33 Bone Marrow Aspiration (38220)... 33 Procedure : Bone Marrow Aspiration... 34 Bone Marrow Biopsy (38221)... 34 Procedure : Bone Marrow Biopsy... 35 Bone Marrow Aspiration (38220) vs. Biopsy (38221)... 35 Resource/Reference List... 36 Audio Seminar Discussion... 36 Become an AHIMA Member Today!... 37 Audio Seminar Information Online... 37 Upcoming Audio Seminars... 38 Thank You/Evaluation Form and CE Certificate (Web Address)... 38 Appendix... 39 Resource/Reference List... 40 CE Certificate Instructions AHIMA 2009 Audio Seminar Series
Objectives Identify various hematological disorders and applicable ICD-9-CM diagnostic codes Review relevant AHA Coding Clinic references and clinical documentation practices to support accurate hematology coding Review bone marrow procedures and related code assignments 1 Agenda Overview of blood cell lines Anemia Myelodysplastic disease Neutropenia Leukemoid reaction Thrombocytopenia Hematologic neoplasms Hypercoagulable states 2 AHIMA 2009 Audio Seminar Series 1
Myel, as in myelitis or myelopathy, refers to the spinal cord myelitis is inflammation of the spinal cord myelopathy is disease of the spinal cord Clinically Speaking... Conundrum: Myel/Myelo- Myel/Myelo- Myel/Myelo- Myel, as in myelodysplasia or myelofibrosis, refers to the bone marrow myelofibrosis is fibrosis of the bone marrow myelodysplasia exists when the bone marrow does not produce enough mature blood cells 3 Blood Cell Lines 238.71 Essential thrombocythemia 238.72 Low grade myelodysplastic syndrome lesions 238.73 High grade myelodysplastic syndrome lesions 238.74 Myelodysplastic syndrome with 5q deletion 238.75 Myelodysplastic syndrome, unspecified 238.76 Myelofibrosis with myeloid metaplasia 238.79 Other lymphatic and hematopoietic tissues 4 AHIMA 2009 Audio Seminar Series 2
Peripheral Blood and Bone Marrow 5 Peripheral Blood and Bone Marrow Suffixes: -osis too many of (thrombocytosis too many platelets, erythrocytosis too many red cells) -emia in the blood (thrombocythemia too many platelets in the peripheral blood; anemia not enough blood) -ia excess of (basophilia too many basophils) -penia too few of (leukopenia too few white cells, thrombocytopenia too few platelets) -plasia production of (aplasia no production of) 6 AHIMA 2009 Audio Seminar Series 3
Get to Know Your Blood Cells Granulocytes Platelets among erythrocytes Segmented neutrophil Eosinophil Basophil Lymphocyte Monocyte Mononuclear white cells 7 Hematology Tests: Reference Value Examples Cell Type Too Few Range Too Many Red Cells Anemia Hb 13(12) - 18(16) Erythrocytosis Platelets Thrombocytopenia 150,000-400,000 Thrombocytosis All White Cells Leukocytopenia Granulocytes Granulocytopenia Polymorphonuclears (PMNs) 4,300-10,800 Leukocytosis Granulocytosis -Neutrophils Neutropenia 50% - 70% Neutrophilia - Eosinophils Eosinopenia 1% - 3% Eosinophilia -Basophils Basophilopenia 0.4% - 1% Basophilia Agranulocytes Mononuclears Agranulocytopenia Agranulocytosis -Lymphocytes Lymphocytopenia 25% - 35% Lymphocytosis - Monocytes Monocytopenia 4% - 6% Monocytosis 8 AHIMA 2009 Audio Seminar Series 4
Get to Know Your Blood Cells Mononuclears Lymphocyte Polymorphonuclear leukocytes 9 WBC Differentials and Shifts "Normal" Differential Mets Bands SegmentedNeutrophils / PolymorphonuclearLeukocytes Lymphocytes Monocytes Eos Baso 0% 0-5% 60-75% 20-35% 0-10% 0-5% 0-3% Left Shift Mets Bands Segmented Neutrophils/Polymorphonuclear Leukocytes Lymphocytes MonosEos Bas Right Shift MetsBands Segmented Neutrophils / Polymorphonuclear Leukocytes Lymphocytes Monocytes Eos Baso 10 AHIMA 2009 Audio Seminar Series 5
Common Anemia Codes 285.1 anemia due to acute blood loss FROM name it 280.0 anemia due to chronic blood loss FROM name it 285.21 anemia in chronic kidney disease effect of chronic kidney disease 285.22 anemia in neoplastic disease effect of the tumor 285.29 anemia in chronic illness and name that illness (chronic hepatitis, lupus, osteomyelitis, etc.) 11 Subcategory 285.2x, Anemia in Chronic Illnesses These codes can be used as the principal/first listed code if the reason for the encounter is to treat the anemia. They may also be used as secondary codes if treatment of the anemia is a component of an encounter, but not the primary reason for the encounter. When using a code from subcategory 285.2x, it is also necessary to use the code for the chronic condition causing the anemia. 12 AHIMA 2009 Audio Seminar Series 6
Anemia Designations 284.89 Acquired (secondary) aplastic anemia. Includes that due to antineoplastic chemotherapy. 285.0 Refractory (primary) anemia due to drug, toxin or hereditary. Also includes congenital, drug-induced, hereditary, sex-linked hypochromic and vitamin B 6 - responsive refractory sideroblastic anemia. 238.72 Idiopathic refractory (primary) anemia or that due to myelodysplastic syndrome. 13 Coding Clinic References Anemia of chronic disease CC 4 th Qtr 2008, volume 25, number 4, pages 195-201 CC 4 th Qtr 2000, pgs 39-40 Diseases associated with anemia in chronic illness if you don t know the chronic disease and it s not linked to the anemia, 285.29 is not the code! Anemia due to chemotherapy CC 2 nd Qtr 2008, pg 6 (284.89 + E933.1) 14 AHIMA 2009 Audio Seminar Series 7
Myeloproliferative Disorders Conditions resulting from variations in the bone marrow s ability to proliferate (produce by reproduction) cell lines Acute disorders may be result of stimulants or poisonings Chronic disorders may be late effects of above or primary bone marrow disorders May be too many or too few in peripheral blood Essential thrombocythemia bone marrow produces too many megakaryocytes release too many platelets spontaneous coagulation, blood clots, embolism Myelodysplastic syndromes of other cell lines neoplasms with excessive production of blasts and release of few mature forms into peripheral blood Too few red cells, inadequate oxygenation and organ failures Too few white cells, subject to overwhelming infection 15 Coding Perspective and DRG Assignment Alpha: Syndrome, myelodysplastic; Thrombocytopenia Tabular: Chapter 2, Neoplasms (140-239) IPPS MDC: MDC 16, Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders MDC 17, Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms As PrDx: For 238.71-238.75 DRG 811 Red blood cell disorders w MCC DRG 812 Red blood cell disorders w/o MCC 16 AHIMA 2009 Audio Seminar Series 8
Coding Perspective and DRG Assignment (cont d) As PrDx: For 238.76-238.79 DRG 823 Lymphoma & non-acute leukemia w other O.R. proc w MCC DRG 824 Lymphoma & non-acute leukemia w other O.R. proc w CC DRG 825 Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC DRG 840 Lymphoma & non-acute leukemia w MCC DRG 841 Lymphoma & non-acute leukemia w CC DRG 842 Lymphoma & non-acute leukemia w/o CC/MCC DRG 820 Lymphoma & leukemia w major O.R. procedure w MCC DRG 821 Lymphoma & leukemia w major O.R. procedure w CC DRG 822 Lymphoma & leukemia w major O.R. procedure w/o CC/MCC 17 Blood Cell Lines 284.01 Constitutional red blood cell aplasia limitation of production of red cell line only due to in utero infection by Parvovirus or other viral infection 284.09 Other constitutional aplastic anemia reduction in all three cell lines hereditary disorder (Fanconi s anemia) 18 AHIMA 2009 Audio Seminar Series 9
Blood Cell Lines 284.1 Pancytopenia A lab finding code showing that all three cell lines are deficient justifies studies need conclusions as to etiology. Aplastic anemia's result in pancytopenia. 284.2 Myelophthisis Invasion of bone marrow with cells or bacteria or fungi that replace and crowd out the cells that make blood or support the cells that make blood, leading to deficiency in all cell lines. 19 Coding Perspective and DRG Assignment Alpha: Syndrome, Blackfan-Diamond; Anemia, Fanconi s; Pancytopenia, Myelophthisis Tabular: Chapter 4, Diseases of the Blood and Blood-Forming Organs (280-289) IPPS MDC: MDC 16, Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders MDC 17, Myeloproliferative Diseases and Disorders and Poorly Differentiated Neoplasms As PrDx: For 284.01-284.09 DRG 811 Red blood cell disorders w MCC DRG 812 Red blood cell disorders w/o MCC 20 AHIMA 2009 Audio Seminar Series 10
Coding Perspective and DRG Assignment (cont d) As PrDx: For 284.1-284.2 DRG 823 Lymphoma & non-acute leukemia w other O.R. proc w MCC DRG 824 Lymphoma & non-acute leukemia w other O.R. proc w CC DRG 825 Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC DRG 840 Lymphoma & non-acute leukemia w MCC DRG 841 Lymphoma & non-acute leukemia w CC DRG 842 Lymphoma & non-acute leukemia w/o CC/MCC DRG 820 Lymphoma & leukemia w major O.R. procedure w MCC DRG 821 Lymphoma & leukemia w major O.R. procedure w CC DRG 822 Lymphoma & leukemia w major O.R. procedure w/o CC/MCC 21 Blood Cell Lines 288.0 Neutropenia, unspecified 288.00 Neutropenia, unspecified 288.01 Congenital neutropenia 288.02 Cyclic neutropenia 288.03 Drug induced neutropenia 288.04 Neutropenia due to infection 288.09 Other neutropenia 22 AHIMA 2009 Audio Seminar Series 11
Rationale & Clinical Insight The understanding of hematological disorders has grown over the years. Not feasible to reclassify all of these conditions; decision to provide specific codes. It will be useful for better comparison to differentiate the various disorders and to consistently classify them between ICD-9-CM and ICD-10-CM. Neutropenia is a hematological disorder characterized by an abnormally low number of neutrophil granulocytes (a type of white blood cells). Neutrophils make up 50-70% of all circulating white blood cells. Neutrophils serve as the primary defense against infections by destroying bacteria in the blood. 23 Coding Perspective and DRG Assignment Alpha: Neutropenia Tabular: Chapter 4, Diseases of the Blood and Blood- Forming Organs (280-289) IPPS MDC: MDC 16, Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders MDC 25, Human Immunodeficiency Virus Infections As PrDx: DRG 814 Reticuloendothelial and immunity disorders w MCC DRG 815 Reticuloendothelial and immunity disorders w CC DRG 816 Reticuloendothelial & immunity disorders w/o CC/MCC DRG 977 HIV w or w/o other related condition 24 AHIMA 2009 Audio Seminar Series 12
Blood Cell Lines 288.4 Hemophagocytic syndromes destruction of all three cell lines but not from lack of precursor cells from destruction of maturing cells in bone marrow or in peripheral blood 288.50 Leukocytopenia, unspecified all white cell lines deficient 288.51 Lymphocytopenia lymphocyte deficiency only 288.59 Other decreased white blood cell count 25 Rationale & Clinical Insight New code for macrophage disorders 288.4 was created due to the rare nature of these disorders. Allow better statistical capture of this condition. Macrophage disorders have an excessive and abnormal activation of macrophages, which are mature forms of the monocytes of the blood and blood marrow. These macrophages destroy blood cells, cause liver damage and promote bleeding problems. 26 AHIMA 2009 Audio Seminar Series 13
Coding Perspective and DRG Assignment Alpha: Syndrome, hemophagocytic; Hemophagocytic syndrome Tabular: Chapter 4, Diseases of the Blood and Blood- Forming Organs (280-289) IPPS MDC: MDC 16, Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders As PrDx: DRG 814 Reticuloendothelial and immunity disorders w MCC DRG 815 Reticuloendothelial and immunity disorders w CC DRG 816 Reticuloendothelial & immunity disorders w/o CC/MCC 27 Neutropenias Terminology is important Neutropenia only neutrophils are deficient (see leukocytopenia later, 288.50) Agranulocytosis (granulocytopenia) implies deficiency of neutrophils, eosinophils and basophils but functionally only impacts neutrophils 288.0x series Granulocytosis is excessive granulocytes (see later, 288.6x) 28 AHIMA 2009 Audio Seminar Series 14
Blood Cell Lines 288.60 Leukocytosis, unspecified 288.61 Lymphocytosis (symptomatic) 288.62 Leukemoid reaction 288.63 Monocytosis (symptomatic) 288.64 Plasmacytosis 288.65 Basophilia 288.69 Other elevated white blood cell count 29 Coding Perspective and DRG Assignment Alpha: Leukocytosis; Lymphocytosis; Monocytosis; Plasmacytosis; Basophilia Tabular: Chapter 4, Diseases of the Blood and Blood- Forming Organs (280-289) IPPS MDC: MDC 16, Diseases and Disorders of the Blood and Blood-Forming Organs and Immunological Disorders As PrDx: DRG 814 Reticuloendothelial and immunity disorders with MCC DRG 815 Reticuloendothelial and immunity disorders with CC DRG 816 Reticuloendothelial & immunity disorders w/o CC/MCC 30 AHIMA 2009 Audio Seminar Series 15
Leukemoid Reaction 288.62 Excessive production or release of white cells in response to infection Number over 50,000 (normal 5,000 10,000) Must rule out leukemia's We are used to seeing WBC increases in response to steroids and assigning 288.8 and E932.0 NOT a leukemoid reaction 31 Other -osis Leukocytosis abundance of white cells does not specify which line Present in bacterial infections Must rule out myelogenous leukemia Monocytosis abundance of monocytes Seen in mononucleosis Must rule out monocytic leukemia Plasmacytosis abundance of plasma cells Must rule out plasmacytoma (multiple myeloma) 32 AHIMA 2009 Audio Seminar Series 16
Blood Cell Lines 289.53 Neutropenic splenomegaly 289.83 Myelofibrosis 33 Clinical Insight Neutropenic splenomegaly a group of conditions in which it is believed that the spleen traps neutrophils through some mechanism and causes a decrease in peripheral circulating neutrophils; synonyms: Splenic neutropenia Doan-Wiseman syndrome 1938, Doan and Wiseman described a condition in which neutropenia was helped by splenectomy. Myelofibrosis primary form is unknown scarring of bone marrow, leading to decrease in all cell lines (another aplastic anemia results) 34 AHIMA 2009 Audio Seminar Series 17
Primary Thrombocytopenia 287.30 Primary thrombocytopenia, unspecified 287.31 Immune thrombocytopenic purpura 287.32 Evan s syndrome 287.33 Congenital and hereditary thrombocytopenic purpura 287.39 Other primary thrombocytopenia 35 Thrombocytes (platelets) 36 AHIMA 2009 Audio Seminar Series 18
Rationale 287.3 has included non-essential modifiers for a variety of thrombocytopenic conditions, excluding thrombotic thrombocytopenic purpura 446.6 and transient thrombocytopenic purpura of the newborn 776.1. All are primary (not caused by another process) but have different primary etiologies. This breakdown permits better designation of the type of the primary etiologies. 37 Clinical Aspects Platelets and Platelet Deficiencies Platelets (or thrombocytes) are very small cellular components of blood that help the clotting process by sticking to the lining of blood vessels. Platelets are made in the bone marrow and survive in the circulatory system for an average of 9-10 days before being removed from the body by the spleen. Platelets are vital to life, because they help prevent massive blood loss resulting from trauma, as well as blood vessel leakage that would otherwise occur in the course of normal, day-to-day activity. Normal counts are about 150,000 to 350,000. With counts under 50,000, a patient is prone to have spontaneous bleeding. 38 AHIMA 2009 Audio Seminar Series 19
The Primary Thrombocytopenias The immune thrombocytopenic purpura idiopathic thrombocytopenic purpura (ITP). Occurs in children after a viral infection and is often selflimited. In adults, lasts longer, again often following a viral infection or taking some medications or during a pregnancy. May involve the body s immune system developing a tendency to destroy the body s own platelets. Evans Syndrome is a combination of ITP and autoimmune hemolytic anemia (AIHA). May be associated with neutropenia in 15% of patients. Cause is unknown. Can have transient course or be recurrent and even fatal. 39 The Primary Thrombocytopenias Congenital and hereditary thrombocytopenia (its title should be that way, not purpura) is a hereditary condition of decreased production of platelets, not of immune origin as is ITP. Where ITP responds to certain immunologic drugs, as steroids or immune globulins, congenital thrombocytopenia does not. It s fortunately a rare variety of primary thrombocytopenia. Normal platelet count Thrombocythemia (-osis) 40 AHIMA 2009 Audio Seminar Series 20
Chapter 4 DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (280-289) 287 Purpura and other hemorrhagic conditions Excludes: hemorrhagic thrombocythemia (238.7) 287.3 Primary thrombocytopenia Evans' syndrome Megakaryocytic hypoplasia Purpura, thrombocytopenic Congenital Hereditary Idiopathic 41 Chapter 4 DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (280-289) (cont d) Thrombocytopenia: Congenital Hereditary Primary Tidal platelet dysgenesis Excludes: Thrombotic thrombocytopenic purpura (446.6) Transient thrombocytopenia of newborn (776.1) 42 AHIMA 2009 Audio Seminar Series 21
Lymphoma Current Status Lymphomas have been named by their discoverer or by some oddity of their activity, related to other diseases or manifestations Recently divided into Hodgkins and highgrade, intermediate grade and low grade activity Non-Hodgkin s lymphoma (NHL) WHO (World Health Organization) has standardized the nomenclature proposed by the Revised European-American Lymphoma classification (REAL) 43 Lymphatic Cell Lines B-cell lymphocytes T-cell lymphocytes Natural killer cell lymphocytes And other minor groups 44 AHIMA 2009 Audio Seminar Series 22
Clinical Perspective REAL Revised European-American Lymphoma Classification First classified by cell type the cell which, if normal, most closely looks like the tumor cell B-cell tumors T-cell tumors Natural killer cell tumors And other minor groups http://dir.niehs.nih.gov/dirlep/liverpath/hyperplastic/lymph5.htm 45 Mature B-Cell Tumors (NHL) Chronic lymphocytic leukemia/small lymphocytic lymphoma B-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma/waldenström macroglobulinemia Splenic marginal zone lymphoma Plasma cell neoplasms plasma cell myeloma, plasmacytoma, monoclonal deposit disease, heavy chain diseases Extranodal marginal zone B cell lymphoma (mucosa-associated lymphoid tissue, MALT lymphoma) 46 AHIMA 2009 Audio Seminar Series 23
Mature B-Cell Tumors (NHL) (cont d) Nodal marginal zone B cell lymphoma Follicular lymphoma Mantle cell lymphoma Diffuse large B cell lymphoma Mediastinal (thymic) large B cell lymphoma Intravascular large B cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukemia Lymphomatoid granulomatosis 47 Mature T-Cell and Natural Killer Cell Tumors (NHL) T cell prolymphocytic leukemia T cell large granular lymphocytic leukemia Aggressive NK cell leukemia Adult T cell leukemia/lymphoma Extranodal NK/T cell lymphoma, nasal type Enteropathy-type T cell lymphoma Hepatosplenic T cell lymphoma Blastic NK cell lymphoma 48 AHIMA 2009 Audio Seminar Series 24
Mature T-Cell and Natural Killer Cell Tumors (NHL) (cont d) Mycosis fungoides/sezary syndrome Primary cutaneous CD30-positive T cell lymphoproliferative disorders Primary cutaneous anaplastic large cell lymphoma Lymphomatoid papulosis Angioimmunoblastic T cell lymphoma Peripheral T cell lymphoma, unspecified Anaplastic large cell lymphoma 49 Hodgkin s Lymphoma Nodular lymphocyte-predominant Hodgkin lymphoma Classical Hodgkin lymphoma Nodular sclerosis Mixed cellularity Lymphocyte-rich Lymphocyte depleted or not depleted 50 AHIMA 2009 Audio Seminar Series 25
Immunodeficiency-Associated Lymphoproliferative Disorders Associated with a primary immune disorder Associated with the Human Immunodeficiency Virus (HIV) Post-transplant Associated with Methotrexate therapy 51 Histiocytic and Dendritic Cell Neoplasms (CNS) Histiocytic sarcoma Langerhans cell histiocytosis Langerhans cell sarcoma Interdigitating dendritic cell sarcoma/tumor Follicular dendritic cell sarcoma/tumor Dendritic cell sarcoma, unspecified 52 AHIMA 2009 Audio Seminar Series 26
Classification by Immunologic Subtype and Aggressiveness B cell small lymphocytic lymphoplasmacytic follicular marginal zone, MALT marginal zone, nodal mantle cell diffuse large B cell primary mediastinal large B cell Burkitt's-like T cell peripheral T-cell anaplastic large T/null cell lymphoblastic 53 Our Newer Subdivisions (2007) 200.3x Marginal zone 200.4x Mantle zone 200.5x Primary CNS 200.6x Anaplastic large cell 200.7x Large cell lymphoma 202.70 Peripheral T-cell.x0 Unspecified site.x1 Head, face, neck nodes.x2 Intrathoracic nodes.x3 Intraabdominal nodes.x4 Nodes axilla, upper limb.x5 Inguinal, lower limb.x6 Pelvic nodes.x7 Spleen.x8 Multiple sites 54 AHIMA 2009 Audio Seminar Series 27
Leukemias (204 208 series) Acute varieties (208.0) Chronic varieties (208.1) Myelogenous all bone marrow mostly granulocytes Granulocytic neutrophilic, basophilic, eosinophilic precursors blasts Histiocytic Lymphocytic (lymphoid synonyms) Monocytic (monocytoid synonyms) Megakaryocytic (platelet precursors) Plasmacytic (plasma cell) 55 Maturation in the Bone Marrow 56 AHIMA 2009 Audio Seminar Series 28
Leukemias Chemotherapeutic regimens depend on stage Initial acute remission induction to induce remission In remission consolidation chemo In relapse (recurrence) may need reinduction to induce remission again Beware of chronic lymphoma with TRANSFORMATION! May become acute leukemia! Ask the physician! 57 Code Series 289.8x This code series has been expanded to include: 289.81 Primary hypercoagulable state 289.82 Secondary hypercoagulable state 289.84 Heparin-induced thrombocytopenia (HIT) 289.89 Other specified diseases of blood and blood-forming organs 58 AHIMA 2009 Audio Seminar Series 29
Hypercoagulable States This has become more and more identified in the last two years in patients with DVT and embolic phenomena It has led to the use of Coumadin for anticoagulation in addition to the usual DVT patient or the Atrial fibrillation or the patient with MI or occlusive stroke and the problems that arise from longterm Coumadin use 59 Coding Primary Hypercoagulable State (289.81) Conditions due to inborn errors and lack of certain chemicals that influence the prevention of clot formation under normal conditions Antithrombin deficiency Protein C deficiency Protein S deficiency Activated Protein C Resistance Dysfibrinogenemias Inherited abnormalities of fibrinolysis 60 AHIMA 2009 Audio Seminar Series 30
Coding Secondary Hypercoagulable State (289.82) Derived conditions leading to tendency to make clots at undesirable times Lupus anticoagulant syndrome Malignancies, especially pancreas Myeloproliferative disorders Paroxysmal nocturnal hemoglobinuria Pregnancy Nephrotic syndrome Inflammatory bowel disease (Crohn s) Drug-related 61 Coding HIT - Heparin-Induced Thrombocytopenia (289.84) Distinct, relatively common life-threatening clinical condition occurring in 3-5% of all patients receiving unfractionated heparin for at least 5 days. Totally different clinical picture from other drug-induced thrombocytopenias. Presents with arterial or venous thrombosis (DVT, PE, stroke, MI) Transfusion of platelets generally contraindicated Patients require therapeutic doses of alternative anticoagulant 62 AHIMA 2009 Audio Seminar Series 31
Coding Clinic Reference Heparin-Induced Thrombocytopenia (HIT) CC 4 th Qtr 2008, pg 100-101 Remember there can be documented Heparin Induced Thrombocytopenia with Thrombosis! (HITT) same code 63 Procedure Issues in Hematology Bone marrow biopsy/aspiration ICD-9-CM: 41.31 - same code for both biopsy and aspiration of bone marrow CPT: 38220 bone marrow aspiration only 38221 bone marrow biopsy, needle or trocar HCPCS: G0364 (temporary) - Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service 64 AHIMA 2009 Audio Seminar Series 32
CPT Assistant Reference Bone Marrow Biopsy, Bone Marrow Aspiration, and Bone Biopsy, July 1998, Volume 08, Issue 7, pages 4-7 65 Bone Marrow Aspiration (38220) May be performed independent of bone marrow biopsy or may immediately follow a biopsy Evaluates cellular population not the alteration of cells due to disease Following penetration of bone cortex, syringe is attached to the needle and fluid aspirated 66 AHIMA 2009 Audio Seminar Series 33
Procedure: Bone Marrow Aspiration Close-up of technique used to obtain bone marrow sample by aspiration through a needle. 67 Bone Marrow Biopsy (38221) Evaluates Presence and relative quantification of abnormal cells (lymphoma, leukemia, etc.) Relative abundance of normal marrow cells Presence of tumor metastasis Presence of myelofibrosis 68 AHIMA 2009 Audio Seminar Series 34
Procedure: Bone Marrow Biopsy Posterior view of pelvic region with target area for bone marrow biopsy highlighted. Posterior view of pelvis with hypodermic needle penetrating skin at an angle to reach the ilium just below the iliac crest. Needle slowly advanced with twisting motion. After penetration of bone, needle/trocar is rotated several times, withdrawn several millimeters, then reinserted to the original depth at a slightly different angle. Rotated again, then withdrawn using the same twisting motion used during insertion. 69 Bone Marrow Aspiration (38220) vs. Biopsy (38221) Aspiration Retrieving fluid from bone marrow Obtained via needle (University of Illinois) Does not produce intact tissue Biopsy Retrieving cancellous bone Obtained via needle (e.g. Jamshidi) or trocar Produces core of intact marrow 70 AHIMA 2009 Audio Seminar Series 35
Resource/Reference List National Center for Health Statistics; ICD-9- CM Coordination and Maintenance Committee: http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm ASH http://www.hematology.org ICD-9-CM Official Coding Guidelines for Coding and Reporting http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf AHA Coding Clinics Coder s Desk Reference 71 Audio Seminar Discussion Following today s live seminar Available to AHIMA members at www.ahima.org Click on Communities of Practice (CoP) icon on top right AHIMA Member ID number and password required for members only Join the Coding Community from your Personal Page under Community Discussions, choose the Audio Seminar Forum You will be able to: Discuss seminar topics Network with other AHIMA members Enhance your learning experience AHIMA 2009 Audio Seminar Series 36
Become an AHIMA Member Today! To learn more about becoming a member of AHIMA, please visit our website at ahima.org/membership to Join Now! AHIMA Audio Seminars Visit our Web site http://campus.ahima.org for information on the 2009 seminar schedule. While online, you can also register for seminars or order CDs, pre-recorded Webcasts, and *MP3s of past seminars. *Select audio seminars only AHIMA 2009 Audio Seminar Series 37
Upcoming Seminars/Webinars Coding for Multi-System Trauma Patients April 9, 2009 Effective Denials Management April 16, 2009 Procedure Coding for Skin Lesions and Lacerations April 30, 2009 Thank you for joining us today! Remember sign on to the AHIMA Audio Seminars Web site to complete your evaluation form and receive your CE Certificate online at: http://campus.ahima.org/audio/2009seminars.html Each person seeking CE credit must complete the sign-in form and evaluation in order to view and print their CE certificate Certificates will be awarded for AHIMA Continuing Education Credit AHIMA 2009 Audio Seminar Series 38
Appendix Resource/Reference List... 40 CE Certificate Instructions AHIMA 2009 Audio Seminar Series 39
Appendix Resource/Reference List http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm http://www.hematology.org AHIMA 2009 Audio Seminar Series 40
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