Coding for Hematology
Audio Seminar/Webinar April 2, 2009
Practical Tools for Seminar Learning
© Copyright 2009 American Health Information Management Association. All rights reserved.
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AHIMA 2009 Audio Seminar Series • http://campus.ahima.org/audio i American Health Information Management Association • 233 N. Michigan Ave., 21st Floor, Chicago, Illinois
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
(CONTINUED) AHIMA 2009 Audio Seminar Series
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 Coding for Hematology Notes/Comments/Questions
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
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Agenda
Overview of blood cell lines Anemia Myelodysplastic disease Neutropenia Leukemoid reaction Thrombocytopenia Hematologic neoplasms Hypercoagulable states 2
AHIMA 2009 Audio Seminar Series 1 Coding for Hematology Notes/Comments/Questions
Clinically Speaking... Conundrum: Myel/Myelo-
Myel/Myelo- Myel/Myelo- “Myel,” as in “myelitis” or “Myel,” as in “myelopathy,” refers to “myelodysplasia” or the spinal cord “myelofibrosis,” refers myelitis is inflammation of to the bone marrow the spinal cord myelofibrosis is fibrosis of myelopathy is disease of the bone marrow the spinal cord myelodysplasia exists when the bone marrow does not produce enough mature blood cells
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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 Coding for Hematology Notes/Comments/Questions
Peripheral Blood and Bone Marrow
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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 Coding for Hematology Notes/Comments/Questions
Get to Know Your Blood Cells
Granulocytes
Platelets among Segmented neutrophil Eosinophil erythrocytes 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 4,300 - 10,800 Leukocytosis fGranulocytes Granulocytopenia Granulocytosis Polymorphonuclears (PMNs)
-Neutrophils Neutropenia 50% - 70% Neutrophilia
- Eosinophils Eosinopenia 1% - 3% Eosinophilia
-Basophils Basophilopenia 0.4% - 1% Basophilia fAgranulocytes Agranulocytopenia Agranulocytosis Mononuclears -Lymphocytes Lymphocytopenia 25% - 35% Lymphocytosis
- Monocytes Monocytopenia 4% - 6% Monocytosis 8
AHIMA 2009 Audio Seminar Series 4 Coding for Hematology Notes/Comments/Questions
Get to Know Your Blood Cells
Mononuclears Polymorphonuclear leukocytes Lymphocyte
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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
Segmented MetsBands Neutrophils/Polymorphonuclear Lymphocytes Monocytes Eos Baso Leukocytes
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AHIMA 2009 Audio Seminar Series 5 Coding for Hematology Notes/Comments/Questions
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.)
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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.
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AHIMA 2009 Audio Seminar Series 6 Coding for Hematology Notes/Comments/Questions
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 B6- responsive refractory sideroblastic anemia. 238.72 – Idiopathic refractory (primary) anemia or that due to myelodysplastic syndrome.
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Coding Clinic References
Anemia of chronic disease • CC 4th Qtr 2008, volume 25, number 4, pages 195-201 • CC 4th 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 2nd Qtr 2008, pg 6 (284.89 + E933.1) 14
AHIMA 2009 Audio Seminar Series 7 Coding for Hematology Notes/Comments/Questions
Myeloproliferative Disorders
Conditions resulting from Essential thrombocythemia – variations in the bone bone marrow produces too marrow’s ability to many megakaryocytes – release proliferate (produce by too many platelets – reproduction) cell lines spontaneous coagulation, blood Acute disorders may be clots, embolism result of stimulants or Myelodysplastic syndromes of poisonings other cell lines – neoplasms with Chronic disorders may be excessive production of blasts late effects of above or and release of few mature forms primary bone marrow into peripheral blood disorders • Too few red cells, inadequate oxygenation and organ failures May be too many or too few in peripheral blood • 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 for Hematology Notes/Comments/Questions
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
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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)
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AHIMA 2009 Audio Seminar Series 9 Coding for Hematology Notes/Comments/Questions
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.
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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 for Hematology Notes/Comments/Questions
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
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AHIMA 2009 Audio Seminar Series 11 Coding for Hematology Notes/Comments/Questions
Rationale & Clinical Insight
The understanding of Neutropenia is a hematological disorders hematological disorder has grown over the years. characterized by an Not feasible to reclassify abnormally low number of all of these conditions; neutrophil granulocytes (a decision to provide specific type of white blood cells). codes. Neutrophils make up 50- It will be useful for better 70% of all circulating white comparison to differentiate blood cells. the various disorders and Neutrophils serve as the to consistently classify primary defense against them between ICD-9-CM infections by destroying and ICD-10-CM. 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
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AHIMA 2009 Audio Seminar Series 12 Coding for Hematology Notes/Comments/Questions
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 macrophage have an excessive and disorders 288.4 was abnormal activation of created due to the macrophages, which are mature forms of the rare nature of these monocytes of the blood disorders. and blood marrow. Allow better These macrophages statistical capture of destroy blood cells, cause this condition. liver damage and promote bleeding problems.
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AHIMA 2009 Audio Seminar Series 13 Coding for Hematology Notes/Comments/Questions
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)
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AHIMA 2009 Audio Seminar Series 14 Coding for Hematology Notes/Comments/Questions
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 Coding for Hematology Notes/Comments/Questions
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 Coding for Hematology Notes/Comments/Questions
Blood Cell Lines
289.53 Neutropenic splenomegaly 289.83 Myelofibrosis
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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 Coding for Hematology Notes/Comments/Questions
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
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Thrombocytes (platelets)
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AHIMA 2009 Audio Seminar Series 18 Coding for Hematology Notes/Comments/Questions
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.
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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 Coding for Hematology Notes/Comments/Questions
The Primary Thrombocytopenias
The immune thrombocytopenic Evans’ Syndrome is a purpura idiopathic combination of ITP and thrombocytopenic purpura (ITP). autoimmune hemolytic Occurs in children after a viral anemia (AIHA). infection and is often self- limited. May be associated with neutropenia in 15% of In adults, lasts longer, again patients. often following a viral infection or taking some medications or Cause is unknown. during a pregnancy. Can have transient May involve the body’s immune course or be recurrent system developing a tendency to and even fatal. destroy the body’s own platelets. 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. Normal platelet count 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. Thrombocythemia (-osis) 40
AHIMA 2009 Audio Seminar Series 20 Coding for Hematology Notes/Comments/Questions
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)
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AHIMA 2009 Audio Seminar Series 21 Coding for Hematology Notes/Comments/Questions
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 high- grade, 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
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AHIMA 2009 Audio Seminar Series 22 Coding for Hematology Notes/Comments/Questions
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 Coding for Hematology Notes/Comments/Questions
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 Coding for Hematology Notes/Comments/Questions
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 Coding for Hematology Notes/Comments/Questions
Immunodeficiency-Associated Lymphoproliferative Disorders
Associated with a primary immune disorder Associated with the Human Immunodeficiency Virus (HIV) Post-transplant Associated with Methotrexate therapy
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Histiocytic and Dendritic Cell Neoplasms (CNS)
Histiocytic sarcoma Langerhans cell histiocytosis Langerhans cell sarcoma Interdigitating dendritic cell sarcoma/tumor Follicular dendriticcell sarcoma/tumor Dendritic cell sarcoma, unspecified
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AHIMA 2009 Audio Seminar Series 26 Coding for Hematology Notes/Comments/Questions
Classification by Immunologic Subtype and Aggressiveness
B cell T cell • small lymphocytic • peripheral T-cell • lymphoplasmacytic • anaplastic large • follicular T/null cell • marginal zone, MALT • lymphoblastic • marginal zone, nodal • mantle cell • diffuse large B cell • primary mediastinal large B cell • Burkitt's-like 53
Our Newer Subdivisions (2007)
200.3x Marginal zone .x0 Unspecified site 200.4x Mantle zone .x1 Head, face, neck nodes 200.5x Primary CNS .x2 Intrathoracic nodes 200.6x Anaplastic large .x3 Intraabdominal nodes cell .x4 Nodes axilla, upper limb 200.7x Large cell .x5 Inguinal, lower limb lymphoma .x6 Pelvic nodes 202.70 Peripheral T-cell .x7 Spleen .x8 Multiple sites 54
AHIMA 2009 Audio Seminar Series 27 Coding for Hematology Notes/Comments/Questions
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
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AHIMA 2009 Audio Seminar Series 28 Coding for Hematology Notes/Comments/Questions
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
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AHIMA 2009 Audio Seminar Series 29 Coding for Hematology Notes/Comments/Questions
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 long- term Coumadin use
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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 for Hematology Notes/Comments/Questions
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 for Hematology Notes/Comments/Questions
Coding Clinic Reference
Heparin-Induced Thrombocytopenia (HIT) CC 4th Qtr 2008, pg 100-101 Remember there can be documented Heparin Induced Thrombocytopenia with Thrombosis! (HITT) – same code
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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 Coding for Hematology Notes/Comments/Questions
CPT® Assistant Reference
Bone Marrow Biopsy, Bone Marrow Aspiration, and Bone Biopsy, July 1998, Volume 08, Issue 7, pages 4-7
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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
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AHIMA 2009 Audio Seminar Series 33 Coding for Hematology Notes/Comments/Questions
Procedure: Bone Marrow Aspiration
Close-up of technique used to obtain bone marrow sample by aspiration through a needle.
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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
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AHIMA 2009 Audio Seminar Series 34 Coding for Hematology Notes/Comments/Questions
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 Biopsy Retrieving fluid Retrieving from bone marrow cancellous bone Obtained via Obtained via needle (University needle (e.g. of Illinois) Jamshidi) or trocar Does not produce Produces core of intact tissue intact marrow
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AHIMA 2009 Audio Seminar Series 35 Coding for Hematology Notes/Comments/Questions
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
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Audio Seminar Discussion
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AHIMA 2009 Audio Seminar Series 36 Coding for Hematology Notes/Comments/Questions
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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.
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AHIMA 2009 Audio Seminar Series 37 Coding for Hematology Notes/Comments/Questions
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:
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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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