Coding for Hematology - campus.ahima.org · 285.22 – anemia in neoplastic disease – effect of the tumor 285.29 – anemia in chronic illness – and name that illness (chronic

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Coding for Hematology

Audio Seminar/Webinar April 2, 2009

Practical Tools for Seminar Learning

Disclaimer

AHIMA 2009 Audio Seminar Series • http://campus.ahima.org/audio American Health Information Management Association • 233 N. Michigan Ave., 21st Floor, Chicago, Illinois

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Faculty

AHIMA 2009 Audio Seminar Series ii

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.

Table of Contents

AHIMA 2009 Audio Seminar Series

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)

Table of Contents

AHIMA 2009 Audio Seminar Series

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 1

Notes/Comments/Questions

Objectives

Identify various hematological disorders and applicable ICD-9-CM diagnostic codesReview relevant AHA Coding Clinic references and clinical documentation practices to support accurate hematology codingReview bone marrow procedures and related code assignments

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Agenda

Overview of blood cell linesAnemiaMyelodysplastic diseaseNeutropeniaLeukemoid reactionThrombocytopeniaHematologic neoplasmsHypercoagulable states

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Clinically Speaking... Conundrum: Myel/Myelo-

Myel/Myelo-“Myel,” as in “myelitis” or

“myelopathy,” refers to the spinal cordmyelitis is inflammation of the spinal cord

myelopathy is disease of the spinal cord

Myel/Myelo-“Myel,” as in

“myelodysplasia” or “myelofibrosis,” refers to the bone marrowmyelofibrosis is fibrosis of the bone marrow

myelodysplasia exists when the bone marrow does not produce enough mature blood cells

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Blood Cell Lines

238.71 Essential thrombocythemia238.72 Low grade myelodysplastic syndrome

lesions238.73 High grade myelodysplastic syndrome

lesions238.74 Myelodysplastic syndrome with 5q

deletion238.75 Myelodysplastic syndrome, unspecified238.76 Myelofibrosis with myeloid metaplasia238.79 Other lymphatic and hematopoietic

tissues 4




Peripheral Blood and Bone Marrow

5

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)

Peripheral Blood and Bone Marrow

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Get to Know Your Blood Cells

Granulocytes

Platelets among erythrocytes

Segmented neutrophil Eosinophil

Basophil

LymphocyteMonocyte

Mononuclear white cells7

Hematology Tests: Reference Value Examples

Cell Type Too Few Range Too Many

Red Cells Anemia Hb 13(12) - 18(16) Erythrocytosis

Thrombocytopenia 150,000 - 400,000 Thrombocytosis

Leukocytopenia 4,300 - 10,800 Leukocytosis

Granulocytes Polymorphonuclears (PMNs)

Granulocytopenia Granulocytosis

- Neutrophils Neutropenia 50% - 70% Neutrophilia

- Eosinophils Eosinopenia 1% - 3% Eosinophilia

- Basophils Basophilopenia 0.4% - 1% BasophiliaAgranulocytesMononuclears- Lymphocytes Lymphocytopenia 25% - 35% Lymphocytosis

- Monocytes Monocytopenia 4% - 6% Monocytosis

Platelets

All White Cells

Agranulocytopenia Agranulocytosis

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Get to Know Your Blood Cells

Lymphocyte

Mononuclears Polymorphonuclear leukocytes

9

WBC Differentials and “Shifts”

10

Mets

0%

Bands

0-5%

Lymphocytes

20-35%

SegmentedNeutrophils/PolymorphonuclearLeukocytes

60-75%

Eos

0-5%

Baso

0-3%

Monocytes

0-10%

"Normal" Differential

Mets Bands Segmented Neutrophils/Polymorphonuclear Leukocytes Lymphocytes MonosEos Bas

Left Shift

MetsBands LymphocytesSegmented

Neutrophils/PolymorphonuclearLeukocytes

Eos BasoMonocytes

Right Shift




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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Anemia Designations

284.89 – Acquired (secondary) aplastic anemia.Includes that due to antineoplasticchemotherapy.

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 sideroblasticanemia.

238.72 – Idiopathic refractory (primary) anemia or that due to myelodysplasticsyndrome.

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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)

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Myeloproliferative Disorders

Conditions resulting from variations in the bone marrow’s ability to proliferate (produce by reproduction) cell linesAcute disorders may be result of stimulants or poisoningsChronic disorders may be late effects of above or primary bone marrow disordersMay 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, embolismMyelodysplastic 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 infection15

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




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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284.01 Constitutional red blood cell aplasia

284.09 Other constitutional aplasticanemia

Blood Cell Lines

reduction in all three cell lines – hereditary disorder (Fanconi’s anemia)

limitation of production of red cell line only due to in utero infection by Parvovirus or other viral infection

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284.1 Pancytopenia

284.2 Myelophthisis

Blood Cell Lines

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.

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.

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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




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

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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

Blood Cell Lines

22




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.

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Alpha: NeutropeniaTabular: 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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288.4 Hemophagocytic syndromes

288.50 Leukocytopenia, unspecified –all white cell lines deficient

288.51 Lymphocytopenia –lymphocyte deficiency only

288.59 Other decreased white blood cell count

Blood Cell Lines

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

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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





Alpha: Syndrome, hemophagocytic; Hemophagocyticsyndrome


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/MCC27

Neutropenias

Terminology is importantNeutropenia only neutrophils are deficient (see leukocytopenia later, 288.50)

Agranulocytosis (granulocytopenia) implies deficiency of neutrophils, eosinophilsand basophils but functionally only impacts neutrophils – 288.0x series

Granulocytosis is excessive granulocytes (see later, 288.6x)

28




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

Blood Cell Lines

29


Alpha: Leukocytosis; Lymphocytosis; Monocytosis; Plasmacytosis; Basophilia


IPPS MDC: MDC 16, Diseases and Disorders of the Blood and Blood-Forming Organs and ImmunologicalDisorders

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/MCC30




Leukemoid Reaction – 288.62

Excessive production or release of white cells in response to infectionNumber over 50,000 (normal 5,000 –10,000)Must rule out leukemia'sWe are used to seeing WBC increases in response to steroids and assigning 288.8 and E932.0 – NOT a leukemoidreaction

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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




289.53 Neutropenic splenomegaly289.83 Myelofibrosis

Blood Cell Lines

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 neutropeniawas helped by splenectomy.

Myelofibrosis – primary form is unknown scarring of bone marrow, leading to decrease in all cell lines (another aplastic anemia results)

34




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




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 AspectsPlatelets 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




The Primary Thrombocytopenias

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.

The immune thrombocytopenic purpura idiopathic thrombocytopenic purpura (ITP). Occurs in children after a viral infection and is often self-limited. 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.

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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




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

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Chapter 4 DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (280-289) (cont’d)

Thrombocytopenia:• Congenital• Hereditary• PrimaryTidal platelet dysgenesisExcludes:• Thrombotic thrombocytopenic purpura

(446.6)• Transient thrombocytopenia of newborn

(776.1)

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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

44

• B-cell lymphocytes• T-cell lymphocytes• Natural killer cell

lymphocytes• And other minor groups




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

Clinical Perspective REALRevised European-American Lymphoma Classification

Mature B-Cell Tumors (NHL)

Chronic lymphocytic leukemia/small lymphocytic lymphomaB-cell prolymphocytic leukemia Lymphoplasmacytic lymphoma/WaldenströmmacroglobulinemiaSplenic marginal zone lymphomaPlasma cell neoplasms – plasma cell myeloma, plasmacytoma, monoclonal deposit disease, heavy chain diseasesExtranodal marginal zone B cell lymphoma (mucosa-associated lymphoid tissue, MALT lymphoma)

46




Mature B-Cell Tumors (NHL) (cont’d)

Nodal marginal zone B cell lymphoma Follicular lymphomaMantle cell lymphoma Diffuse large B cell lymphoma Mediastinal (thymic) large B cell lymphoma Intravascular large B cell lymphoma Primary effusion lymphoma Burkitt lymphoma/leukemiaLymphomatoid 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




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




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 histiocytosisLangerhans cell sarcoma Interdigitating dendritic cell sarcoma/tumor Follicular dendritic cell sarcoma/tumor Dendritic cell sarcoma, unspecified

52




Classification by ImmunologicSubtype 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 sites54




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




Leukemias

Chemotherapeutic regimens depend on stageInitial acute – remission induction – to induce remissionIn remission – consolidation chemoIn relapse (recurrence) – may need reinduction to induce remission againBeware of chronic lymphoma with TRANSFORMATION! May become acute leukemia! Ask the physician!

57

Code Series 289.8x

This code series has been expanded toinclude:

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




Hypercoagulable States

This has become more and more identified in the last two years in patients with DVT and embolic phenomenaIt 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

59

Coding – Primary HypercoagulableState (289.81)

Conditions due to inborn errors and lack ofcertain chemicals that influence the prevention of clot formation under normalconditions

Antithrombin deficiencyProtein C deficiencyProtein S deficiencyActivated Protein C ResistanceDysfibrinogenemiasInherited abnormalities of fibrinolysis

60




Coding – Secondary Hypercoagulable State (289.82)

Derived conditions leading to tendencyto make clots at undesirable times

Lupus anticoagulant syndromeMalignancies, especially pancreasMyeloproliferative disordersParoxysmal nocturnal hemoglobinuriaPregnancyNephrotic syndromeInflammatory 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

anticoagulant62




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

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




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 biopsyEvaluates cellular population not the alteration of cells due to diseaseFollowing penetration of bone cortex, syringe is attached to the needle and fluid aspirated

66




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




Procedure: Bone Marrow Biopsy

Posterior view of pelvic region with target area for bone marrow biopsy highlighted.

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.

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.

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Bone Marrow Aspiration (38220) vs. Biopsy (38221)

AspirationRetrieving fluid from bone marrowObtained via needle (University of Illinois)Does not produce intact tissue

BiopsyRetrieving cancellous boneObtained via needle (e.g. Jamshidi) or trocarProduces core of intact marrow

70




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

ASHhttp://www.hematology.org

ICD-9-CM Official Coding Guidelines for Coding and Reportinghttp://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

AHA Coding ClinicsCoder’s Desk Reference

71

Audio Seminar Discussion

Following today’s live seminarAvailable to AHIMA members at

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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

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Become an AHIMA Member Today!

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website at ahima.org/membership to Join Now!

AHIMA Audio Seminars

Visit our Web site http://campus.AHIMA.orgfor 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




Upcoming Seminars/Webinars

Coding for Multi-System Trauma PatientsApril 9, 2009

Effective Denials ManagementApril 16, 2009

Procedure Coding for Skin Lesions and LacerationsApril 30, 2009

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AHIMA Audio Seminars Web site to complete your evaluation form

and receive your CE Certificate online at:

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Each person seeking CE credit must complete the sign-in form and evaluation in order to view and

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Certificates will be awarded forAHIMA Continuing Education Credit

Appendix


Resource/Reference List ....................................................................................... 40 CE Certificate Instructions

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

To receive your

CE Certificate

Please go to the AHIMA Web site

http://campus.ahima.org/audio/2009seminars.html click on the link to

“Sign In and Complete Online Evaluation” listed for this seminar.

You will be automatically linked to the

CE certificate for this seminar after completing the evaluation.

Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information after the seminar, in order to view

and print the CE certificate.

Documents

Coding for Hematology - campus.ahima.org · 285.22 – anemia in neoplastic disease – effect of the tumor 285.29 – anemia in chronic illness – and name that illness (chronic