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April 16, 2007

Coding for Transplant Complications
For The Record
Vol. 19 No. 8 P. 35

With today’s advanced medical technology, many organs are available for transplantation, such as the following:

• bone marrow including stem cell (41.xx);

• combined heart-lung (33.6);

• cornea (11.6x);

• heart (37.51);

• intestine (46.97);

• kidney (55.6x);

• liver (50.5x);

• lung (33.5x);

• pancreas (52.8x); and

• spleen (41.94).

After a patient receives a transplanted organ, several complications may occur. The most serious complication is rejection, which occurs when the recipient’s immune system attacks the transplanted organ.

The symptoms the patient may experience will vary depending on the transplanted organ. In general, the organ may not function properly, causing the patient to experience general discomfort. To prevent organ rejection, immunosuppressive drugs are needed for the rest of the patient’s life. Patients may take one or a combination of the following medications:

• azathioprine (Imuran);

• basiliximab;

• corticosteroids;
• cyclosporine (Neoral, Sandimmune);

• daclizumab;

• muromonab CD3 (Orthoclone OKT3);

• mycophenolate mofetil (CellCept);

• mycophenolic acid;

• prednisone (Novo Prednisone, Apo Prednisone);

• sirolimus (Rapamune); and

• tacrolimus or FK506 (Prograf).

Because the immune system is suppressed, an infection may occur. In addition, the patient may experience side effects from taking the prescribed medications.

To check for complications, the patient will require frequent posttransplantation monitoring and diagnostic tests, including the following:

• monitoring blood pressure;

• blood tests;

• frequent biopsies of transplanted organ; and

• scope procedures (site will depend on transplanted organ).

When status posttransplant patients are admitted to the hospital for care, the coder needs to determine the status of the transplant before assigning an ICD-9-CM code. A code from subcategory 996.8, Complications of transplanted organ, is assigned when the following occurs:

• the transplanted organ is being rejected by the recipient;

• there are other complications or diseases of the transplanted organ;

• a pre-existing condition affects the function of the transplanted organ; and/or

• a posttransplant medical condition affects the function of the transplanted organ.

Two codes are necessary to completely classify a transplant complication. One code identifies the transplanted organ (996.8x). The fifth digit subclassification is required to identify the specific organ affected, while the second code is needed to identify the complication.

For example, a status post-liver transplant patient is admitted for hepatitis. Assign codes 996.82 and 573.3 since the hepatitis is affecting the function of the liver transplant. Another example is when a status post-heart transplant patient is admitted for congestive heart failure (CHF). The CHF is a chronic condition that existed prior to the heart transplant. The correct code assignments are 996.83 and 428.0. The CHF is affecting the function of the transplanted organ (AHA Coding Clinic for ICD-9-CM, 1998, third quarter, pages 3-7).

An exception to this rule is the presence of chronic kidney disease (CKD) status post-kidney transplant. The presence of CKD after a kidney transplant does not indicate a transplant complication since the transplant may not fully restore kidney function. It is appropriate to assign code V42.0, Kidney replaced by transplant, with a code from category 585 if no transplant complication is documented. However, if a transplant complication (such as transplant failure or rejection) is documented, assign code 996.81, Complications of transplanted kidney. Query the physician for clarification if the documentation is unclear regarding the presence of a transplant complication (AHA Coding Clinic for ICD-9-CM, 2006, fourth quarter, pages 180 and 200).

If the transplant complication is due to cytomegalovirus (CMV) infection, assign code 078.5 as an additional diagnosis after the appropriate code from subcategory 996.8. However, CMV infections can occur in sites other than the transplanted organ. If the transplanted organ is not affected by the CMV infection because the infection was located elsewhere, assign code 078.5 without the transplant complication code (AHA Coding Clinic for ICD-9-CM, 2003, first quarter, pages 10-11).

It would not be appropriate to assign a code from subcategory 996.8x when the following occurs:

• a posttransplant surgical complication does not affect the function of the transplanted organ;

• a pre-existing condition does not affect the function of the transplanted organ; and/or

• a posttransplant medical condition does not affect the function of the transplanted organ.

For example, a status post-kidney transplant patient is admitted with pneumonia. It is not documented that the pneumonia is affecting the kidney transplant, and there are no documented complications of the transplant. The appropriate code assignments are 486 and V42.0. A code from category V42 is typically assigned as a secondary diagnosis to identify the status of a patient who previously underwent a transplant procedure. It is not appropriate to assign a V42 code when there is a complication of the organ replaced or when a patient presents for treatment of a condition that affects the function of the transplanted organ. “A V42 code is never used in conjunction with a 996.8 code when there is a complication of the same transplanted organ” (AHA Coding Clinic for ICD-9-CM, 1998, third quarter, page 3).

Coding and sequencing for transplant complications are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.