July 24, 2006

Coding for Parkinson’s Disease
For The Record
Vol. 18 No. 15 P. 37

Parkinson’s disease is a chronic, progressive disorder that damages or destroys nerve cells in the part of the brain controlling muscle movement. It is caused by a severe shortage of dopamine, a neurotransmitter that directs and controls movement, and usually affects patients after the age of 50.

Primary or Idiopathic Parkinson’s
Primary or idiopathic Parkinson’s disease is classified to ICD-9-CM code 332.0. Though considered a “senior” disease, this code also includes Parkinson’s documented as “juvenile.”

Secondary Parkinson’s
Parkinson’s disease may also be caused from medications such as haloperidol (Haldol, Halperon), chlorpromazine (Thorazine, Sonazine), metoclopramide (Reglan), prochlorperazine (Compazine, Compro), or valproate (Depakene, Depacon). N-MPTP (n-methyl-1,2,3,4, tetrahydropyridine), which is a heroin byproduct, has been documented as a cause in some IV users. If Parkinson’s disease is due to drugs, assign code 332.1. An E-code is also assigned to identify the drug and the circumstances surrounding the administration of the drug thought to have caused the disease. The patient’s symptoms disappear after the drug is stopped.

Other sources of secondary Parkinson’s disease include carbon monoxide poisoning, manganese poisoning, hydrocephalus, and tumors in the midbrain and subdural hematoma.

Parkinson’s Associated with Other Conditions
If Parkinson’s disease is associated with orthostatic hypotension, progressive supranuclear palsy, or Shy-Drager syndrome, assign code 333.0. Parkinsonism in Huntington’s disease is classified to code 333.4, and syphilitic Parkinson’s is assigned to code 094.82.

Parkinson’s Disease With Dementia
Dementia with Parkinson’s disease is classified to code 331.82. In addition, assign code 294.1x as a secondary diagnosis to identify any associated behavorial disturbances, which may include aggressive, combative, or violent behavior, or wandering off.

Symptoms
The following are the primary symptoms of Parkinson’s disease:

• tremors/shaking — usually affects the hands, arms, and legs and often disappears during sleep;

• bradykinesia — slowness of movement or difficulty in moving from a resting position;

• akinesia — difficulty in initiating movement;

• rigid muscles — increased tone or stiffness affecting limbs and neck, limiting movement (eg, an arm that doesn’t swing when walking);

• poor balance and coordination — may experience repeated falls; and

• gait disturbance.

Diagnosis
A diagnosis of Parkinson’s disease is based primarily on medical history, observation of symptoms, and a neurological evaluation. No laboratory tests are available to assist in the diagnosis of Parkinson’s disease. However, laboratory tests may be performed to rule out similar conditions.

Treatment
Physical therapy may be utilized to improve mobility, range of motion, and muscle tone, as well as relieve stress. While exercise does not stop the progression of the disease, it plays an important role in helping the patient remain as active as possible. A high-fiber diet is also recommended.

Medications utilized to help control the symptoms associated with Parkinson’s disease are typically initiated when symptoms start to interfere with daily activities. The following are common medications used to treat Parkinson’s disease:

• Levodopa is transformed into dopamine by the brain. Long-term use, however, may cause side effects such as spasmodic movements (dyskinesia), hallucinations, or orthostatic hypotension.

• Carbidopa (Sinemet) is sometimes used in combination with levodopa because it causes levodopa to get into the brain and helps reduce some of the therapy’s side effects.

• Dopamine agonists are used as an adjunct to levodopa therapy. Common examples include bromocriptine (Parlodel), pergolide (Permax), pramipexole (Mirapex), and ropinirole (Requip).

• Selegiline (Atapryl, Carbex, Eldepryl) is used as an adjunct to levodopa to help prevent the breakdown of both naturally occurring dopamine and dopamine formed from levodopa.

• Catechol-O-methyltransferase (COMT) inhibitors, which prolong the effects of levodopa therapy, include tolcapone (Tasmar) and entacapone (Comtan).

Surgery is another treatment option for patients with Parkinson’s disease and may include the following:

• thalamotomy — destruction of a small amount of tissue in the thalamus;

• pallidotomy — destruction of a small amount of tissue in the globus pallidus; and

• deep brain stimulation — consists of a unit implanted in the chest and transmits electric impulses through a wire to tiny electrodes in the globus pallidus. The generator codes used to classify deep brain stimulation include the following:

- 86.94 — Insertion or replacement of single array neurostimulator pulse generator, not specified as rechargeable;

- 86.95 — Insertion or replacement of dual array neurostimulator pulse generator, not specified as rechargeable;

- 86.96 — Insertion or replacement of other neurostimulator pulse generator;

- 86.97 — Insertion or replacement of single array rechargeable neurostimulator pulse generator; and

- 86.98 — Insertion or replacement of dual array rechargeable neurostimulator pulse generator.

Assign as an additional procedure code any associated lead implantation into the brain (02.93).

Specific code assignment will depend on the procedure performed, device used, and documentation provided by the surgeon.

Coding and sequencing for Parkinson’s disease 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 payors 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.

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