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August 2013

The Conundrum That Is Congenital Coding
By Judy Sturgeon, CCS, CCDS
For The Record
Vol. 25 No. 11 P. 8

With all the “excitement” surrounding the impending implementation of ICD-10-CM, it’s easy to lose sight of the existing confusion regarding coding rules in the current system. The American Hospital Association continues to publish Coding Clinic rules to clarify how to code correctly in ICD-9, but sometimes an answer only generates new questions.

Newborn encounters are among the most challenging cases that a coder can tackle. One may expect them to be an easy assignment because in many cases they involve short stays, few medical complexities, and only rare surgeries. On the other hand, there are newborn coding rules that contradict every other basic rule in the codebook. Additional rules, clarifications, and exceptions create confusion and uncertainty when dealing with what many coders would expect to be a straightforward file.

Chapter 15 of the ICD-9 codebook is dedicated to neonates, defined as birth to 28 days old, and covers other conditions originating in the perinatal period, codes 764 to 779. Some conditions in the chapter, however, don’t follow that description. Such anomalies are why those who help make and interpret the rules continue to assist today’s coders with the complex rules and terminology that lead to different codes in different circumstances.

Exceptions Are the Rule
If an infant who qualifies as a neonate receives a physician/provider-documented diagnosis, several decisions must be made to arrive at the correct code. Consider a newborn with a diagnosis of conjunctivitis. There is a specific neonatal code in chapter 15: 771.6, Neonatal conjunctivitis and dacryocystitis.

Easy enough? Not quite. There are numerous exceptions to this example.

Exception 1: If the baby is born intact but later catches pinkeye from a cousin, even though the subject may still be within the neonatal period, this is no longer a neonatal condition. Instead, it is one that was acquired after birth. The correct code would then change to 372.03, Other mucopurulent conjunctivitis. The coder must remember, however, that if the condition in a neonate may be congenital and acquired and there is no way to receive clarification from the provider, then the default is to the neonatal code (Official Coding Guidelines I.C.15.a.3).

Exception 2: If the neonate has a congenital condition and the codebook index leads to an option for congenital as one of the modifiers, there could be a specific code in chapter 14 instead of chapter 15. Chapter 14, “Congenital Anomalies,” includes code categories 740 to 759. Examples include diagnoses such as congenital aortic valve insufficiency (746.4), congenital liver cyst (751.62), and congenital skin tag (757.39) (Official Coding Guidelines I.C.15.g and Coding Clinic, first quarter, 2013, p 14).

Exception 3: If the newborn’s diagnosis does not have a specific neonatal code in chapter 15 and the index gives no direction to a specific congenital version of the code in chapter 14, then the coder is instructed to use the code from the “regular” chapters. An additional chapter 14 code is required and should be sequenced first: 779.89, Other specified conditions originating in the perinatal period. This code pair reports that the diagnosis in question, despite having a code located outside of the congenital and neonatal chapters, really did originate in the perinatal period (Official Coding Guidelines I.C.15.a.2).

Exception 4: Even if the patient is older than 28 days, there are some conditions that must continue to be coded from the neonatal chapter—770.7, Chronic respiratory disease arising in the perinatal period, for example. This code describes conditions, including bronchopulmonary dysplasia and interstitial pulmonary fibrosis of prematurity, that can continue to cause medical problems later in life. (This includes the note at the beginning of chapter 15 in the ICD-9-CM codebook.)

Exception 5: If the neonate has a condition or syndrome that has a specific congenital code from chapter 14 and has an associated additional diagnosis that does not have a chapter 14 or 15 code, that additional code does not need to be reported in conjunction with 779.89. The association with the initial congenital code is considered sufficient to ensure correct reporting of congenital origin.

An example of this situation is a baby born with congestive heart failure caused by coarctation of the aorta, a congenital defect assigned to code 747.10 from chapter 14. Coding Clinic (first quarter, 1999, p. 17) assures us that no additional code 779.89 is needed to report the congestive heart failure because there is a documented congenital defect that resulted in the heart failure. Similarly, instructions found in the second quarter of 2011 (p. 13 and 14) explain that if the main problem already has a code from the congenital chapter, then the associated condition is merely a further description of the anomaly.

Sickle Cell Puzzler
One might suppose that five detailed exceptions to a major coding rule would be sufficient to cover all possible scenarios. This, however, is coding, and there apparently is no end to exceptions.

Exception 6: Coding Clinic (third quarter, 2012, p. 5) explores yet another congenital coding conundrum. The case in question involves a newborn who is diagnosed with sickle cell trait (282.5). There is no index option for a specific code in the neonatal chapter or in chapter 14. It is neither “associated with” or “describing more completely” another diagnosis that does have a specific code in the congenital chapter.

The new twist? If the diagnosis itself is, by definition, always an inherited/genetic condition then no additional code 779.89 is needed, even if its code is not located in chapter 14.

However, the explanation offered creates even more confusion. As Coding Clinic explains, “Code 779.8 … is not used to describe congenital, genetic, or chromosomal disorders.” The new question is whether this means that all congenital conditions no longer need code 779.89 even if they don’t have their own specific neonatal or congenital code.

It is doubtful that an official clarification will be forthcoming before Coding Clinic for ICD-9 is stopped in favor of the ICD-10 version. However, with the caveat that an unofficial opinion does not constitute official coding instruction, it seems that the answer to the question would be no.

The sickle cell trait coding instruction refers to a specific inherited genetic (and therefore always congenital) disorder. The key word seems to be “disorder.” Coding Clinic did not state that congenital conditions don’t need 779.89. The formal reference, in the context of a question about sickle cell trait, appears to be that inherently congenital disorders, such as genetic and chromosomal, do not need the additional code 779.89 even if the correct code is located in chapters other than 14 or 15.

On a positive note, ICD-10-CM should alleviate the confusion and resolve all coding questions after October 1, 2014.

Postscript to the council on ICD-9-CM: Please feel free to add one more clarification on newborn coding rules in Coding Clinic before the industry makes the permanent switch to ICD-10. You know, just in case it isn’t the universal solution to all our coding problems after all.

— Judy Sturgeon, CCS, CCDS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 22 years.