ICD-10 Coordination and Maintenance Committee Discusses Code Proposals for Sepsis, Synthetic Opioids
By Sue Bowman, MJ, RHIA, CCS, FAHIMA
At the September meeting of the ICD-10 Coordination and Maintenance (C&M) Committee, members discussed ICD-10-CM proposals for codes for identification of specific synthetic opioids and revisions to the sepsis/severe sepsis codes. Other diagnosis code proposals included cytokine release syndrome, Chimeric Antigen Receptor T-cell (CAR-T) therapy status, DRESS syndrome, immunodeficiency status, stage 3 chronic kidney disease, cyclin-dependent kinase-like 5 (CDKL5) deficiency disorder, and electric scooter and other micro-mobility devices. Unless otherwise noted below, AHIMA supported these code proposals in our comment letter submitted to the National Center for Health Statistics (NCHS).
Opioid Updates
An expansion of subcategory T40.4, Poisoning by, adverse effect of and underdosing of other synthetic narcotics, was proposed to distinguish fentanyl or fentanyl analogs and tramadol. The rapid increases in illicit fentanyl and fentanyl analog deaths and high misuse of diverted pharmaceutical tramadol indicate the need to intensify efforts to reduce overdoses from these opioids. As public health researchers and practitioners strive to reduce opioid-related mortality and morbidity, surveillance data on synthetic opioid-specific codes (differentiating fentanyl or fentanyl analogs from tramadol) is critical because different preventive measures are required.Fentanyl and fentanyl analogs are highly potent opioids. Pharmaceutical fentanyl, prescribed as transdermal patches or lozenges, is approved for treating severe pain. Chemically identical counterfeit fentanyl, as well as carfentanil and other fentanyl analogs not approved for human use, are sold through illegal drug markets for their opioid-like effect. They are often combined with heroin, cocaine, and other substances, or mixed with fillers and pressed into counterfeit opioid pills. Law enforcement reports have indicated that clandestinely produced fentanyl and fentanyl analog products are causing increases in synthetic opioid overdoses. Misuse of tramadol, an opioid analgesic approved for the treatment of moderate to moderately severe pain in adults, can cause serious problems including overdose and death. Tramadol is commonly diverted and abused by narcotic addicts, chronic pain patients, and health professionals.
Sepsis Proposals
Revisions to the codes for sepsis and severe sepsis were proposed in order to update the classification and improve the accuracy and consistency of coded data. The proposal included the deletion of subcategory R65.2, Severe sepsis, and code R65.11, Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction. New code R57.2, Septic shock would be created. AHIMA recommended retaining code R65.11. Because code R65.10, Systemic inflammatory response syndrome (SIRS) of noninfectious origin without acute organ dysfunction, is not being deleted as part of this proposal, a code for SIRS of noninfectious origin with acute organ dysfunction is still needed. AHIMA also recommended that a unique code or subcategory be created for viral sepsis.Cytokine release syndrome is a condition that may occur after treatment with some types of immunotherapy, such as monoclonal antibodies and CAR T-cell therapy. This syndrome is caused by a large, rapid release of cytokines into the blood from immune cells affected by the immunotherapy. Two code options were presented—one involving the creation of a single unique code and the other involving several new codes identifying the specific grade. AHIMA’s comments supported the option involving grade-specific codes. A new status code was also proposed to track patients who have received CAR-T cell therapy in the past. While AHIMA supported creation of a code for CAR-T status, we recommended that the new code be created in subcategory Z92.8, Personal history of other medical treatment, rather than in sub-subcategory Z98.89, Other specified postprocedural states.
A proposed new code would identify patients with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome. DRESS syndrome is a severe, life-threatening drug reaction characterized by widespread skin rash accompanied by marked systemic symptoms including fever, lymphadenopathy, facial edema, and maculopapular rash. DRESS syndrome has been attributed to a synergistic interaction of lymphocyte activation, drug metabolic enzyme defects with accumulation of drug metabolites, eosinophil activation, and viral infection reactivation (human herpesvirus-6, cytomegalovirus, Epstein-Barr virus) in individuals with genetic susceptibility in association with certain human leukocyte antigen (HLA) class I alleles. Autoimmune diseases, including type 1 diabetes mellitus, autoimmune thyroid disease, sclerodermoid graft-versus-host disease, systemic lupus erythematosus, and bullous pemphigoid may occur up to four years after resolution.
Proposed new codes for immunodeficiency would identify patients who are immunocompromised due to an underlying condition, a drug, or an external cause (such as exposure to ionizing radiation). Instructional notes would provide direction regarding sequencing of the new immunodeficiency codes and the underlying condition, adverse effect of drug, or external cause. Individuals who are immunocompromised are more prone to serious infections, opportunistic infections, and other types of complications.
Proposed Kidney Disease Codes
An expansion of the code for chronic kidney disease, stage 3, was proposed to identify stages 3a and 3b. It was stated at the meeting that stages 3a and 3b are universally recognized.A new code was proposed for cyclin-dependent kinase-like deficiency disorder (CDKL5). CDKL5 deficiency disorder is a developmental encephalopathy caused by pathogenic variants in the gene CDKL5. This disorder presents with early infantile onset refractory epilepsy, hypotonia, developmental, intellectual and motor disabilities, as well as cortical visual impairment. It also causes autonomic problems and gastrointestinal dysfunction that range from oral adversity, swallow dysfunction, gastroesophageal reflux, and constipation. A unique ICD-10-CM code would make it possible to track outcomes from clinical interventions and facilitate the development of protocols for standard of care. C&M meeting attendees questioned the placement of the new code in category G40, Epilepsy and recurrent seizures because the disorder has other manifestations in addition to epilepsy. However, the NCHS indicated that the placement of the new code in category G40 aligns with the classification of CDKL5 deficiency disorder in ICD-11. AHIMA recommended that instructional notes be added under the new code indicating that any associated conditions should also be coded.
New external cause codes were proposed to differentiate injuries related to electric scooters (e-scooters) and other ultralight micro-mobility devices from injuries associated with other types of pedestrian conveyances. The code proposal classifies e-scooters as “pedestrian conveyances” because they are closest in form and function to other types of transportation in which the rider is standing and maintains a high center of gravity, such as skateboards and rollerblades.
If approved, the code proposals presented at the September C&M meeting would be implemented on October 1, 2020.
For more details about the code proposals described above, or for information about ICD-10-CM code proposals presented at the September C&M meeting that were not mentioned in this article, see the link below for the C&M ICD-10-CM materials.
The September C&M ICD-10-CM materials can be found on the NCHS website.
A recording of the September C&M meeting can be found on the Centers for Medicare and Medicaid Services (CMS) website.
For information regarding the ICD-10-PCS code proposals presented at the September C&M meeting, see the ICD-10-PCS handout on the CMS) website. To read AHIMA’s comments on the ICD-10-PCS code proposals, access this link: http://bok.ahima.org/PdfView?oid=302879
Sue Bowman (sue.bowman@ahima.org) is senior director, coding policy and compliance at AHIMA.