September ICD-10 C&M diagnosis meeting highlights

The diagnosis portion of the September ICD-10 Coordination and Maintenance (C&M) meeting, hosted by the National Center for Health Statistics (NCHS), of the Centers for Disease Control (CDC), was marked by an announcement that many in the coding community knew was coming - a tribute to Donna Pickett, who died recently after a long struggle with cancer. Carolyn Greene, MD, of the CDC, offered the tribute, describing Donna’s role at the NCHS and her decades of service there.  

Donna’s formal job title was medical systems administrator, chief of classifications and public health data staff standards, but those attending the meeting knew her as one of the four cooperating parties— representatives of the four organizations—NCHS, Centers for Medicare & Medicaid Services (CMS), American Health Information Management Association (AHIMA) and American Hospital Association (AHA)—that have collective responsibility in the U.S. for maintenance, update and education of the ICD-10-CM/PCS classification used in this country. In addition, Donna was the U.S. representative internationally for WHO maintenance and updates of ICD, including involvement in developing ICD-11. Greene described Donna as, “a dear friend and colleague, not only a respected subject matter expert but a generous mentor.” She continued, saying that we will miss her kindness and leadership. 

Donna had a reputation for great kindness, diplomacy and dignity in everything she did. I had the privilege of working with Donna for the last 15 years and can attest that this is so. She was a model of measured speech and careful attention, not only to the details of the job but to the people around her. She will certainly be missed. 

Also announced at the meeting was the news that Dr. David Berglund, a longtime CDC medical officer assigned to the ICD-10-CM classification maintenance team for many years, will serve as interim cooperating party representing NCHS for C&M functions and on the ICD-10 Coding Clinic’s Editorial Advisory Board (EAB). Before beginning with the first diagnosis topic on the agenda, Dr. Berglund said that each of us who worked with Donna misses her and hope to carry on with the work she led. And then he did just that—carried on with the work and got started with the first scheduled clinical presentation. 

Here are brief descriptions of a handful of the topics I found most interesting, with their location on the topic packet PDF: 

Adverse effects of immune checkpoint inhibitor (ICI) immunotherapy, p. 17 

Immune checkpoint therapies are a manufactured cancer therapy, used since 2011, that work via the surface proteins on T-cells and has become the standard of care for many types of cancer. A formidable array of adverse effects can occur with ICI therapy, including pericarditis, myocarditis, hypothyroidism, diabetes, colitis, pancreatitis, hepatitis, arthritis, meningitis, encephalitis, vision changes and acute kidney injury. New toxic effect codes were proposed, with separate codes for postoperative or later effects, as they can surface long after the therapy ends. For example, a friend who underwent experimental immunotherapy for advanced malignant melanoma ended up with insulin-dependent diabetes and, even later, a dicey liver for which she is on steroid treatment. The treatment saved her life, but these powerful drugs can have other effects, and these new codes would enable tracking those effects. 

Anosognosia, p. 28 

It’s not surprising since many words for medical conditions have Greek roots, but it was news to me that there is a term for people who adamantly deny they have a severe illness! Of course, this diagnosis is not for the people you nag to go see a doctor—here we’re talking about the majority of people with schizophrenia, 80 percent of those with Alzheimer’s, and varying percentages of people who have other neurological conditions like Huntington’s disease, Parkinson’s and severe traumatic brain injury. The idea behind this code is that a recorded diagnosis of anosognosia can help medical professionals, family members and even the court system to manage treatment decisions more effectively. 

Gulf War illness, p. 74 

The codes proposed include one for Gulf War illness/syndrome and another for effects of other war theaters, in addition to a code for exposure/suspected exposure in the context of the Gulf War theater. Gulf War illness refers specifically to personnel exposed to certain drugs or chemicals during the 1990-91 Persian Gulf conflict. As a result, they suffer from a chronic multi-symptom illness with three to six distinct symptoms of moderate to severe presentation: fatigue or sleep symptoms, neurological/cognitive/mood symptoms, pain, respiratory symptoms, gastrointestinal symptoms or dermatologic symptoms. The strongest evidence to date links Gulf War illness with prolonged exposure to carbamate pesticides and organophosphates (used as both pesticides and nerve agents). 

Injection drug use, p. 82 

I was probably not alone in thinking, “Huh, this seems obviously important when I hear it described, but it had not even occurred to me before!” The three newly proposed Z codes capture current, past or unspecified injection drug use, independent of the substance used or pattern of use. This will allow for more effective use of resources in programs such as syringe exchange programs and early identification of people at risk for hepatitis C (according to the requestor, injection drug use is the number one risk factor for contracting hepatitis C). 

Many other topics on the agenda I found interesting, including:  

• Changing the default external cause for firearm injury from “accidental” to “assault” (p. 43) which would bring the coded data in line with current reality (and ICD-11) 
• Creating new early stage Type 1 diabetes codes, allowing early tracking, identification and treatment of children in this category 
• Adding new, separate codes for pediatric obesity BMI (body mass index) because the percentiles for determining obesity in children are different than in adults 

The PDF of the agenda and the Zoom recordings of both days of the meeting are available on the NCHS website. The agenda for the ICD-10-PCS procedure topics is much shorter, but also worth a look, and the Zoom recording for that portion of the meeting is the first two hours of Day 1. 

Rhonda Butler is a clinical research manager with 3M Health Information Systems.