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Monday Musings

by | Nov 2, 2015 | Cassandra Chronicles: Regulatory and Coverage Policy, Miscellaneous Musings, Pressure Cooker: Rethinking Pressure Ulcers, US Wound Registry | 0 comments

You may remember a previous blog post of mine explaining why even though at first blush, the ICD-10 code cross-walked for the 990 “late effects of radiation” code might not seem to make sense, it really did? I won’t go back through the logic here, but the point is that CMS was trying to do us a favor, finding a code that linked whatever problem the patient was having to the original radiation event  without having to identify the specific radiation injury code for every possible organ.
Listen up, because now we have a problem. The Palmetto MAC decided to remove all the non-specific ICD-10 codes from its LCD. It’s darn hard to find this, too: “CR9252: Per Palmetto, removed NOC codes:  990/T66xxxA.” So, CMS issues a “one time notification” (OTN) that T66XXXA has been removed.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1547OTN.pdf
They make the comment that this doesn’t represent a policy change, but it absolutely IS a policy change. The T66.XXXA code is the correct mapping from the ICD-9 code 990 to ICD-10. This code has been covered for more than a decade and is the late effect of radiation code. Removing it just made a host of conditions NOT COVERED for late effects of radiation.
I am not a certified coder, so I can only tell you what makes the most sense to me as we go forward after this MAJOR POLICY CHANGE THAT DID NOT GO THROUGH THE PROPER NOTIFICATION, but here goes:

  1. For ORN of the jaw: I would use M27.8 and still include T66.XXXA as a secondary code. I think we should use the T66.XXXA as a secondary code with all of the “late effects of radiation” codes (except in cases where it is mutually exclusive such as L59.9). The T66.XXXA code is not inaccurate and it tells a more holistic story for HBOT. In addition, there are likely private payers that will recognize it.
    1. Everyone, please note that M27.8 is the payable code –which is “other specified diseases of the jaws” –and NOT M27.2 which you would think would be the logical choice since that is the code for osteoradionecrosis. This is another issue we ought to debate with CMS.
  2. For a wound in irradiated tissue, or head and neck radiation tissue injury: I’d use L59.9 (disorder of the skin and subcutaneous tissue related to radiation, unspecified) (Note that T66 EXCLUDES the L59.9 code so don’t use this as a second code here)
  3. For Radiation cystitis: I’d use N30.40 or N30.41  (these are the radiation cystitis codes and are listed on the NCD as payable codes so use these) and include T66.XXXA as a secondary code
  4. For Radiation enteritis: I’d use K52.0 (clinically this is the correct code, but unfortunately, this is not a covered code).
  5. For Radiation proctitis: I’d use K62.7,W88.8XXS, with K62.5 in cases where there is hemorrhage (Note that the K62.5 code is hemorrhage of anus and rectum, hematochezia and bright red blood per rectum– not necessarily related to XRT so it could be used as a secondary code only if there is bleeding –but never alone) Note the K62.7 code requires that you specify the TYPE of radiation so I selected W88.8XXS as the best description for the radiation type but if you having coding expertise and understand this better let me know.

Just to be clear, now that the T66.XXXA code has been removed, there are NO covered codes for radiation enteritis or colitis unless you believe that enteritis and colitis can be described with L59.9 “disorder of the skin and subcutaneous tissue related to radiation”.
In case you are interested, we did a quick look at US Wound Registry data and about 40% of patients treated for late effects of radiation in 2014 would be affected by the loss of the T66.XXXA code. If you are going to treat patients with radiation proctitis and enteritis you will now need to have them sign an Advanced Beneficiary Notice (ABN) that Medicare does not cover HBOT for their condition.
If this isn’t a policy change from CMS, I don’t know what is. It is particularly frustrating in view of the fact that, thanks to the tireless work of Dick Clarke, there is data from a randomized controlled trial (HORTIS) demonstrating that HBOT makes a difference for these patients.
So, we need to go to battle with CMS to get T66.XXXA back on the list of covered codes, or get the codes for radiation proctitis and enteritis added to the list of covered codes (or both).
http://www.ncbi.nlm.nih.gov/pubmed/18342453
http://www.ncbi.nlm.nih.gov/pubmed/22592699

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