Polycythemia vera

Case: A 52-year-old male was admitted through the Emergency Department (ED) for pleuritic chest pain, shortness of breath, and dizziness. Outpatient labs obtained last week revealed elevated white blood cells, platelets, and hematocrit. The patient has a recent history of dizziness, fatigue, and shortness of breath, for which he recently saw his primary care physician. Labs were obtained, and the patient was to return to his physician’s office on the day of admission. He had nearly collapsed at his office, and was brought to the hospital by a colleague in significant discomfort. Angina was ruled out. Bone marrow biopsy was obtained based on his symptoms and elevated blood tests. Findings were diagnostic for polycythemia vera. The patient improved significantly post therapeutic phlebotomy. The patient was given information regarding his diagnosis and advised of treatment options. The patient understands regular phlebotomy is likely necessary. He was discharged in improved condition.

Procedure: The skin over the iliac crest was cleansed with antiseptic solution and a local anesthetic was injected to numb the skin. The biopsy needle was inserted into the bone. The core of the needle was removed and the needle pressed forward and rotated in both directions. An adequate sample of bone marrow was obtained within the needle. The needle was removed and pressure applied to the biopsy site. A bandage was applied.

Procedure: Two pints of blood were drawn and collected from the patient by venipuncture of the right cephalic vein under sterile conditions. The patient tolerated the procedure well with no complaints.

Pre-procedure Primary Diagnosis: Pleuritic chest pain, dizziness, shortness of breath

Post-procedure Principal Diagnosis: Polycythemia vera

Assign the ICD-9-CM and ICD-10-CM codes for the principal diagnosis:

ICD-9-CM Diagnosis:
Polycythemia vera - 238.4

ICD-10-CM Diagnosis:
Polycythemia vera - D45 M9950/1

Rationale:
The ICD-10-CM Draft Alphabetic Index directs the coder to assign code D45 to classify polycythemia vera. A supplementary term, "vera" is enclosed in brackets by the main term "polycythemia", which is listed with code D45. Modifying terms direct the coder to category D75 for secondary and hereditary polycythemia.

An instructional note listed with code D45 directs the coder to assign morphology code M9950/1 with this diagnosis. Section 2.3 of The Draft ICD-10-CM Official Guidelines for Coding and Reporting Guidelines states:

"Though the Neoplasm Table provides codes based on the histologic type, it only distinguishes between in-situ, benign, malignant or "of uncertain behavior." A secondary morphology code is needed to specifically identify the histologic type of the tumor. A morphology code should be included on a medical record that has a neoplasm diagnosis whenever possible. The morphology codes are found in a separate section of the classification. The proper morphology code can be located in the Index under the term for the histology of the neoplasm."

Click here to download The Draft ICD-10-CM Official Guidelines for Coding and Reporting for Acute Short-term and Long-term Hospital Inpatient and Physician Office and other Outpatient Encounters.