ICD-9-CM Coding Guidelines Chapter 4 ICD-9-CM Coding Guidelines

ICD-9-CM Official Guidelines for Coding and Reporting Rules developed by the cooperating parties for the ICD-9-CM to accompany and complement the official conventions and instructions provided within ICD-9-CM Companion to ICD-9-CM (continued)

ICD-9-CM Official Guidelines for Coding and Reporting Cooperating parties consist of: American Hospital Association (AHA) AHIMA CMS NCHS

HIPAA Alert! HIPAA regulations require providers and third-party payers to adhere to ICD-9-CM Official Guidelines for Coding and Reporting. A violation of coding guidelines is a violation of HIPAA.

Official Guidelines for Coding and Reporting Four sections: Section I Section II Section III Section IV

Historical Perspective Bertillon International Statistical Classification of Causes of Death International Classification of Diseases (ICD) ICD-9-CM ICD-10-CM and ICD-10-PCS (future)

General Guidelines Use both the ICD-9-CM Index to Diseases and the Tabular List of Diseases. Locate term in the Index to Diseases first, and verify the code in the Tabular List of Diseases. Assign the highest level of digits available.

Guidelines Signs and symptoms that are integral to the disease should not be assigned as additional codes. The etiology and manifestation convention requires two codes to be reported to completely describe a single condition. (continued)

Guidelines Multiple coding Acute (or subacute) and chronic conditions Use additional code Code first If applicable, code any causal condition first Acute (or subacute) and chronic conditions Combination code versus multiple code

Late Effect Residual condition that develops after acute phase of illness or injury has ended No time limit on reporting Combination code assigned For example, painful cicatrix following severe burn to the elbow or left-sided paralysis due to previous cerebrovascular accident (CVA)

General Procedure Guidelines Based on anatomy rather than surgical specialty Numeric codes Use both Index to Procedures and Tabular List of Procedures (continued)

General Procedure Guidelines Index to Procedures main terms organized in alphabetic order according to type of procedure Report codes using highest number of digits available — omit code (continued)

General Procedure Guidelines Common key terms: Application Closure Correction Destruction Division Incision Insertion Operation Procedure Release Removal Repair (continued)

General Procedure Guidelines Common key terms: Resection Revision Suture Test Therapy Transfer (continued)

General Procedure Guidelines Combination codes Multiple codes And/Or Open procedure versus closed procedure Endoscopic procedures Biopsies Canceled surgery

Chapter-Specific Guidelines Principal diagnosis Principal procedure Secondary diagnoses Secondary procedures First-listed diagnosis

Chapter 1: Infectious and Parasitic Diseases 001–139 Organisms Infections “Supplemental Classification of Factors Influencing Health Status and Contact with Health Services” Human immunodeficiency virus (HIV)

HIV Positive Status Key terms: HIV disease HIV infection HIV infected Acquired immune deficiency syndrome (AIDS)

HIV HIV-related conditions and opportunistic infections Sequence HIV code (042) first and then opportunistic infection code Sequencing of HIV codes with admission for unrelated condition (continued)

HIV Asymptomatic HIV Inconclusive HIV serology

Chapter 2: Neoplasms 140–239 Neoplasm “New growths or tumors in which cell reproduction is out of control” Benign Malignant (continued)

Chapter 2: Neoplasms Six classifications: Primary malignancy Secondary malignancy Carcinoma (CA) in situ Benign Uncertain behavior Unspecified nature (continued)

Chapter 2: Neoplasms Contiguous sites (overlapping sites) Re-excision of tumors

Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders 240–279 Diabetes mellitus Type I Patient’s body unable to produce insulin Type II Patient’s body unable to properly use insulin produced

Chapter 4: Diseases of the Blood and Blood-Forming Organs 280–289 Hematopoiesis Anemia Red cell volume Hemoglobin content Shape (morphology) Purpura

Chapter 5: Mental Disorders 290–319 WHO guidelines: When classifying behavioral disorders, organically based illnesses are reported before functional illnesses. Within a functional group, classify disorders as psychoses, neuroses, personality disorders, and others. (continued)

Chapter 5: Mental Disorders WHO guidelines: When coding mental illnesses associated with physical conditions, assign as many codes as necessary to fully describe the clinical picture.

Chapter 6: Nervous System and Sense Organs 320–389 Nervous system, including meninges Central nervous system Brain Spinal cord Peripheral nervous system

Chapter 7: Circulatory System 390–459 Hypertension, hypertensive table Malignant (accelerated) Benign Unspecified Cerebral infarction, stroke, CVA Late effects of cerebrovascular disease Myocardial infarction

Chapter 8: Respiratory System 460–519 Nose, sinuses, pharynx, larynx, trachea, bronchi, and lungs Chronic obstructive pulmonary disease Refer to main term “obstruction” Pneumonia Asthma (status asthmaticus) Acute exacerbation

Chapter 9: Digestive System 520–579 Major digestive organs include pharynx, esophagus, stomach, and intestines Accessory (secondary) organs include salivary and parotid glands, jaw, and teeth Structures that support the digestive process are gallbladder, pancreas, and liver

Chapter 10: Genitourinary System 580–629 Chronic kidney disease (CKD) Kidney transplant status (V42.0) CKD with other conditions

Chapter 11: Pregnancy, Childbirth, and Puerperium 630–677 Conditions occurring during pregnancy, childbirth, and six weeks immediately following childbirth Never report these codes on baby’s record Outcome of delivery (V27.0–V27.9) (continued)

Chapter 11: Pregnancy, Childbirth, and Puerperium 630–633 (ectopic or molar pregnancy) 639 (complications following abortion and ectopic or molar pregnancy) Fifth digits to identify abortive stage Unspecified (0) Incomplete (1) Complete (2) (continued)

Chapter 11: Pregnancy, Childbirth, and Puerperium 640–648 (complications related to pregnancy) 650 (normal delivery) Minimal or no assistance Episiotomy permitted Fetal manipulation (e.g., use of forceps) not permitted (continued)

Chapter 11: Pregnancy, Childbirth, and Puerperium Fifth digit required for current episode of care Unspecified as to episode of care (0) Delivered with or without mention of antepartum condition (1) Delivered with mention of postpartum complication (2) Antepartum condition or complication (3) Postpartum condition or complication (4)

Chapter 12: Skin and Subcutaneous Tissue 680–709 Epidermis, dermis, subcutaneous tissue, nails, sebaceous glands, sweat glands, hair, and hair follicles

Chapter 13: Musculoskeletal System and Connective Tissue 710–739 Bones, muscles, cartilage, fascia, ligaments, synovia, tendons, and bursa Localized osteoarthrosis Primary Unknown etiology Secondary Caused by external or internal injury

Chapter 14: Congenital Anomalies 740–759 Classifies all conditions according to a principal or defining defect rather than cause Except for chromosome abnormalities May be apparent at birth or hidden and identified sometime after birth Codes may used throughout patient’s life

Chapter 15: Conditions Originating in Perinatal Period 760–779 Perinatal period Interval of time before, during, and up to 28 days following birth Never report these codes for the mother’s episode of care

Chapter 16: Symptoms, Signs, Ill-Defined Conditions 780–799 Includes symptoms, signs, and abnormal results of laboratory or other investigative procedures (continued)

Chapter 16: Symptoms, Signs, Ill-Defined Conditions Key terms: Abnormal, abnormality Decrease, decreased Elevation Findings, abnormal, without diagnosis

Chapter 17: Injury and Poisoning 800–999 Injuries Fractures Burns Adverse effects, poisonings, and toxic effects

Fractures Open/Compound fracture Closed/Simple fracture Comminuted Depressed Fissured Greenstick Impacted (continued)

Fractures Closed/Simple fracture Complicated Malunion (late effect) Linear Slipped epiphysis Spiral fracture Complicated Malunion (late effect)

Burns 940–949 Classified according to: Depth Extent First degree (erythema) Second degree (blistering) Third degree (full thickness) Extent Percentage of body surface Agent (e.g., chemicals, fire, sun) E codes assigned

Adverse Effects, Poisonings, and Toxic Effects Adverse effect (adverse reaction) Appearance of pathologic condition caused by ingestion or exposure to chemical substance properly administered or taken For example, allergic rash due to penicillin Table of Drugs and Chemicals

Poisoning Occurs as result of overdose Wrong substance administered or taken or intoxication that involves combining prescribed drugs with nonprescribed drugs or alcohol For example, coma due to overdose of codeine (continued)

Poisoning 960–979 Manifestation of poisoning Accidental (E850–E869) Suicide attempt (E950–E952) Assault (E961–E962) Undetermined (E980–E982)

Toxic Effects When someone ingests or comes into contact with a harmful substance

V Codes (V01–V85) Supplementary Classification of Factors Influencing Health Status and Contact with Health Services Classifies occasions when circumstances other than disease or injury are recorded as diagnoses or problems (continued)

V Codes Categories: Contact/Exposure Inoculations and vaccinations Status History (of) Screening Observation Aftercare (continued)

V Codes Follow-up Donor Counseling Obstetrics and related conditions Newborn, infant, and child Routine and administrative examinations Miscellaneous

E Codes (E800–E999) Supplemental Classification of External Causes of Injury and Poisoning Classifies environmental events, circumstances, and conditions as cause of injury, poisoning, or other adverse effect (continued)

E Codes Reported in addition to a code from Chapters 1–17 to indicate nature of condition Machinery accidents (E919) Late effects of accidents (E929, E959, E969, E977, E989, E999) Transport accidents (E800–E848) (continued)

E Codes Place of occurrence (E849) Describes place where event occurred Not patient’s activity at the time