1. Chapter 6A
ICD-9-CM Coding

2. ICD-9-CM Coding International Classification of Diseases (ICD)
Used to code and classify mortality (death) data from death certificates

3. ICD-9-CM Coding
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
Used to code and classify morbidity (disease) data from inpatient and outpatient records

4. Overview of ICD-9-CM ICD-9-CM is organized into three volumes.
Tabular List
Volume 2
Index to Diseases
Volume 3
Index to Procedures and Tabular List

5. Mandatory Reporting of ICD-9-CM Codes
Medicare Catastrophic Coverage Act of 1988
Mandated reporting of ICD-9-CM diagnosis codes on Medicare claims

6. Mandatory Reporting of ICD-9-CM Codes
Medical necessity
Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury
Criteria
Purpose
Scope
Evidence
Value

7. ICD-9-CM Annual Updates
CMS enforces regulations pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act (MMA).
Requires all code sets reported on claims to be valid at the time services are provided.

8. ICD-9-CM Annual Updates
Compliance means
Traditional mid-year (April 1) and end-of-year (October 1) coding updates
Must be immediately implemented so that accurate codes are reported on submitted claims

9. ICD-9-CM Annual Updates
If outdated codes are submitted on claims
Providers and healthcare facilities will incur administrative costs associated with resubmitting corrected claims and delayed reimbursement for services provided.

10. Outpatient Coding Guidelines
Diagnostic Coding and Reporting Guidelines for Outpatient Services: Hospital-Based and Provider-Based Office
Developed by the federal government for use in reporting diagnoses for claims submission

11. Outpatient Coding Guidelines
Developed and approved by
– American Health Information Management Association (AHIMA)
– American Hospital Association (AHA)
– Centers for Medicare and Medicaid Services (CMS, formerly HCFA)
– National Center for Health Statistics (NCHS)

12. Outpatient Coding Guidelines
Although the guidelines were originally developed for use in submitting government claims, insurance companies have also adopted them.

13. Coding Tip
Most critical rule involves beginning the search for the correct code assignment using the Index to Diseases/of Diseases.

14. Selection of First-Listed Condition
In the outpatient setting
Term “first-listed diagnosis” is used.
Determined in accordance with ICD-9-CM’s coding conventions as well as general and disease-specific coding guidelines.

15. Selection of First-Listed Condition (cont.)
Outpatient treated in one of four settings
– Ambulatory surgery center (ASC)
• Patient is released prior to a 24-hour stay.
– Healthcare provider’s office

16. Selection of First-Listed Condition (cont.)
– Hospital clinic, emergency or outpatient department, or same-day surgery unit
– Hospital observation setting
Patient’s length of stay is 23 hours, 59 minutes, and 59 seconds or less.

17. Coding Tip Outpatient surgery
Code reason for surgery as the first-listed diagnosis (reason for the encounter)
Even if surgery is not performed due to a contraindication

18. Coding Tip Observation stay
When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis.

19. Coding Tip Outpatient surgery requires observation stay.
A patient presents for outpatient surgery and develops complications requiring admission to observation.
Code the reason for the surgery as the first reported diagnosis, followed by codes for the complications as secondary diagnoses.

20. Coding Tip
An inpatient is a person admitted to a hospital or long-term care facility for treatment with an expected stay of 24 hours or more.

21. Coding Tip
In medical literature, you may see principal diagnosis referred to as first-listed diagnosis.
Remember!
The outpatient setting’s first-listed diagnosis is not the principal diagnosis.

22. Coding Tip Inpatient principal diagnosis
Condition determined after study that resulted in the patient’s admission to the hospital
UB-04 secondary diagnoses include comorbidities and complications.

23. ICD-9-CM Tabular List of Diseases
Must be used to identify diagnoses, symptoms, conditions, problems, complaints, or any other reason for the encounter/visit.

24. Accurate Reporting of ICD-9-CM Diagnosis Codes
Documentation should describe patient’s condition using terminology that includes specific diagnoses as well as symptoms, problems, or reasons for the encounter.

25. Reason for Encounter Codes 001.0–999.9
Codes are frequently used to describe the reason for the encounter.
Codes are from the section of the ICD-9-CM designated for the classification of diseases and injuries.

26. Signs and Symptoms
Codes that describe signs and symptoms are acceptable for reporting purposes when the physician has not documented an established or confirmed diagnosis.

27. Factors Influencing Health Status and Contact with Health Services (V Codes)
Provides codes to deal with encounters for circumstances other than a disease or injury.

28. Level of Detail in Coding
Codes contain three, four, or five digits.
Codes with three digits
Included in ICD-9-CM as the heading of a category of disease codes
May be further subdivided into four or five digits
Provide greater specificity

29. Level of Detail in Coding (cont.)
Three-digit disease code is assigned only if it is not further subdivided.
If fourth-digit subcategories or fifth-digit subclassifications are provided
They must be assigned.
If not, the code is invalid.

30. Sequencing ICD-9-CM Diagnosis
First code for the diagnosis, condition, problem, or other reason for encounter shown in the medical record to be chiefly responsible for the services provided.

31. Sequencing ICD-9-CM Diagnosis (cont.)
Additional codes that describe coexisting conditions that were treated or medically managed during the encounter should also be reported.

32. Qualified Diagnoses Do not code diagnoses documented as
Probable, suspected, questionable, rule out, or working diagnosis, because these are considered qualified diagnoses.
Instead, code condition to the highest degree of certainty for that encounter.
These are a necessary part of the patient chart and are reported on the UB-04 for inpatient hospital claims.

33. Qualified Diagnoses Qualified diagnosis
Working diagnosis that is not yet proven or established
Example
Suspected pneumonia
Code the sign or symptom
Wheezing, shortness of breath, etc.

34. Chronic Diseases If treated on an ongoing basis
May be coded and reported as many times as the patient receives treatment and care for the condition.

35. Code all Documented Conditions that Coexist
Code all documented conditions that coexist at the time of the encounter, and require or affect patient care, treatment, or management.

36. Code all Documented Conditions that Coexist (cont.)
Do not code conditions that were previously treated and no longer exist.
However, history codes may be reported as secondary codes.

37. Encounter for Diagnostic Services
First, report the diagnosis, condition, problem, or reason for the encounter that is documented in the patient record as being chiefly responsible for the outpatient services provided during the encounter.

38. Encounter for Therapeutic Services
Sequence first the diagnosis, condition, problem, or other reason for the encounter shown in the medical record to be chiefly responsible for the outpatient services provided.

39. Encounter for Therapeutic Services (cont.)
Assign code(s) to other diagnoses (e.g., chronic conditions) that are treated or medically managed or would affect the patient’s receipt of therapeutic services during this encounter/visit.

40. Encounter for Preoperative Evaluation
Assign appropriate subclassification code.

41. Ambulatory Surgery
Assign a code to the diagnosis for which the surgery was performed. If the postoperative diagnosis is different from the preoperative diagnosis when the diagnosis is confirmed, assign a code to the postoperative diagnosis instead.

42. Routine Outpatient Prenatal Visits
For routine outpatient prenatal visits when no complications are present, report code V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy) as the first-listed diagnosis.

43. ICD-9-CM Coding System ICD-9-CM has three volumes. Tabular List
Index to Diseases
Index to Procedures and Tabular List

44. ICD-9-CM Coding System Tabular List and Index to Diseases
Used in provider and health facilities to code diagnoses
Index to Procedures and Tabular List
Used in hospitals to code inpatient procedures

45. ICD-9-CM Coding System
Publishers make coding easier by placing the Index to Diseases in front of the Tabular List.

46. Supplementary Classifications: V Codes and E Codes
V codes are assigned when a circumstance other than a disease or injury is present.

47. V Codes and E Codes
Like V codes, E codes are located in the Tabular List.
E codes describe external causes of injury, like poisoning, accidents, or other adverse reactions affecting a patient’s health.

48. Appendices
Appendices serve in coding neoplasms, adverse effects of chemicals and drugs, and external causes of disease and injury.
In addition, the disease category codes are listed as an appendix.

49. Appendices
Morphology of Neoplasms (M codes) contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology.

50. Appendices Morphology Benign Malignant
Indicates tissue type of a neoplasm
Benign
Not cancerous
Malignant
Cancerous

51. Appendices
Classification of Drugs by AHFS List contains the American Hospital Formulary Services List number and its ICD-9-CM code number.
Organized in numerical order according to AHSF List number

52. Appendices
Classification of Industrial Accidents According to Agency based on employment injury statistics
Adopted by the International Conference of Labor Statisticians
If difficult to locate the E code entry in the ICD-9-CM Index to External Causes, use this appendix.

53. Appendices
List of three-digit categories contains a breakdown of three-digit category codes organized beneath section headings.

54. Index to Diseases Within the ICD-9-CM Index to Diseases
Two official tables that make it easier to code hypertension and neoplasms

55. Great Tools within the ICD-9-CM Index
Table of Drugs and Chemicals
Index to External Causes (E codes)

56. Volume 3: Index to Procedures and Tabular List
Included in hospital version of commercial ICD-9-CM books
Index to Diseases – alphabetical listings of main terms or conditions

57. Index to Diseases Main terms Subterms (essential modifiers)
Printed in boldface type and are followed by the code number
Subterms (essential modifiers)
Qualify the main term by listing alternate sites, etiology, or clinical status

58. Index to Diseases
Step 1
Locate main term in the Index to Diseases.

59. Index to Diseases (cont.)
Step 2
If the phrase “see condition” is found after the main term
A descriptive term (an adjective) or the anatomic site has been referenced instead of the disorder.
Referenced instead of the disorder or the disease (the condition) documented in the diagnostic statement

60. Index to Diseases (cont.)
Step 3
When the condition listed cannot be found
Locate main terms such as “syndrome,” “disease,” “disorder,” “derangement of,” or “abnormal.”
See Table 6-1, which lists special main terms, for additional help.

61. Index to Diseases (cont.)
Coding conventions – rules that apply to the assignment of ICD-9-CM codes
Codes in slanted brackets
Eponyms
Essential modifiers
NEC
Nonessential modifiers

62. Index to Diseases (cont.)
Notes
See
See also
See also condition

63. Tabular List
Chapters
Chapter heading is printed in uppercase letters and preceded by the chapter number.
Instructional “Notes” that follow the chapter heading detail general guidelines for code selections within the entire chapter.
EXCLUDES statement reference applies to the entire chapter.

64. Tabular List Major topic headings
Printed in bold uppercase letters and followed by codes in parentheses

65. Tabular List Categories
Major topics are divided into three-digit categories.
Printed in upper- and lowercase and are followed by three-digit codes

66. Tabular List Subcategories
Four-digit subcategories are indented and printed in the same way as major category headings.

67. Tabular List Subclassifications
Some fourth digits are further subdivided into subclassifications, which require the task of a fifth digit.

68. Tabular List
Fifth digits
Required when indicated in the code book

69. Tabular List Fifth-digit entries are associated with Chapters
Major topic headings
Categories
Subcategories

70. Using the Tabular List After reviewing main terms and subterms
Locate the first possible code in the Index to Disease.

71. Using the Tabular List (cont.)
In the Tabular List
Locate code, review code descriptions, and review any EXCLUDES notes to determine whether the condition being coded is excluded.
Assign any required fifth digit.

72. Using the Tabular List (cont.)
Make sure that the code number is appropriate for the age and gender of the patient.
Return to the Index to Disease for other possible code selections.
If code description does not fit condition or reason for visit
Enter the final code.

73. Using the Tabular List (cont.)
Apply to disease and condition codes and to additional classification codes.
Index to Procedures and Tabular List
Included only in hospital version of commercial ICD-9-CM books

74. Tabular List Coding Conventions
And
Bold type
Braces
Brackets
Code first underlying disease
Colon
Excludes

75. Tabular List Coding Conventions (cont.)
Format
Fourth and fifth digits
Includes
NOS
Notes
Parentheses
Use additional code
With

76. Index to Procedures and Tabular List of Procedures
Principal procedures
A procedure performed for definitive treatment rather than diagnostic purpose
One performed to treat a complication
One that is most closely related to the principal diagnosis

77. Index to Procedures and Tabular List of Procedures
Secondary procedures
Additional procedures performed during the same encounter as the principal procedure

78. Index to Procedures and Tabular List of Procedures
Coding conventions
Omit
Code also any synchronous procedures

79. Hypertension/Hypertensive Table
Malignant
Severe form of hypertension with vascular damage and a diastolic pressure reading of 130 mm Hg or greater
Benign
Mild or controlled hypertension
Unspecified
No notation of benign or malignant status

80. Neoplasm Table Neoplasms
New growths or tumors, where cell reproduction is out of control.
Provider should specify whether the tumor is benign or malignant.
Neoplasms should be coded from the pathology report.

81. Neoplasm Table Another term related with neoplasm is lesion.
Defined as any discontinuity of tissue

82. Neoplasm Table
Mass
Cyst
Dysplasia
Polyp
Adenosis

83. Neoplasm Table Primary malignancy Original tumor site
All malignant tumors are considered primary
Unless otherwise documented as metastatic or secondary

84. Neoplasm Table Secondary malignancy
Tumor has spread to a secondary site.
Either adjacent to the primary site or to a distant area of the body

85. Neoplasm Table Carcinoma (Ca) in situ
Tumor that is localized, limited, encapsulated, and noninvasive

86. Neoplasm Table
Benign
Noninvasive, nonspreading, nonmalignant tumor

87. Neoplasm Table Uncertain behavior
Pathology makes it impossible to predict subsequent morphology or behavior from the submitted specimen.

88. Neoplasm Table Unspecified nature Neoplasm is identified.
But no more signs of histology or nature of the tumor is in the documented diagnosis

89. Neoplasm Table Primary malignancies
Malignancy is coded as the primary site if the diagnostic statement documents
Metastatic from a site
Spread from a site
Primary neoplasm of a site
Malignancy for which no specific classification is documented
Recurrent (repeating) tumor

90. Secondary Malignancies
Metastatic and show that a primary cancer has spread to another site

91. Secondary Malignancies (cont.)
Cancer described as metastatic from a site is primary of that site.
Assign code to the primary neoplasm.
Assign second code to the secondary neoplasm of the specified site or unspecified site.

92. Secondary Malignancies (cont.)
Cancer described as metastatic to a site is considered secondary of that site.
Assign one code to the secondary site and a second code to the specified primary site or unspecified site.

93. Secondary Malignancies (cont.)
When anatomic sites are recognized as metastatic
Assign secondary neoplasm code(s) to those sites.
Assign unspecified site code to the main malignant neoplasm.

94. Secondary Malignancies (cont.)
If the diagnostic statement does not specify whether the neoplasm site is primary or secondary
Code the site as primary unless the documented site is the following.

95. Secondary Malignancies (cont.)
Bone, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneum, pleura, retroperitoneum, spinal cord, or classifiable to 195

96. Anatomic Site Not Documented
If the cancer diagnosis does not contain documentation of the anatomic site but the term “metastatic” is documented, then assign codes for “unspecified site” for both the primary and secondary sites.

97. Primary Malignancy Site No Longer Present
Do not assign the code for primary unspecified site. Instead, classify the previous primary site by assigning the appropriate code from category V10, “Personal history of malignant neoplasm.”

98. Contiguous or Overlapping Sites
Contiguous sites (or overlapping sites) occur when the origin of the tumor (primary site) involves two adjacent sites.
Neoplasms with overlapping site boundaries are classified to the fourth-digit subcategory .8, “Other.”

99. Re-excision of Tumor
A surgeon, when performing a second excision to widen the margins of the original tumor site,
Ensures that all tumor cells have been removed.
Uses the diagnostic statement found in the report of the original excision to code the reason for the re-excision.

100. Coding Tip Read notes that apply to the condition you are coding.
Never assign a code directly from the table or Index to Diseases.
Be certain codes represent the current status of the neoplasm.

101. Coding Tip Assign a neoplasm code Assign a V code
If a tumor has been excised and the patient is still undergoing radiation or chemotherapy
Assign a V code
If a tumor is not present
If the patient is not receiving treatment but is returning for follow-ups

102. Coding Tip In a pathology report
Classification stated on a pathology report overrides the morphology classification in the Index to Diseases.

103. Table of Drugs and Chemicals
Poisonings occur as a result of an overdose, wrong substance administered or taken, or intoxication.

104. Table of Drugs and Chemicals (cont.)
Six columns are in the table
Poisoning
Assigned according to classification of drug or chemical
Accident
Accidental overdosing
Wrong substance given
Drug inadvertently taken
Accidents during a medical or surgical procedure

105. Table of Drugs and Chemicals (cont.)
Therapeutic use
Effect caused by proper substance administered in therapeutic setting
Suicide attempt
Self-inflicted poisoning
Assault
Poisoning inflicted by another person who intended to kill or injure the patient

106. Table of Drugs and Chemicals (cont.)
Undetermined
If used, it will not state whether poisoning was intentional or accidental.
E codes are used to explain the cause of poisoning or effect.

107. Supplementary Classifications
ICD-9-CM contains two supplementary classifications.
V codes
Factors influencing health status and contact with health services
E codes
External causes of injury and poisoning

108. V Codes
Classification of factors influencing the person’s health status
These services fall into one of three categories
Problems
Issues that could affect patient’s health status

109. V Codes (cont.) Services Factual reporting
Patient seen for treatment not caused by illness or injury
Factual reporting
Used for statistical purposes

110. V Code and Description
Persons with potential health hazards related to communicable diseases
Persons with need for isolation, other health hazards, and prophylactic measures
Persons with potential health issues related to personal or family history

111. V Code and Description (cont.)
Persons encountering services in circumstances related to reproduction and development
Live born infants according to type of birth
Persons with a condition influencing their health

112. V Code and Description (cont.)
Encountering health services for specific procedures and aftercare
Encountering health services in other circumstances

113. V Code and Description (cont.)
Person without reported diagnosis encountered during examination and investigation of individuals and population

114. Coding Special Disorders
HIV/AIDS
Record states that patient is HIV and associated with AIDS – 042
When HIV is identified by provider – with 042
When screening for HIV was reported as nonspecific –
Patient exposed to virus but not tested – V01.71 to V01.79

115. Coding Special Disorders (cont.)
When patient is HIV positive but not showing symptoms – V08
Counseling a patient after HIV testing – V65.44

116. Coding Special Disorders (cont.)
Common closed fractures
Comminuted
Linear
Spiral
Impacted
Simple
Greenstick

117. Coding Special Disorders (cont.)
Common open fractures
Compressed
Compound
Missile
Puncture
Fracture with a foreign body
Infected fracture

118. Coding Special Disorders (cont.)
Late effects
Residual effect of a previous acute illness or long-term effect of the disorder
Two codes required
Primary code
Identifies original illness
Secondary code
Represents original condition of the late effect

119. Late Effects Original conditions Fracture CVA Third-degree burn Polio
Laceration
Breast implant

120. Late Effects (cont.) Malunion Hemiplegia Deep scarring Contractures
Keloid
Ruptured implant

121. Burns Burns require two codes. – First for site and degree
Second for percentage of body surface

122. Congenital versus Perinatal Conditions
Congenital anomalies are disorders diagnosed in infants at birth.
Adults can also be diagnosed with congenital anomalies because such disorders may have been previously undetected.
Perinatal conditions occur before birth, during birth, or within the perinatal period, or the first 28 days of life.

123. E Codes
Codes are used to describe the circumstances of an illness or injury.
Many states require their use; insurance companies do not.
These codes can expedite claims payment.
NEVER use as a first-listed diagnosis on a claim.