1. CHAPTER-SPECIFIC GUIDELINES (ICD-9-CM CHAPTERS 9-17)
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2. Chapter 9 Diseases of Digestive System
Mouth to anus and accessory organs
Extensive subcategories
574 Cholelithiasis (10 subcategories)
Each has fifth digit subclassification
Presence of hemorrhage associated with diseases in this chapter
Query provider if documentation is not clear
The categories are sequenced in a manner that follows the path of the digestive system from the mouth to the anus, beginning with disorders of the teeth.
For a hemorrhage to be coded, active bleeding is not necessary; however, documentation must support the fact that active bleeding has occurred.
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3. Chapter 10 Diseases of Genitourinary System Commonly used codes
Urinary tract infection (599.0)
Inflammation of prostate (601.X)
Disorders of menstruation ( ) & breast ( )
Use additional code to identify organism
Use additional codes to identify lower urinary tract symptom
Chapter 10 includes conditions and diseases of the male and female genital organs and urinary tract and disorders of the breast.
An additional code must be used to identify the organism when infections of the urinary tract or genital organs are coded.
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4. Chapter 11, Complications of Pregnancy, Childbirth, and the Puerperium
Extensive multiple coding with many fifth digit assignments and notes
Chapter 11 codes take precedence over codes from other chapters
Admission for pregnancy, complication
Obstetric complication = first-listed diagnosis
This may be the most difficult chapter from which to code:
Physicians may overlook documentation of diagnoses that should be coded.
Multiple coding is used extensively.
Fifth-digit assignment for pregnancy is often difficult to determine.
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5. Section I.C.11. Complications of Pregnancy, Childbirth, and Puerperium
Chapter 11 codes
Mother’s medical record (600 series codes)
Not on newborn medical record (Newborn, 700 series codes)
Chapter 11 codes are never used on the record of the newborn.
Coders may find it helpful to code the mother’s and baby’s records at the same time.
Conditions documented on the birth certificate may appear on the newborn’s record but not the mother’s record.
Additional documentation to support coding may have to be obtained from the physician.
(Cont’d…)
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6. Section I.C.11. Complications of Pregnancy, Childbirth, and Puerperium
(…Cont’d)
Mother’s record
Outcome of delivery code (V27.0-V27.9) when delivered
Category V27, Outcome of delivery, can be assigned as an additional coding to the mother’s record.
An outcome of delivery code should be included on every maternal record when a delivery has occurred.
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7. Section I.C.11.a. General Rules for Obstetric Cases
Not all encounters are pregnancy related
Example, pregnant woman, broken ankle
Broken ankle
V22.2 Pregnant state incidental, must be documented in medical record as treated condition not affecting pregnancy
If an encounter with a pregnant woman is not pregnancy related, code the primary diagnosis first and the pregnancy status (V22.2) second
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8. Section I.C.11.a.4. Fifth Digit
All categories EXCEPT 650 (Normal delivery)
Requires fifth digit for:
Antepartum
Postpartum
Delivery
Complications related mainly to pregnancy ( ) designate fifth-digit subclassifications for antepartum conditions, delivery, and postpartum complications.
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9. Codes 640-676.9 Share Fifth-Digit Subclassification
Denotes current episode of care
0 Unspecified as to episode of care or not applicable
1 Delivered, with or without mention of antepartum condition
2 Delivered, with mention of postpartum complication
3 Antepartum condition or complication
4 Postpartum condition or complication
The fourth digit represents the status of the pregnancy.
Which fifth digit would be used if the patient has delivered with no complications? (1)
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10. Section I.C.11.b. Selection of Principal Diagnosis—Obstetric
No delivery: Principal diagnosis = principal complication
>1 complication, sequence any first
(Cont’d…)
In episodes when no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy that necessitated the encounter.
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11. Section I.C.11.b. Selection of Primary Diagnosis
(…Cont’d)
Routine prenatal visits no complications:
V22.0, Supervision, normal first pregnancy or
V22.1, Supervision, other normal pregnancy
Always primary diagnosis
Prenatal outpatient visits for high-risk pregnancies:
V23, Supervision of high-risk pregnancy (V23.X)
For routine outpatient prenatal visits when no complications are present, codes V22.0 and V22.1 should be used as the first-listed diagnoses.
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12. Section I.C.11.c.1. Fetal Conditions Affect Mother
Codes from Categories 655 and 656
Assign only if known or suspected fetal or placenta problems affects management of the mother
Requires additional diagnostic studies, observation, special care or termination of the pregnancy
The existence of a fetal condition alone does not justify reporting these codes
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13. Section I.C.11.c.2. In Utero Surgery
When surgery is performed on the fetus, report a code from Category 655 identifying the fetal condition
No code from Chapter 15, perinatal codes, should be used on the mother’s record to identify fetal conditions
Surgery performed in utero on the fetus is still coded as an obstetric encounter
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14. Section I.C.11.d. HIV Infection in Pregnancy, Childbirth, Puerperium
Patient admitted during this period because of an HIV-related illness should receive
a principal code of 647.6x
followed by 042
Patient admitted with asymptomatic HIV status should be reported
647.6x
V08
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15. Section I.C.11.e. Current Conditions Complicating Pregnancy
Assign a code from Category 648.X for patient with current condition that affects management of the pregnancy, childbirth or the puerperium
Use additional secondary code from other chapters to identify conditions
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16. Section I.C.11.f. Diabetes Mellitus in Pregnancy
Significant complicating factor in pregnancy
Diabetic pregnant patients should be assigned code 648.0X AND
A secondary code from Category 250 to identify type of diabetes
Code V58.67, Long-term (current) use of insulin should also be reported if appropriate
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17. Section I.C.11.g. Gestational Diabetes
Occurs in second and third trimester in women who were not diabetic prior to pregnancy
Can cause complications in pregnancy similar to those of pre-existing diabetes
Puts women at greater risk of developing diabetes after the pregnancy
(Cont’d…)
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18. Section I.C.11.g. Gestational Diabetes
(…Cont’d)
Report 648.8X
NEVER report codes 648.0X and 648.8X together
Code V58.67, Long-term (current) use of insulin should also be reported if gestational diabetes is being treated with insulin
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19. Section I.C.11.h. Normal Delivery, 650
No complications, principal diagnosis = 650
With complications = NOT 650
V27.0 (Single liveborn)
Only outcome for 650 (Normal Delivery)
Normal delivery with resolved antepartum condition = 650
Code 650 is always a principal diagnosis.
Code 650 cannot be used if any other code from Chapter 11 is needed to describe a current complication.
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20. Section I.C.11.i.1. Postpartum and Peripartum Periods
After delivery and continues for 6 weeks
Peripartum period
Last month of pregnancy to five months postpartum
A postpartum complication is any complication that occurs within 6 weeks of delivery.
Chapter 11 codes may be used to describe pregnancy-related complications that occur after the 6-week period if the physician documents that the condition is pregnancy related.
Postpartum complications that occur during the same admission as the delivery are identified with a fifth digit of “2”; subsequent admissions/encounters for postpartum complications are identified with a fifth digit of “4.”
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21. Section I.C.11.i.2.,3.,4. Postpartum Complications
Any complication occurring within the 6-week period
Complications occurring after the 6-week period may be reported with Chapter 11 codes, if the provider documents they are pregnancy related
Complications occurring during the same admission as delivery are reported with fifth digit “2”; subsequent admissions/encounters with fifth digit “4”
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22. Section I.C.11.i.5. Care following delivery outside hospital
If delivered prior to admission
In ambulance
At home
In ED
DO NOT CODE delivery
Code any postpartum care
If a patient delivers outside the hospital, whether at home or in the ambulance on the way to the hospital, do not code the delivery. Only the postpartum care would be coded for.
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23. Section I.C.11.j. Late Effect of Complication of Pregnancy
Category 677
Reported when an initial complication of pregnancy requires care or treatment at a future date
Category reported any time after initial postpartum period
Like all late effects, code is sequenced following the complicating condition code
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24. Section I.C.11.k. Abortions Codes 634-637 require fifth digits:
0: Unspecified
1: Incomplete (POC, product of conception) NOT expelled
2: Complete, all (POC) expelled prior to care
A code from categories and may be used as an additional code with an abortion code to indicate the complication that led to the abortion.
Always apply a fifth digit to these codes.
What would happen if the fifth digit were not applied? (This would be incorrect coding and it would be denied by the third-party payer.)
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25. Section I.C.11.k.1. Fifth-Digits
Appropriate fifth-digits listed under each code
640.0, Threatened abortion
0: Unspecified episode
1: Delivered with or without complication
3: Antepartum condition or complication
Note that NOT all fifth-digits may be assigned (2 and 4)
Not all fifth digits may be reported with every code.
Read Notes carefully.
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26. Section I.C.11.k.4. Abortion with Liveborn Fetus
Attempted abortion results in liveborn fetus:
(Early onset of delivery) appropriately
Use V27 (Outcome of delivery)
Attempted abortion procedure code also assigned
In this case, three codes are assigned.
The three codes would be the early onset of delivery, the outcome of delivery, and an attempted abortion code.
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27. Section I.C.11.k.5. Retained Products of Conception
Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are reported with code from:
634 Spontaneous abortion
635 Legally induced abortion
With fifth digit “1” (incomplete)
Appropriate even if patient previously discharged with diagnosis of “complete”
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28. Chapter 12, Diseases of the Skin and Subcutaneous Tissue
Epidermis
Dermis
Subcutaneous tissue
Infectious Skin/Subcutaneous Tissue
Scar tissue
ACCESSORY ORGANS
Sweat glands
Sebaceous glands
Nails
Hair and hair follicles
Other
(Cont’d…)
Chapter 12 describes diseases or conditions of the Integumentary System.
Does the Integumentary System only include the skin? (No)
What else is included in the Integumentary System? (glands, nails, and hair follicles)
What are the two glands that are covered in the Integumentary System? (sweat and sebaceous)
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29. Chapter 12 Multiple codes often necessary
(…Cont’d)
Multiple codes often necessary
Example: Cellulitis due to Staph
Cellulitis 682.9
Staph 041.1X
If there isn’t a combination code to describe the diagnosis (cellulitis) and cause (staph infection), then both of these diagnoses would be coded to fully describe the condition.
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30. Chapter 13, Diseases of Musculoskeletal System and Connective Tissue
Ligaments
Muscle
Synovia
Tendons
Bone
Bursa
Cartilage
Fascia
Chapter 13 describes diseases or conditions of the bone, joints, and muscles.
The note at the beginning of the chapter presents important information on fifth-digit subclassifications.
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31. Chapter 13 Sections
Arthropathies (joint disease) and Related Disorders
Dorsopathies (curvature of spine)
Rheumatism, Excluding back
Osteopathies, Chondropathies, and Acquired Musculoskeletal Deformities
Newly Diagnosed Pathologic Fractures
Extensive notes and fifth digits
Watch fifth digits. Remember you want to code to the highest level of specificity.
A medical dictionary will always be a handy tool to use when there are medical terms that you may not know—for example, dorsopathies.
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32. Chapter 13, Diseases of Musculoskeletal System and Connective Tissue
Refer to the note at the beginning of the chapter regarding fifth-digit sub-classifications
Details located there are not repeated in the categories
Used for Categories , , , and 730
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33. Chapters 14 and 15
Congenital Anomalies (abnormality at birth) ( )
Conditions Originating in Perinatal Period
Perinatal period through 28th day following birth
Codes can be used after 28th day if documented that condition originated during perinatal period
An anomaly is an abnormality of a structure or organ.
Congenital refers to an abnormality with which a person is born.
The term perinatal applies only to the baby, and postpartum applies only to the mother.
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34. Section I.C.15.b. Use of Codes V30-V39
V30-V39 liveborn infant(s)
Example:
V30, Single liveborn
V31, Liveborn twins
Inpatient: Principal diagnosis
Note: V30 ONLY used once, hospital where baby delivered
When coding the birth of an infant, assign a code from categories V30-V39, according to the type of birth.
The code is assigned as a principal diagnosis. Other conditions or congenital anomalies documented, if any, are coded as secondary diagnoses.
The code is assigned only once to a newborn, at the time of birth.
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35. Section I.C.15.d. Use of Category V29
Assign code when healthy newborn/infant is evaluated for suspected condition not found
Do not use when patient has signs/symptoms of a suspected problem, code the signs/symptoms
V29 is used secondary to V30
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36. Section I.C.15.f. Maternal Causes of Perinatal Morbidity
Codes from Categories are assigned only when the maternal condition actually affected the fetus/newborn
The fact that the mother has a medical condition or experiences a complication does not justify routine reporting of these categories
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37. Section I.C.15.h. Coding Additional Perinatal Diagnoses
Code newborn conditions that require:
Treatment
Further investigation
Additional resource
Prolonged length of stay (LOS)
Implications for future care
All clinically significant conditions noted on a routine newborn examination should be coded.
(Cont’d…)
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38. Section I.C.15.h. Coding Additional Perinatal Diagnoses
(…Cont’d)
Insignificant newborn conditions, signs, symptoms
Resolve with no treatment
Need no code
EVEN IF documented
When coding perinatal, a resolved condition or one that doesn’t require treatment does not have to be coded.
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39. Section I.C.15.i. Prematurity and Fetal Growth Retardation
Codes for newborns from categories
764 (Slow fetal growth and fetal malnutrition) and
765 (Disorders relating to short gestation and low birthweight)
What is the difference between categories 764 and 765? (Category 764 is for slow fetal growth and malnutrition and 765 is for short gestation and low birthweight.)
(Cont’d…)
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40. Section I.C.15.i. Prematurity and Fetal Growth Retardation
(…Cont’d)
Not assigned solely on birthweight or gestational age of newborn
Use clinical assessment instead
Use physician’s assessment of maturity
Use additional code for number of weeks of gestation (765.0 and 765.1)
Codes from category 764 and subcategories and should not be assigned solely on the basis of recorded birth weight or estimated gestational age but on the physician’s clinical assessment of the infant’s maturity.
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41. Section I.C.15.j. Newborn Sepsis
Code should be assigned a secondary code from category 041 to identify the organism
Do not report category 038
Do not assign , Sepsis, assign
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42. Chapter 16, Symptoms, Signs, and Ill-Defined Conditions
Do NOT code a sign or symptom if:
Definitive diagnosis made (symptoms are part of disease)
Only used if no specific diagnosis stated
Signs/symptoms are transient or cause not determined
Patient fails to return and provisional diagnosis is all that is documented
Signs and symptoms codes are used for encounters until a definitive diagnosis can be made.
No specific diagnosis can be made after investigation.
Signs and symptoms reported as existing at the time of the initial encounter prove to be transient or a cause cannot be determined.
A patient fails to return, or is referred elsewhere, and all the coder has is a provisional diagnosis.
A more precise diagnosis is not available for any other reason.
Certain symptoms that represent important problems in medical care exist, and it might be desirable to classify them in addition to the known cause.
(Cont’d …)
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43. Chapter 16, Symptoms, Signs, and Ill-Defined Conditions
(…Cont’d)
More precise diagnosis not available for any other reason
Certain symptoms that may represent important problems in medical care exist and might be desirable to classify them in addition to the known cause
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44. Chapter 17, Injury and Poisoning, Section Examples
Fractures
Dislocations
Sprains and Strains
Intracranial Injury
Internal Injury
Crushing Injury
Foreign Body
Burns
Late Effects
Poisoning
External causes of injury and poisoning codes are intended to provide data for injury research and evaluation of injury prevention strategies.
At the beginning of this chapter, notes provide specific instructions for the entire chapter.
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45. Section I.C.17.c. Burns Sequence highest degree burn first
Current burns ( ) classified by
Depth (severity)
Extent (% body surface)
Site And if necessary, agent
Sequence first the code that reflects the highest degree of burn when more than one burn is present.
(Cont’d …)
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46. Section I.C.17.c. Burns Depth of burn is classified as
(…Cont’d)
Depth of burn is classified as
First degree: Erythema
Second degree: Blistering
Third degree: Full-thickness involvement
Nonhealing burns are coded as acute burns.
If different degrees of burns are documented at the same site, assign a code to burns of highest degree only.
Second-degree burns may also be referred to as “partial-thickness burns.”
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47. Section I.C.17.c. Burns Classified
According to extent body surface involved
Burn site NOT specified
Additional data required
Burns of different degrees/same local site
Report highest degree only
Non-healing burns are reported as acute burns
Report as additional code for infected burn site
Assign codes from category 948, Burns, Classified according to the extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data.
The coder may use 948 as an additional code.
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48. Section I.C.17.c.6. Category 948
Fourth digits = % total body surface involved
Fifth digits = % body surface involved in third-degree burns
Rule of Nines applies
(Cont’d…)
The fourth digit represents the amount of body surface involved, and the fifth digit represents the amount that is third degree.
The Rule of Nines is used to estimate the body surface involved.
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49. Rule of Nines (…Cont’d) Figure: 12.6 SXS12ierPPT-INTC12_P2
For adults: Head and neck are assigned 9%, each arm 9%, each leg 18%, the anterior trunk 18%, the posterior trunk 18%, and genitalia 1%.
Physicians may change these percentage assignments when necessary.
Figure: 12.6
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50. Section I.C.17.d. Debridement of Wounds, Infection, or Burn
Excisional debridement (86.22)
Cut away
Performed by physician
Nonexcisional procedure (86.28)
Shaved or scraped (includes water scalpel [jet])
Performed by physician or
Nonphysician
Excisional debridement involves a cutting away, as opposed to a mechanical debridement, which involves brushing, scrubbing, or washing.
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51. Section I.C.17. Injury and Poisoning (800-999)
Separate code for each injury
Most serious injury first
Superficial injuries not reported if in same location as more serious injury
Wounds
Without mention of complication
Complicated
Documented delayed healing/treatment, foreign body, primary infection
With tendon involvement
When coding multiple injuries, assign separate codes for each injury unless a combination code is provided.
The code for the most serious injury, as determined by the physician, is sequenced first.
Superficial injuries such as abrasions or contusions are not coded when they are associated with more severe injuries of the same site.
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52. Section I.C.17.a.2. Vessel and Nerve Damage
Code primary injury first
Use additional code if nerve/vessel damage minor
Primary injury = nerve/vessel damage
Code nerve/vessel damage first
When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury code is sequenced first.
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53. Section 1.C.17.b.1. Acute Fracture vs. Aftercare
Active treatment of fracture ( ) may be:
Physician evaluation
ER encounter
Surgical treatment
Closed treatment
After active treatment completed, use aftercare codes
Aftercare involving internal fixation (V54.X)
Aftercare for healing traumatic fracture (V54.1X)
Other orthopedic aftercare (V54.8X)
Unspecified orthopedic aftercare (V54.9)
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54. Section I.C.17.b.2. Multiple Fractures
Same coding principles as multiple injuries
Code multiple fractures, by site
Sequenced by severity
Codes describe accidents, injury, open wounds, etc.
Fractures of specified sites are coded individually by site.
Combination categories for multiple fractures may be used when there is insufficient detail in the medical record, when the reporting form limits the number of codes, or when there is insufficient specificity at the fourth- or fifth-digit level.
(Cont’d …)
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55. Fractures Not indicated as closed or open = closed
(…Cont’d)
Not indicated as closed or open = closed
Same bone fractured AND dislocated
Code fracture ONLY (highest level of injury)
If there is any doubt, check with the physician as to the nature of the fracture (open or closed).
If a bone is both fractured and dislocated, you would only code the fracture repair. Fixing the dislocation is included with the fracture repair.
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56. Section I.C.17.e. Adverse Effects, Poisoning, and Toxic Effects
Properties of some drugs, medicinal, and biological substances, or combinations may cause toxic reactions
Classify as Adverse Effect when drug was correctly prescribed/administered
Code effect first
E-code from therapeutic column for drug
(Cont’d…)
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57. Section I.C.17.e. Adverse Effects, Poisoning, and Toxic Effects
(…Cont’d)
Poisoning occurs when drugs/chemical substances are not taken as directed
Wrong dosage given in error
Medication given to wrong person
Medication taken by wrong person
Medication overdose has occurred
Medications (prescription or over-the-counter) taken in combination with alcohol and/or recreational drugs
Over-the-counter taken in combination with prescription drugs without provider approval
(Cont’d…)
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58. Section I.C.17.e. Adverse Effects, Poisoning, and Toxic Effects
(…Cont’d)
Sequencing of Poisoning:
Poisoning code from Table of Drugs & Chemicals first
Manifestation(s) of the poisoning second
Corresponding E code from the Table of Drugs and Chemicals last
If intent unknown or questionable, report intent as undetermined (E980-E989)
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59. E Codes Provides supplemental information Never first-listed diagnosis
Identify:
Cause of an injury or poisoning,
Intent (unintentional or intentional), and
Place it occurred
E codes are used to supplement basic ICD-9-CM codes.
Can E codes be used as the principle diagnosis? (No)
What does the E stand for within ICD-9-CM? (External cause)
E codes give statistical information. (An example would be, What is the rate of suicides in a given time period? Are suicides on the rise?)
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60. General E Code Guidelines
Use with any code in Vol. 1
Initial encounter
Use E code
Subsequent encounter
Use late effects E codes
An E code may be used with any code in Volume 1 that indicates an injury, poisoning, or adverse effect due to an external cause.
No late effect E codes are used for adverse effects of drugs because the effect is immediate.
Assign as many E codes as necessary to fully explain each cause.
Use an additional code from category E849 to indicate the place of occurrence for injuries and poisonings.
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61. Intent Intent Code As Unknown Unspecified Questionable Undetermined*
* (E980-E989)
If the intent is not confirmed, it should be coded as undetermined from the range of E980-E989.
There has to be a definitive diagnosis of intent from the physician in order to use a specific code.
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62. Section I.C.19.c. Table of Drugs and Chemicals
Alphabetic listing with codes
Do NOT code directly from Table
Always reference Tabular
If the same E code would describe the causative agent for more than one adverse reaction, assign the code only once.
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63. Section I.C.19.c. Two or More Substances Involved
If two or more substances involved code:
Each unless combination code exists
Code substance more closely related to principal diagnosis, and
Include one code from each category (cause, intent, place)
Interaction of a drug(s) and alcohol
Using poisoning and E codes for both
If two or more drugs or medicinal or biological substances are reported, each should be coded individually unless the combination code is listed in the Table of Drugs and Chemicals.
The first-listed E code should correspond to the cause of the most serious diagnosis.
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64. Section I.C.19.e. Unknown or Suspected Intent
Unspecified
Questionable
Undetermined
E980-E989
You need a definitive cause to code a definitive code. If undetermined, use external cause codes E980-E989.
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65. Section I.C.19.f. Undetermined Cause
Intent known, cause unknown, use
E928.9, Unspecified accident
E958.9, Suicide and self-inflicted injury by unspecified means
E968.9, Assault by unspecified means
These E codes should rarely be used, as the documentation should normally provide sufficient detail to determine the cause of the injury.
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66. Section I.C.19.g. Late Effects of External Cause
Should be used with late effect of a previous injury/poisoning
Should NOT be used with related current injury code
Late effect E codes exist for injuries and poisonings but not for adverse effects of drugs, misadventures, and surgical complications.
The late effects E codes should never be used with a current injury.
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67. CHAPTER-SPECIFIC GUIDELINES (ICD-9-CM CHAPTERS 9-17)
Conclusion CHAPTER 12
CHAPTER-SPECIFIC GUIDELINES
(ICD-9-CM CHAPTERS 9-17)
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