1. ICD-9-CM Coding Chapters 10-19

2. Objectives Chapter 10: Diseases of Genitourinary System
Chapter 11: Complications of Pregnancy, Childbirth, and the Peurperium
Chapter 12: Diseases of Skin and Subcutaneous Tissue
Chapter 13: Diseases of Musculoskeletal and Connective Tissue
Chapter 14: Congenital Anomalies
Chapter 15: Certain Conditions Originating in the Perinatal Period
Chapter 16: Signs, Symptoms and Ill-Defined Conditions
Chapter 17: Injury and Poisoning
Chapter 18: Classification of Factors Influencing Health Status and Contact with Health Services (V codes)
Chapter 19: Supplemental Classification of External Causes of Injury and Poisoning
In Chapter 4, we discussed the detail of ICD-9-CM chapters In this chapter, we will focus on ICD-9-CM Chapters We will review the guidelines for each chapter and discuss some common diseases found in that chapter. We are not going to read through every entry in the guidelines for these chapters. It will be important for you to read through each and every word in the guidelines.

3. Chapter 10: Diseases of Genitourinary System
Kindeys, bladder, ureters, urethra
Male Genital System
Prostate, penis, testis, scrotum, epididymis
Female Genital System
Breast, uterus, fallopian tubes, ovaries, vagina, and external genitalia
Common diagnoses
chronic kidney disease, acute kidney failure, urinary incontinence, urinary tract infections, kidney stones, benign prostatic hypertrophy, endometriosis, uterine fibroids, dysplasia, and pelvic inflammatory disease
Chapter 10 of the ICD-9-CM includes diagnoses of the urinary system and male and female genital organs. The urinary system includes the kidneys, bladder, ureters, and urethra. The male genital organs include the prostate, penis, testis, scrotum, and epididymis. The female genital organs include the breast, uterus, fallopian tubes, ovaries, vagina, and external genitalia.
Common diagnoses found in this chapter of ICD-9-CM include chronic kidney disease, acute kidney failure, urinary incontinence, urinary tract infections, kidney stones, benign prostatic hypertrophy, endometriosis, uterine fibroids, dysplasia, and pelvic inflammatory disease.

4. Chronic Kidney Disease (CKD)
Stage I—GFR > 90 ml/min/1.73 m2
Stage II—GFR ml/min/1.73 m2
Stage III—GFR ml/min/1.73 m2
Stage IV—GFR ml/min/1.73 m2
Stage V — GFR < 15 ml/min/1.73 m2
End Stage Renal Disease (ESRD)—GFR < 15 ml/min/1.73 m2, and the patient is on dialysis or undergoing kidney transplant.
The only guidelines found in the Official Coding Guidelines for this chapter are for Chronic Kidney Disease, referred to as CKD. When reporting chronic kidney disease, the fourth digit identifies the stage of CKD which helps quantify the severity of the disease. Glomerular filtration rate (GFR) is the best way to determine how much kidney function a person has and is used to determine the stage to CKD. The patient’s age, weight, gender, and serum creatinine which is waste product in the blood from muscle activity, is used to calculate the GFR. There are five stages of CKD.

5. Chronic Kidney Disease (CKD)
CKD and Transplant Status
CKD is not necessarily considered a complication of kidney transplant
585 CKD
V42.0 Kidney transplant status
CKD due to Transplant
organ rejection, transplant failure
996.81
Unclear – query physician
Acute Renal Failure
When a patient has a kidney transplant, the kidney may not restore to its normal function leaving the patient with continued chronic kidney disease. This is not necessarily considered a complication of the transplant. Unless there is documentation stating the CKD is due to the transplant, which could include rejection of the kidney or transplant failure, a code from category 585 should be reported for the CKD and code V42.0 should be reported for the kidney transplant status. If it is documented the patient’s CKD is due to the transplant rejection or failure, code should be reported. If you are uncertain if there is a causal relationship, query the physician.
Acute renal failure is not the same as Chronic Kidney Disease. CKD is chronic and develops over a long period of time. Acute renal failure is when the kidney’s ability to function decreases rapidly, over a few hours or over a few days. It can be caused by an injury to the kidney, or from another disease. Acute renal failure is coded with category 584, with a fifth digit to specify the location of the lesion.

6. Chapter 10: Diseases of Genitourinary System
Urinary Incontinence
Urge incontinence
Stress incontinence
Urinary Tract Infections
Kidney Stones
This ICD-9-CM Chapter also contains codes for urinary incontinence and urinary tract infections. Urinary incontinence is the loss of urine involuntarily. Subcategory for urinary incontinence requires a fifth digit to specify the type of incontinence. The two most common types are urge incontinence and stress incontinence.
Urinary tract infections can occur anywhere in the urinary system. Typically, the infection is of the lower urinary tract which is the bladder and urethra. If not treated, it can spread to the kidneys. In the alphabetic index, there are indentations for the types of organism causing the infection. Urinary tract, unspecified is reported using ICD-9 code An additional code may be reported if the organism is known.
Kidney stones are also referred to as calculus or nephrolithiasis. In the alphabetic index, if you look for “stone” you are directed to “see also Calculus.”

7. Chapter 10: Diseases of Genitourinary System
Benign Prostatic Hypertrophy (BPH)
600.0x
If obstructed, report symptoms
Endometriosis
Benign Prostatic Hypertrophy, or BPH, is an enlargement of the prostate gland. The prostate gland surrounds the urethra. When it becomes enlarged, it can cause urinary symptoms such as a weak stream, urgency, and incomplete emptying of the bladder. BPH is reported with subcategory A fifth digit identifies whether or not there is obstruction. Typically, when the patient is being seen for symptoms of a definitive diagnosis, the symptoms are not reported. However, code has an instructional note to use an additional code to identify the symptoms.
Endometriosis is a disorder of the female reproductive system where the endometrium, or inner lining, of the uterus grows outside of the uterus. Endometriosis is reported with category A fourth digit is used to identify the location.

8. Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium
Report only on the maternal record
Do not report on the newborn’s record
Sequencing priority over all other chapters
Chapter 11 of the ICD-9-CM is for reporting of diseases and disorders that occur during pregnancy, childbirth, and postpartum. Codes from this chapter are only reported on the mother’s record and should not be reported on the newborn’s record. Codes from this chapter have sequencing priority over all other codes in the ICD-9-CM manual. This does not mean codes from other chapters will not be used, but they will be sequenced after codes from this chapter.

9. Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium
Fifth digit subclassification
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
complications
3 antepartum condition or complication
4 postpartum condition or complication
Pay attention to brackets
Categories have a fifth digit subclassification. This digit identifies the stage of pregnancy the mother is in for the current episode of care. The complication can occur antepartum, during delivery, or postpartum. Antepartum is before delivery, and postpartum is after delivery. For each diagnosis code, there will be digits in brackets beneath the code, indicating which of these fifth digits can be utilized for that code.

10. Delivery Normal Complicated 650 Normal Delivery
V27.0-V27.9 Outcome of delivery
Complicated
Code for complication(s)
When the baby is delivered, the mothers chart should have a code to indicate the delivery, and the outcome of delivery. Code 650 is use for a normal delivery. If the delivery is complicated, report the complication, or complications if multiple. In either case, a code from category V27 should be reported to indicate the outcome of the delivery. V27.0 is the only outcome of delivery code appropriate for use with 650.

11. HIV in Pregnancy HIV related illness
647.6x
042
HIV related illness codes
HIV positive with no history of related illness
V08
When a pregnant patient is treated for an HIV-related illness, the first listed diagnosis is 647.6x Other specified infectious and parasitic diseases in the mother classified elsewhere, followed by 042 and the codes for the HIV-related illness.
If the patient is HIV positive and there is no history of an HIV-related illness, the correct codes are 647.6x and V08. The mother can be treated to possibly prevent the baby from being HIV positive.

12. Diabetes in Pregnancy Diabetic patient who is pregnant
648.0x Diabetes mellitus complicating pregnancy
Code from 249 or 250 to report type and status of diabetes
Also code V58.67 for Type II DM treated with insulin
Gestational diabetes
648.8x Abnormal glucose tolerance
Also code V58.67 if use of insulin is required
A patient can be diabetic prior to pregnancy, or develop diabetes during the second or third trimester which is called gestational diabetes. Both diabetes and gestational diabetes can complicate the patient’s pregnancy.
Two codes are required when a diabetic patient is pregnant. The first listed code is 648.0x Diabetes mellitus complicating pregnancy, followed by a code to report the diabetes mellitus. The secondary code reports the type and status of the diabetes. If the patient is a Type II diabetic being treated with insulin, also report V58.67 Long-term use of insulin.
Gestational diabetes is reported with 648.8x Abnormal glucose tolerance. Also report V58.67 if the patient requires insulin. Codes from categories 249 and 250 are not appropriate for patients with gestational diabetes.

13. Postpartum Complications
Postpartum period – 6 weeks following delivery
V24.0 Postpartum care and examination immediately after delivery
Sometimes a patient can develop complications in the postpartum period, which is six weeks following delivery. When a complication develops and is documented as related to the pregnancy, codes from Chapter 11 should be reported. When a baby is delivered outside of the hospital, such as at home, or on the way to the hospital, a delivery code would not be reported. The patient would be admitted for postpartum care, which would be reported with V24.0 for postpartum care and examination immediately after delivery.

14. Abortions Spontaneous abortion (miscarriage)
Elective abortion (legally induced)
Illegally-induced abortion
Failed abortion
Fifth digit
0 unspecified
1 incomplete
2 complete
Abortions are coded based on the type of abortion. Spontaneous abortion, more commonly known as a miscarriage, occurs without any intervention of drugs or instrumentation. A legally induced abortion is induced by a medical professional for therapeutic or elective reasons. When an abortion is not performed by a qualified individual or in accordance with the law, it is considered an illegally-induced abortion. A failed abortion is when an elective abortion is not
successful and the patient is still pregnant.
Categories require a fifth digit to indicate the status of the patient at the beginning of the encounter. If products of conception remain, the abortion is incomplete. If the products of conception are expelled entirely, the abortion is complete.
Abortions that are a result of a complication in pregnancy require an additional code from categories or When selecting a code to report the complication, the fifth digit “3” is reported to indicate an antepartum condition or complication. Do not report a code for the complication with categories because these codes are specific to complications that occur during labor and delivery. If the patient had an abortion, she will not go through labor and delivery. A code from category 639 is reported for complications that result after an abortion.

15. Chapter 12: Diseases of the Skin & Subcutaneous Tissue
Cellulitis
Dermatitis
Pressure Ulcers
ICD-9-CM Chapter 12 is for the reporting of diseases of the skin and subcutaneous tissue. This includes the layers of the skin, nails, hair, sweat glands, and sebaceous glands. Some common disorders found in this chapter include cellulitis, dermatitis, and pressure ulcers. The ICD-9-CM guidelines for this chapter provide the guidelines for reporting Pressure Ulcers.
Cellulitis is a bacterial infection of the skin and subcutaneous tissue. Common signs and symptoms include redness, swelling, and pain. A fever may occur, as may regional lymph node enlargement. Codes for cellulitis are selected based on the anatomical site. If the organism that is causing the cellulitis is identified, use an additional code to report the organism.
Dermatitis is inflammation of the skin and is characterized by itching, swelling, and blistering. Codes for dermatitis are selected based on the type of dermatitis or the substance that caused the dermatitis.

16. Pressure Ulcers Decubitus ulcers/bed sores Coding
Identify the location of the ulcer
Identify the stage of the ulcer
Stage I - Reddened area on the skin that, when pressed, is “nonblanchable” (does not turn white).
Stage II - Skin blisters or forms an open sore. The area around the sore may be red and irritated.
Stage III - The skin breakdown now looks like a crater where there is damage to the tissue below the skin.
Stage IV - The pressure ulcer has become so deep there is damage to the muscle and bone, and sometimes tendons and joints.
Pressure ulcers also are known as bed sores and decubitus ulcers. Pressure ulcers are areas of damaged skin and tissue that develop as a result of compromised circulation. When a patient stays in one position without movement, the weight of the bones against the skin inhibits circulation and causes an ulceration of the tissue. Pressure ulcers usually form near the heaviest bones, such as the buttocks and hips.
There are stages of pressure ulcers that identify the extent of the tissue damage. The definition for each of the stages is located in the ICD-9-CM manual under each code in subcategory
Two codes are required: One to identify the location of the ulcer, and a second to identify the stage of the ulcer. If the pressure ulcer is documented as unstageable, assign Pressure ulcer, unstageable. Unstageable is when the base of the ulcer is covered in eschar or slough so much that it cannot be determined how deep the ulcer is. This diagnosis is determined based on the clinical documentation. This code should not be used if the stage is not documented. In that instance, report the unspecified code,

17. Chapter 13: Diseases of Musculoskeletal and Connective Tissue
Common diagnoses
Arthritis
Pathologic fractures
Stress fractures
Watch for fifth digits
Chapter 13 in ICD-9-CM covers diseases and disorders of bones, muscles, cartilage, fascia, ligaments, tendons, and bursa. Common diagnoses from this chapter include arthritis, pathologic fractures, and stress fractures. The ICD-9-CM guidelines only address coding of pathologic fractures.
Codes for this chapter often require a fifth digit. At the beginning of this chapter, you will see the fifth digit subclassificaitons for categories , , , and 730.

18. Arthritis Osteoarthritis Rheumatoid arthritis Generalized Localized
Primary
Secondary
Rheumatoid arthritis
Arthritis is an inflammation of a joint, and also may involve the muscles and connective tissue. Common signs and symptoms include pain, stiffness, inflammation, and movement limitations. The most common types of arthritis are osteoarthritis and rheumatoid arthritis.
Osteoarthritis is a chronic condition that is a result of the cartilage in the joints wearing down. When the cartilage wears down, movement at the joints become painful because there is bone moving against bone. Codes for osteoarthritis are determined by whether it is generalized
or localized. Generalized involves more than one joint or groups of joints. Localized osteoarthosis involves one joint and is classified further as primary or secondary. Primary does not have a known cause. Secondary develops as a result of an injury or disease.
Rheumatoid arthritis is an autoimmune disease that affects the whole body. Common symptoms are joint pain and swelling, stiffness in the joints in the morning, red and puffy hands, and fatigue. Unlike osteoarthritis, the codes for rheumatoid arthritis do not specify site.

19. Pathologic and Stress Fractures
Pathologic Fracture - occurring in the area of weakened bone
Active care - Subcategory 733.1
Aftercare – routine care during the healing or recovery phase
Stress Fracture – occuring from repetitive application of force or overuse
Subcategory 733.9x
A pathologic fracture is a broken bone that occurs in an area of weakened bone. The bone is typically weakened by a disease such as osteoporosis. This is different from a traumatic fracture that occurs due to an acute injury. Pathologic fractures are reported using a code from subcategory This code should be used while the patient is receiving active treatment for the fracture. When the fracture is in the healing or recovery phase, an aftercare code should be used. According to the guidelines, examples of aftercare include cast change or removal, removal of external or internal fixation device, medication adjustment, and follow up visits following fracture treatment.
Stress fractures occur from repetitive application of force and are coded with subcateogry 733.9x.
Both pathologic fractures and stress fractures have fifth digits to identify the location of the fracture.

20. Chapter 14: Congenital Anomalies
Assign code from Categories
Use additional secondary codes to specify conditions associated
May be used throughout the life of the patient
Reported at time of birth:
Category V30
Congenital Anomaly – Categories
Congenital anomalies are also known as birth defects and are abnormalities that are present at birth. Examples of congenital anomalies are spina bifida and cleft palates and lips.
Assign an appropriate code(s) from categories Congenital anomalies when an anomaly is documented. A congenital anomaly may be the first listed diagnosis on a record, or a secondary diagnosis. Use additional secondary codes from other chapters to specify conditions
associated with the anomaly, if applicable.
Codes from chapter 14 may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly.
For the congenital anomalies reported at the time of birth, the appropriate code from category V30 Liveborn infants according to type of birth should be sequenced first, followed by any congenital anomaly codes.

21. Chapter 15: Newborn (Perinatal) Guidelines
Birth through 28 days
Used on newborn’s record
Can be used throughout the life of the newborn
Sequencing – generally listed first, except for V30-V39 for birth episode
Suspected condition not found, report V29
Maternal condition affecting fetus or newborn, use
ICD-9-CM Chapter 15 is used to report conditions from birth through day 28 following birth. The codes in this chapter should not be used on the maternal record. For the newborn, codes may be used from ICD-9-CM Chapter 15 throughout the life of the patient, as long as the condition is still present
Codes from Chapter 15 should be listed as the primary diagnosis, unless it is the episode of delivery. For the episode of delivery, the appropriate code from V30-V39 should be reported first. If the newborn is observed for a suspected condition at birth, and it is determined the condition is not present, use code V29 for Observation and Evaluation of Newborns and Infants for Suspected Conditions Not Found.
Codes from categories Maternal Causes of Perinatal Morbidity and Mortality are assigned only when the maternal condition has affected the fetus or newborn.

22. Chapter 15: Newborn (Perinatal) Guidelines
Prematurity and Fetal Growth Retardation
Clinical assessment of maturity for the infant
Prematurity should not be reported unless documented
Fifth digit assignment based on
Recorded birth weight
Estimated gestational age
Codes from category 764 and subcategories and should not be assigned based solely on recorded birth weight or estimated gestational age, but on the attending physician’s clinical assessment of maturity of the infant. Because physicians may utilize different criteria in determining prematurity, do not code the diagnosis of prematurity unless the physician documents this condition.

23. Chapter 16: Symptoms, Signs, and Ill-defined Conditions
Use when:
No more-specific diagnoses can be made after investigation
Signs and symptoms existing at the time of the initial encounter proved to be transient, or the cause could not be determined
A patient fails to return and a provisional diagnosis is the only thing recorded
A case is referred elsewhere before a definitive diagnosis could be made A more precise diagnosis was not available for any other reason
Certain symptoms, which represent important problems in medical care, exist and might be classified in addition to a known cause
Do not use when:
A definitive diagnosis is available
There are no chapter specific guidelines for ICD-9-CM Chapter 16. This chapter is used to report signs and symptoms. Remember, though, in Chapter 3 of this curriculum, we discussed the reporting of signs and symptoms. Codes from this chapter should be used when a definitive diagnosis has not been determined or when the symptom is not part of the normal disease process. When a definitive diagnosis is known, symptoms or signs of that diagnosis should not be reported separately.

24. Chapter 17: Injury and Poisoning
Code each injury separately – list the most serious injury first
Do not use multiple injury codes unless there is not documentation to support a more specific code
Superficial injuries are only coded when not associated with more severe injuries of the same site
Primary injury results in minor damage to peripheral nerves or blood vessels
Cause of the injury should be reported with an E code
ICD-9-CM Chapter 17 is used to report diagnosis codes for injuries, fractures, burns, adverse effects, poisonings, toxic effects, and complications of care. Each injury should be reported separately unless a combination code is provided. Multiple injury codes exist, but should only be used when there is no documentation to support more specific code assignment.
Superficial injuries, such as contusion and abrasions are not coded when associated with more severe injuries to the same site. If a patient has a contusion on the forehead and a concussion, only the concussion would be coded.
When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code from categories Injury to nerves and spinal cord, and/or Injury to blood vessels sequenced secondarily.
Anytime there is an injury, the payer wants to know who is responsible for the patient’s care for that injury. The details for the injury are reported using E codes, which are codes reporting the external cause of an injury.

25. Traumatic Fractures Classification Aftercare
Bone involved
Type of fracture
Open or closed
Code as closed unless specified as open
Aftercare
Routine care during healing and recovery phase
Sequence according to severity
Complications
Malunion –
Nonunion –
Earlier in this lecture, we discussed the difference between pathologic, stress, and traumatic fractures. Traumatic fractures are the result of trauma. Fracture codes are classified based on the bone involved, type of fracture, and whether it is open or closed.
An open fracture is where the site has been exposed to the outside elements. If a fracture is not specified as open or closed, it should be coded as closed. Sometimes, you will see documentation stating the fracture is a compound fracture, this is considered an open fracture.
Fractures are coded as long as treatment is rendered. Aftercare codes are reported after the active treatment ends and the patient is receiving routine care for the fracture during the healing or recovery phase. When multiple fractures are reported, they should be sequenced in order of severity, with the most severe fracture listed first.
When complications occur during the healing or recovery phase, they should be coded with the appropriate complication code. A mal-union is when a fracture heals misaligned. A non-union is when the fracture fails to heal.

26. Burns Site Severity (degree) of burn Total Body Surface Area
A burn is coded by site, severity or degree of burn, and the total body surface area, or TBSA.

27. Burns
4th
942 Burn of Trunk
scapular region ( with fifth-digit 6)
The following fifth-digit subclassification is for use with category 942:
0 trunk, unspecified site
1 breast
2 chest wall, excluding breast and nipple
3 abdominal wall
Flank
Groin
4 back [any part]
Buttock
Interscapular region
5 genitalia
Labium (majus)(minus)
Penis
Perineum
Scrotum
Testis
Vulva
9 other and multiple sites of trunk
Excludes
The codes in the burn section are categorized according to the location of the burn. According to the ICD-9-CM guidelines, a separate code should be reported for each burn site. Within the category of the site, the fourth digit specifies the degree of burn, and the fifth digit further specifies the location. In your ICD-9 book, turn to code 942 for Burn of Trunk. Below the 5th digit subclassification box there are codes for unspecified degree of burn, for a first degree burn and so on. Then you are required to add a fifth digit to further specify where on the trunk the burn is located.

28. Degree of Burns First degree Second degree Third degree
Superficial (epidermis only)
Example: Sunburn
Second degree
Partial thickness (epidermis and dermis)
Blister
Nerve endings exposed
Third degree
Full thickness (epidermis, dermis, subcutaneous, underlying structures)
Immediate medical attention
First degree burns are superficial burns through only the epidermis. The area of the burn is usually red, very painful, and blanches to touch. The skin appears intact and no blistering occurs. In general, the skin involved in a first degree burn does not lose its ability to function. A sunburn is the best example of a first degree burn; however, it is not classified in ICD-
9-CM with the rest of the burns. First degree burns typically do not require medical treatment.
Second degree burns often are referred to as a partial thickness burn involving the epidermis and the dermis. These burns usually blister immediately and fill with a fluid. The blisters can be superficial or involve deep dermal damage. They are red, extremely painful, and the areas around the blisters will blanch to touch. The nerve endings are exposed in this level of burn making them the most painful burns. Second degree burns are usually caused by flames, chemicals, or hot liquids.
Third degree burns are full-thickness burns that involve the epidermis, dermis, and varying levels of the subcutaneous and underlying structures. Third degree burns are commonly caused by electricity, chemicals, and fire. They require immediate medical treatment.

29. TBSA Total Body Surface Area
Fourth digit – percent of total body surface involved
Fifth digit – percent of total body surface involved in third degree burns
TBSA stands for the Total Body Surface Area. An ICD-9-CM code from category 948 is used to indicate the TBSA when the site of the burn is unknown, or when there is a need for additional data such as when over 20% of the TBSA has third degree burns.
In this category, the fourth digit identifies the total body surface area involved in any type of burn, regardless of the degree of the burn. The fifth digit identifies the amount of total body surface area that is affected by third degree burns only.
Burn codes should always be sequenced with the highest degree of burn listed first.

30. Adverse Effects, Poisoning and Toxic Effects
External Cause (E-Code)
Drug, chemical
Poisoning
Accident
Therapeutic Use
Suicide
Attempt
Assault
Undete-
Mined
1-propanol
980.3
E860.4
----
E950.9
E962.1
E980.9
2-propanol
980.2
E860.3
2, 4-D (dichlorophenoxyacetic acid)
989.4
E863.5
E950.6
E980.7
2, 4-toluene dilsocyanate
983.0
E864.0
E950.7
E980.6
2, 4, 5-T (trichlorophenoxyacetic
acid)
989.2
14-hydroxydihydromorphinone.
965.09
E850.2
E935.2
E950.0
E962.0
E980.0
ABOB
961.7
E857
E931.7
E950.4
E980.4
Abrus (seed)
988.2
E865.3
Absinthe
980.0
E860.1
beverage
E860.0
Acenocoumarin, acenocoumarol
964.2
E858.2
E934.2
The Table of Drugs and Chemicals is used to identify the substances and causes for adverse effects and poisonings. The codes in the table are organized in a six column format. The first column of codes is for poisoning.
A poisoning is when a drug is taken in the wrong dosage, or is taken in error. It is also for intoxication or poisoning by a drug or other chemical substance. Turn in your ICD-9-CM code book to the Table of Drugs and Chemicals. Here, the additional five columns for the E codes are defined.
Accidental poisoning codes identify accidental ingestion of drugs for correct use in medical or surgical procedures, incorrect administration for ingestion of the drug, or inadvertent or accidental overdose. Therapeutic use codes indicate an adverse effect or reaction to a drug that was administered correctly, either therapeutically or prophylactically. Suicide attempt codes identify the effects of the drugs or substances taken to cause self-inflicted injury or to attempt suicide. Assault codes indicate drugs or substances that are “purposely inflicted” by another person with the intent to cause bodily harm, injury, or death. Undetermined codes apply when the cause of poisoning or injury is unknown.
Coding and sequencing depend on whether it is an adverse effect or a poisoning.

31. Adverse Affect vs Poisoning
Manifestation(s)
E code from Therapeutic column to identify the drug
Poisoning
An adverse affect occurs when a prescription medicine or drug is taken according to physician instruction and the patient develops a reaction in spite of proper administration. To code an adverse affect, two codes are required. First, code the manifestation, then code the drug that caused the reaction from the Therapeutic Use column in the Table of Drugs and Chemicals.
Poisoning occurs when the wrong drug or an incorrect dosage of a correct drug is ingested. Poisoning by drugs can be accidental or purposeful. To code poisoning correctly, list the code from the poisoning column of the Table of Drugs and Chemicals which identifies the drug. The second code should indicate the condition or manifestation that resulted from the poisoning. An E code should be reported to indicate the circumstance, whether it is accidental, suicide attempt, assault, or undetermined.

32. Chapter 18: V Codes Specific Care Specific Type of Care
Routine physical
Screening mammogram
Specific Type of Care
Physical therapy
Chemotherapy
Status of Patient
Family history
Post transplant
ICD-9-CM Chapter 18 is a supplementary classification of factors influencing health status and contact with health services. Not all patient encounters are for a problem or condition. This chapter includes codes that are reported to identify the reason why the patient is receiving services when a disease or disorder is not the reason the services are rendered. Codes in this chapter are referred to as V codes. V codes are reported when the patient is not sick and presents for specific care, such as a routine physical, to report a specific type of care, such as physical therapy, or to identify the status of the patient that may affect the management of care such as a family history of colon cancer. A V code is always the first listed code to report a newborn birth status. V codes can be used as primary or secondary codes. The ICD-9-CM guidelines list V codes that may be listed as the primary diagnosis.

33. Chapter 18: V Codes Exposure Inoculations and vaccinations Status
History of
Personal
Family
Screening
Observation
Aftercare
Follow up
Donor
Counseling
Routine and Administrative Exams
V codes are classified in categories. Exposure codes are used when a patient is exposed to a communicable disease but has not developed any signs or symptoms. Inoculations and vaccinations are used to report the type of vaccination given. Status codes indicate a patient is a carrier of a disease, has the sequelae or residual of a past disease or condition, or has another factor influencing a person’s health status.
There are two types of history codes; personal and family. Family history is important to report because some diseases have a generic predisposition. Personal history is reported if the patient no longer has the disease. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.
Screening codes are used to report tests or services performed to identify problems before a patient starts to exhibit signs or symptoms. Preventive medicine is encouraged to identify potential health problems before they become severe.
Observation codes are used when a patient is being observed for a suspected condition, but it is determined the patient does not have that condition. Aftercare codes have been mentioned a couple of times in this lecture and are used to report the continued care for which the patient presents after the acute phase of treatment.
Follow up codes are used to indicate the surveillance of a condition that has been fully treated and no longer exists. Donor codes are used to report a living donor of blood or other body tissue. Counseling codes are reported when a patient or family member receives counseling following an illness or injury, or when support is required in coping with family or social problems.
Routine and Administrative Examination codes are used when a patient is seen for a routine exam.

34. Chapter 19: E Codes Supplemental – never sequenced first
Sequencing Rules
Child and adult abuse take priority over all other E codes
Terrorism events take priority over all other E codes except child and adult abuse
Cataclysmic events take priority over all other E codes except child and adult abuse and terrorism
Transport accidents take priority over all other E codes except cataclysmic events, child and adult abuse and terrorism.
Activity and external cause status codes are assigned following all causal (intent) E codes
The first listed E code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy listed above.
E codes are supplemental to the diagnosis codes in chapters 1-18 of ICD-9-CM. The external causes of injury and poisoning provide information on how the injury, poisoning, or adverse effect happened, the intent, the person’s status, the associated activity, and the place where the
event occurred. Payers use the information provided with E codes to determine the payer of liability, which is the payer responsible for reimbursing the claim.
The sequencing rules for reporting two or more E codes are as follows:
E codes for child and adult abuse take priority over all other E codes.
E codes for terrorism events take priority over all other E codes except child and adult abuse.
E codes for cataclysmic events take priority over all other E codes except child and adult abuse and terrorism.
E codes for transport accidents take priority over all other E codes except cataclysmic events, child and adult abuse and terrorism.
Activity and external cause status codes are assigned following all causal E codes.
The first listed E code should correspond to the cause of the most serious diagnosis due to an
assault, accident, or self-harm, following the order of hierarchy listed above.
Following the Table of Drugs and Chemicals, there is an alphabetic Index to External Causes that is used to locate E codes. It is used the same way as the Index to Diseases. Locate the main term of the external cause in the Index to External Causes, review all sub terms, and verify the code in the Tabular Index.

35. The End
Chapters 3 through 5 have given you a detailed overview of the ICD-9-CM Guidelines. Each chapter related to body systems will discuss ICD-9-CM coding as it relates to that chapter.