1. Introduction to ICD-9-CM
PART TWO
Introduction to ICD-9-CM
Chapter 2
ICD-9-CM Basics
McGraw-Hill/Irwin
Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

2. LEARNING OUTCOMES After studying this chapter, you should be able to:
2-2
LEARNING OUTCOMES
After studying this chapter, you should be able to:
1. Briefly discuss the History and Background of
ICD-9-CM.
2. Discuss the roles of the NCHS, CMS,AHIMA, and
the AHA in maintaining and updating ICD-9-CM codes.
3. Explain how to locate the periodic updates to ICD-9-
CM codes using the internet.
4. Identify five uses of the ICD-9-CM.
5. Discuss the importance of the ICD-9-CM
Official Guidelines for Coding and Reporting.

3. LEARNING OUTCOMES (cont’d)
2-3
LEARNING OUTCOMES (cont’d)
6. Describe the organization and content of Volumes 1, 2, and 3 of ICD-9-CM.
7. Interpret the formats, conventions, and symbols
used in ICD-9-CM.
8. List the basic process of assigning ICD-9-CM codes.
9. Describe the meaning of coding to the highest level of specificity.
10. Identify common medical resources used to assist in the assignment of accurate ICD-9-CM codes.

4. KEY TERMS Addenda AHA Coding Clinic© for ICD-9-CM
2-4
KEY TERMS
Addenda
AHA Coding Clinic© for ICD-9-CM
Alphabetic Index (Volume 2)
Alphabetic Index to External Cause of Disease and Injury
Alphabetic Index and Tabular List of Procedures (Volume 3)
American Hospital Association (AHA)
Braces
Brackets
Carryover lines
Category
Centers for Disease Control (CDC)
Chapter
Code first underlying disease
Colon
Conventions
Cooperating parties
Cross-references
E code
Encoder
Eponym
Etiology
Excludes
ICD-9-CM Coordination and Maintenance Committee
ICD-9-CM Official Guidelines for Coding and Reporting
ICD-10-CM

5. KEY TERMS (cont’d) Includes International Classification of Diseases
2-5
KEY TERMS (cont’d)
Includes
International Classification of Diseases
Adapted for Indexing of Hospital Records and Operation Classification (ICDA)
International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
Lozenge
Main term
Manifestation
Omit code
Parenthesis
Section mark
Subcategory
Subclassification
Subterm
Supplemental classification system
Table of Drugs and Chemicals
Tabular List (Volume 1)
Use additional code
V code
World Health Organization (WHO)

6. HISTORY AND BACKGROUND
2-6
HISTORY AND BACKGROUND
ICD-9-CM (International Classification of Diseases, Ninth Edition, Clinical Modification
The classification system used to maintain all diagnoses for medical visits in the USA
Maintained by NCHS (National Center for Health Statistics) and CMS (Centers for Medicare and Medicaid Services)
CODE SET
Three Volumes
Volume 1 and 2 = used to classify diagnoses
Volume 3 = used to classify inpatient procedures in hospitals

7. ICD-9-CM Background 1958 U.S. Public Health Service
2-7
ICD-9-CM Background
1958 U.S. Public Health Service
Published ICDA (International Classification of Diseases
Morbidity (illnesses)
Mortality (death)
1978 WHO (World Health Organization) published a ninth revision of ICD called ICD-9

8. *Medical coders must have the most updated version each year
2-8
ICD-9-CM TODAY
Updated every year
Maintained by: NCHS and CDC (Centers for Disease Control)
Addenda: Updating the ICD-9-CM*
October 1 and April 1 of each year
October 1 – Major Updates
April 1 – includes codes that were not in October changes
Codebooks published by U.S. Government Printing Office (GPO) on the Internet and in CD-ROM format each year
*Medical coders must have the most updated version each year

9. Official ICD-9-CM Guidelines (written by NCHS and CMS)
2-9
Official ICD-9-CM Guidelines (written by NCHS and CMS)
The HIPPA (Health Insurance Portability and Accountability Act) RULE mandates the use of guidelines for coding and reporting when codes are selected. Guidelines:
Standardize the assignment of ICD-9-CM for all users
Assist the coder in understanding the basic rules of code selection when using the ICD-9-CM
Explain certain coding rules for specific medical conditions.

10. Official ICD-9-CM Guidelines* (cont’d)
2-10
Official ICD-9-CM Guidelines* (cont’d)
Official ICD-9-CM Guidelines* (cont’d) (written by NCHS and CMS)
Guidelines approved by cooperating parties:
American Hospital Association (AHA)
American Health Information Management Association (AHIMA)
CMS
NCHS
*Basis for consistent and accurate ICD-9-CM reporting

11. PURPOSES AND USE OF ICD-9-CM
2-11
PURPOSES AND USE OF ICD-9-CM
Reporting and Research
Monitoring the Quality of Patient Care
Communications and Transactions
Reimbursement
Administrative Uses

12. I Conventions, general coding guidelines, and chapter-
2-12
Table 2.1 Major Sections of the ICD-9-CM Official Guidelines
for Coding and Reporting
Section Content
I Conventions, general coding guidelines, and chapter-
specific guidelines
II Selection of Principal Diagnosis
III Reporting Additional Diagnoses
IV Diagnostic and Reporting Guidelines for Outpatient Services
Appendix I Present on Admission Reporting Guidelines

13. ICD-9-CM Basic Coding Process
2-13
ICD-9-CM Basic Coding Process
Review complete medical documentation
Abstract the medical conditions and procedures that should be coded
Identify the main term for each condition and procedure
Locate the main terms in the Alphabetic Index
Verify the code in the Tabular List by reading all notes and applying appropriate conventions and guidelines

14. The Three Volumes of the ICD-9-CM
2-14
VOLUME 1(Diseases and Injuries: Tabular List)
VOLUME 2 (Diseases and Injuries: Alphabetic Index)
VOLUME 3 (Procedures: Tabular List and Alphabetic Index)

15. Volume 2 Alphabetic Index (this volume is used first)
2-15
Volume 2 Alphabetic Index (this volume is used first)
Alphabetic Index to Diseases and Injuries
Table of Drugs and Chemical
Alphabetic Index to External Causes of Diseases and Injures

16. Volume 2 Alphabetic Index this volume lists:
2-16
Volume 2 Alphabetic Index this volume lists:
Main Terms (that represent diseases, injuries, problems, complaints, drugs, and external causes of diseases and conditions)
Eponyms (names and phrases based on a person’s name – i.e., Gamstorp’s disease)
Subterms (words that are indented under a main term)

17. Alphabetic Index (example)
2-17
Alphabetic Index (example)
Bronchitis (diffuse) (hypostatic) (infectious) (inflammatory)
(simple) 490
with
emphysema – see Emphysema
influenza, flu, or grippe
obstruction airway, chronic
acute bronchitis
exacerbation (acute)

18. 2-18
CHECKPOINT QUESTION
The Alphabetic Index lists words that describe diseases or injuries
TRUE or FALSE

19. 2-19
TRUE

20. Volume 1 Tabular List Has three divisions:
2-20
Volume 1 Tabular List
Has three divisions:
17 chapters of disease descriptions and codes
Two supplementary classifications
Appendixes

21. Tabular List (example)
2-21
Tabular List (example)
OBSTRUCTIVE CHRONIC BRONCHITIS
Bronchitis:
Emphysematous
Obstructive (chronic) (diffuse)
Bronchitis with:
Chronic airway obstruction
Emphysema

22. Tabular List (Appendixes)
2-22
Tabular List (Appendixes)
APPENDIX A B C D E
TOPIC
Morphology of Neoplasms
Glossary of Mental Disorders (officially removed October 1, 2004)
Classification of Drugs by American Hospital Formulary Service List Number and ICD-9-CM Equivalents
Classification of Industrial Accidents
List of Three-Digit Categories

23. Tabular List (supplementary classifications)
2-23
Tabular List (supplementary classifications)
V CODES (reports circumstances other than disease or injury)
A well-child visit; a visit for a routine chest x-ray
E CODES (classify the causes of injury, poisoning, and adverse events and are used to gather statistics relating to these occurrences)

24. Tabular List Format (reflects this method of identifying diagnoses)
2-24
Tabular List Format (reflects this method of identifying diagnoses)
Chapter Range of codes
Section Range of codes within a chapter
Category Three-digit code
Subcategory Four-digit code
Subclassification Five-digit code

25. Volume 3 Alphabetic Index and Tabular List of Procedures
2-25
Volume 3 Alphabetic Index and Tabular List of Procedures
Covers inpatient procedures coding
Used only by the facility (not used to classify procedures performed by physicians in any setting)

26. 2-26
Volume 3 (cont’d)
Formatted alphabetically by the type of procedure, eponym, or operation
Procedure codes contain three or four digits, with two characters placed to the left of the decimal point
EXAMPLES:
35.0 CLOSED HEART VALVOTOMY
35.10 OPEN HEART VALVULOPLASTY WITHOUT REPLACEMENT, UNSPECIFIED VALVE

27. 2-27
ICD-9-CM Conventions
Conventions or notations appear throughout the ICD-9-CM.
CARDINAL RULE:
Codes are never selected from one volume alone
Always start with the Alphabetic Index
Finish by verifying the code in the Tabular List
Specific details and examples of coding conventions in Tables 3.5 and 3.6

28. ICD-9-CM Conventions(cont’d)
2-28
ICD-9-CM Conventions(cont’d)
Modifiers (also called parenthetical or nonessential modifiers) found in Alphabetic Index (Volumes 2 and 3)
Abbreviations – used in all three volumes
EX: NEC – Not Elsewhere Classified
Notes – used to define terms and give coding instruction.
EX: Infarct, infarction
…..
myocardium, myocardial (acute or with a stated duration of 8 weeks or less) (with hypertension)
_____________________________________________
Note – Use the following fifth-digit subclassification with category 410:
0 episode unspecified
1 initial episode
2 subsequent episode without recurrence

29. ICD-9-CM Conventions (cont’d)
2-29
ICD-9-CM Conventions (cont’d)
Cross-References – The terms see, see also, and see category indicate cross-references. This means that the coder must look elsewhere to code a particular condition.
EX:
Parkinson’s Disease, syndrome or tremor – see Parkinson
Paresthesia – see also Disturbance, sensation
Fever, brain, late effect, - see category 326

30. ICD-9-CM Conventions (cont’d)
2-30
ICD-9-CM Conventions (cont’d)
Punctuation – ICD-9-CM uses various punctuation marks that direct the coders to following certain rules, provide additional meaning, or explain terms.
EX:
Brackets [ ] used to enclose synonyms, alternative words, and explanatory phrases in the Tabular List
Pleuropneumonia-like organisms [PPLO]
Slanted Brackets [ ] – Some conditions may required two codes, one for the etiology (the cause or origin of the condition), and a second for the manifestation (a disease resulting from the underlying disease or disorder)
Anthrax
with pneumonia [484.5]
Parentheses ( ) used in both the Alphabetic Index and the Tabular List to enclose terms that are supplementary. Also used for nonessential terms

31. ICD-9-CM Conventions (cont’d)
2-31
ICD-9-CM Conventions (cont’d)
Punctuation (cont’d)
Colon : is used in the Tabular List after an incomplete term that needs one or more of the terms or modifiers that follow it.
EX:
Pharyngitis (acute):
NOS
Gangrenous
Braces { } are occasionally used in the Tabular List to enclose a series of terms that, when combined with the statement to the right of the brace, results in that specific code assignment
INTERNAL INJURY OF THORAX, ABDOMEN, AND PELVIS ( )
Includes:
{blast injuries, blunt trauma, bruise….}

32. ABBREVIATIONS are only used in
2-32
CHECKPOINT QUESTION
ABBREVIATIONS are only used in
VOLUMES 1 and 2
TRUE or FALSE

33. 2-33
FALSE

34. 2-34
ICD-9-CM Symbols (special symbols instruct the coder that there is a special circumstance regarding that code)
Lozenge □ indicates that a code is unique to ICD-9-CM, the ICD-9-CM code does not appear in the ICD-9. The lozenge symbol is located in the ICD-9-CM Tabular List only and can be ignored by coders.
EX:
□ MAJOR DEPRESSIVE DISORDER,
RECURRENT EPISODE
Section Mark symbol § precedes a code to indicate that there is a footnote with special instructions. This symbol is found in all three volumes.
§ 675 INFECTIONS OF THE BREAST AND NIPPLE
ASSOCIATED WITH CHILDBIRTH

35. ICD-9-CM Symbols (cont’d)
2-35
ICD-9-CM Symbols (cont’d)
Typeface
Bold Boldface print is used to identify main terms and titles in the Alphabetic Index. Bold type in the Tabular List depicts each code and code title.
Italics – In the Tabular List of Disease and Injuries, italics indicate that the code should not be reported alone or listed first. The code in italics typically represents a manifestation of disease – the underlying cause should be reported first, before the code in italics.
EX:
PNEUMONIA IN OTHER INFECTIOUS DISEASE
CLASSIFIED ELSEWHERE
Code first underlying disease, as:
Q fever (083.0)
Typhoid fever (002.0)

36. 2-36
Instructional Notations (these notations tell the coder to do something, or let the coder know that types of disease are included or excluded)
Includes – refers to a code to give an example or define the contents of the code or code series
Ex: TUBERCULOSIS ( )
Includes: Embolism, of basilar…
Excludes – instructs the coder about words or conditions that should be coded elsewhere. In other words, these conditions are not included in the code
Ex: HEMMORRHOIDS
Includes: Hemorrhoids…
Excludes:
that complicating pregnancy, childbirth, or the puerperium (671.8)

37. Instructional Notations (cont’d)
2-37
Instructional Notations (cont’d)
Use Additional Code – tells the coder to also code further information if it is documented.
Ex: URINARY TRACT INFECTION, SITE NOT SPECIFIED
Use additional code to identify organism, such as Escherichia coli [E. coli] (041.4)
Code First Underlying Disease – is located only in the Tabular List with codes that are not intended to be selected as primary disease because they are manifestations of other underlying diseases
Ex: 517 LUNG INVOLVEMENT IN CONDITIONS CLASSIFIED ELSEWHERE
Excludes:
Rheumatic lung ((714.81)
517.1 RHEUMATIC PNEUMONIA
Code first underlying disease (390)

38. Instructional Notations (cont’d)
2-38
Instructional Notations (cont’d)
Omit Code – is found only in the Alphabetic Index to Procedures in Volume 3. It is seen next to a term listing an incision, such a laparatomy.
Ex:
Arthrotomy 80.10
As operative approach – omit code

39. TABLE OF DRUGS AND CHEMICALS
2-39
TABLES
Three tables in ICD-9-CM are used to provide an organized structure for the coding of certain diseases and drugs. The format of each table is based on the need to classify different types of disease, sites of disease, or circumstances of disease.
The tables are:
HYPERTENSION TABLE
NEOPLASM TABLE
TABLE OF DRUGS AND CHEMICALS

40. 2-40
TABLES (cont’d)
HYPERTENSION TABLE – located at the main term hypertension in the Alphabetic Index. It contains a complete listing of conditions associate with hypertension (subterms) and requires classification of the hypertension conditions as malignant, benign, or unspecified
Example: Benign cardiorenal hypertension is classified as code The main term is hypertension; the subterm is cardiorenal, and the second column lists benign.

41. 2-41
TABLES (cont’d)
NEOPLASM TABLE – the table is organized alphabetically by body or anatomical site. The first column list anatomical location, the next six columns relate to the behavior of the neoplasm.

42. 2-42
TABLES (cont’d)
TABLE OF DRUGS AND CHEMICALS is used to classify poisoning or adverse effects, which are conditions inadvertently caused by the correct use of the drug. The table is organized alphabetically by the drug or chemical name.

43. Coding to the Highest Level of Specificity
2-43
Coding to the Highest Level of Specificity
ICD-9-CM codes are to be used at their highest level of specificity
Assign three-digit codes only if there are no four-digit codes within that code category.
Assign four-digit codes only if there is no fifth-digit subclassification for that category.
Assign the fifth-digit subclassification code for those categories where it exists.

44. 2-44
SUMMARY
The best way to keep up-to-date on ICD-9-CM changes is to use the Internet
For all health care providers to use ICD-9-CM accurately and consistently, the Official Guidelines for Coding and Reporting for its use must be followed.
Having the resources to assign ICD-9-CM codes accurately is essential.

45. 2-45
Common Medical Resources for use with assigning accurate ICD-9-CM Codes
Access to national coding guidelines
Medical dictionaries
Medical Internet sites
Published coding advice
Continuing education

46. Internet Resources for ICD-9-CM
2-46
Internet Resources for ICD-9-CM
Official Guidelines for Coding and Reporting --
ICD-9-CM Coordination and Maintenance Committee
ICD-9-CM Code Updates
See also: The American Hospital Association Coding Clinic©
for ICD-9-CM
NCHS Website (National Center for Health Statistics)