1. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 11 CHAPTER-SPECIFIC GUIDELINES (ICD-9-CM CHAPTERS 1-8)

2. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 ICD-9-CM, Chapter 1 Infectious and Parasitic Diseases –Divided based on etiology (cause of disease) –Many combination codes –Example: 112.0 candidiasis infection of mouth, which reports both organism and condition with one code

3. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Multiple Codes Sequencing must be considered –UTI due to Escherichia coli 599.0 (UTI) etiology 041.4X (E. coli) organism –041 category is a secondary-code only

4. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Section I.C.1.a,d,e Human Immunodeficiency Virus Code HIV or HIV-related illness ONLY if stated as confirmed in diagnostic statement 042 HIV or HIV-related illness V08 Asymptomatic HIV status 795.71 Nonspecific HIV serology Once an HIV diagnosis cannot code V08

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Section I.C.1.a.2.f. Previously diagnosed HIV-related illness Code prior diagnosis HIV-related disease 042 (HIV) NEVER assign these patients to: –V08 (asymptomatic) or –795.71 (Nonspecific serologic evidence of HIV)

6. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Section I.C.1.a.2. Selection and sequencing of HIV codes If admitted for HIV-related illness (e.g., pneumonia) –Code 042 (HIV) –Followed by current illness (pneumocystic carinii, 136.3) If admitted for other than HIV-related illness –Code first-listed diagnosis –Then 042 (HIV) (Cont’d…)

7. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Section I.C.1.a.2. Selection and sequencing of HIV codes (…Cont’d) Sequence Reason most responsible for encounter, if HIV (042) –Any additional diagnosis that impacts treatment

8. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Section I.C.1.a.2.g. HIV infection in Pregnancy, Childbirth and the Puerperium Exception to HIV sequencing During pregnancy, childbirth, or puerperium, code: –647.6X (Other specified infections and parasitic diseases) –Followed by 042 (HIV) (stated diagnosis) –Then any HIV-related illness (Cont’d…)

9. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Section I.C.1.a.2.g. HIV and Pregnancy (…Cont’d) Asymptomatic HIV during pregnancy, childbirth, or puerperium –647.6X (Other specified infections and parasitic diseases) and –V08 (Asymptomatic HIV infection status)

10. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Section I.C.1.a.2.e. Patients with inconclusive HIV serology 795.71 (Inconclusive serologic test for HIV)

11. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Section I.C.1.a.2.h. Encounters for testing for HIV Code V73.89 (Screening for other specified viral disease) –Patient in high-risk group for HIV –V69.5 (Other problems related to lifestyle) Patients returning for HIV screening results = V65.44 (HIV counseling)

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Caution Incorrectly applying these HIV coding rules can cause patient hardship –Insurance claims for patients with HIV usually need patient’s written agreement to disclose

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Section I.C.1.b. Septicemia, Septic Shock and SIRS Septicemia: systemic disease of microorganisms or their toxins in the blood (blood poisoning) Septic shock: cardiovascular failure due to sepsis SIRS: Systemic Inflammatory Response Syndrome is a systemic response to infection/trauma Sepsis refers to SIRS due to infection Severe sepsis is sepsis with acute organ dysfunction (Cont’d…)

14. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Section I.C.1.b. Septicemia, Septic Shock and SIRS (…Cont’d) Code septicemia (038.XX) SIRS second (995.9X) If documented, septic shock (785.52) should be reported Sepsis and septic shock associated with OB codes, also use code 630-633, Ectopic and Molar Pregnancy Septic shock is never primary or first-listed diagnosis

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 Sepsis and Severe Sepsis not associated with noninfectious process Infection resulting from Trauma, Other Serious Injury, Pancreatitis –Code Trauma/Injury –SIRS second (995.9X) –Any acute organ dysfunctions When sepsis or severe sepsis is PDx, sequence systemic infection & sepsis codes before non-infectious condition

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 ICD-9-CM, Chapter 2 Neoplasm Two steps for coding neoplasms: 1.Index: Locate histologic type of neoplasm (e.g., sarcoma, melanoma) Review all instructions 2.Locate code identified (usually in Neoplasm Table in Index) by body site Neoplasms Table divided into columns: 1.Malignant (primary, secondary, Ca in situ) 2.Benign 3.Uncertain behavior 4.Unspecified

17. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 ICD-9-CM, Chapter 2 Neoplasm Morphology Codes-Appendix A ICD-9-CM Codes are alpha numeric: M + 4 numeric characters, a slash, followed by 5 th digit (indicates behavior) Assigned by tumor registry coder /0= Benign /1= Uncertain benign/malignant/borderline /2=Carcinoma in situ /3= Malignant, primary site /6= Malignant, secondary/metastatic site /9= Malignant, uncertain if primary/secondary site Not assigned in outpatient setting

18. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 Section I.C.2. Neoplasms Treatment directed at malignancy: Neoplasm is first-listed diagnosis –Except for chemotherapy or radiotherapy: 1. Therapy (treatment) 2. Neoplasm Chemotherapy: V58.11—encounter for reason the patient presents for treatment, #1 diagnosis Radiotherapy: V58.0—encounter for reason the patient presents for treatment, #1 diagnosis (Cont’d…)

19. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Section I.C.2. Neoplasms (…Cont’d) Surgical removal of neoplasm and subsequent chemotherapy or radiotherapy –Code malignancy as first-listed diagnosis Surgery to determine extent of malignancy –Code malignancy as first-listed diagnosis –Code neoplasm as long as patient is receiving treatment or medication following excision (Cont’d…)

20. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Section I.C.2. Neoplasms V10, “Personal history of malignant neoplasm” if –Neoplasm was previously destroyed/removed –No longer being treated (Cont’d…) (…Cont’d)

21. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Section I.C.2. Neoplasms (…Cont’d) If patient receives treatment for secondary neoplasm (metastasis): –Secondary neoplasm is first-listed diagnosis –Even though primary is known –Code primary neoplasm as secondary diagnosis or if no longer treated code personal history of... (Cont’d…)

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Section I.C.2. Neoplasms (…Cont’d) Admission for symptoms of primary or secondary neoplasm –Malignancy first-listed diagnosis –Do NOT code symptoms or signs First-listed is site receiving treatment If both primary and mets are treated, code primary as first-listed (Cont’d…)

23. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Section I.C.2. Neoplasms (…Cont’d) Patient treated for anemia or dehydration due to neoplasm or therapy Code –Anemia or dehydration –Neoplasm Patient admitted for pain control due to neoplasm, 338.3 (Cont’d…)

24. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Section I.C.2. Neoplasms (…Cont’d) Patient admitted to repair complication of surgery for an intestinal malignancy –Complication first-listed diagnosis Complication is reason for encounter –Malignancy secondary diagnosis (Cont’d…)

25. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 V Codes and Neoplasms Patient receiving chemotherapy or radiotherapy post-op removal of neoplasm Code: 1.Therapy 2.Active neoplasm still being treated Do NOT report H/O (history of) neoplasm

26. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 ICD-9-CM, Chapter 3 Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders

27. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Disorders of Other Endocrine Glands Diabetes Mellitus 250 coded frequently –Subterms often have two codes –Example: 1. Diabetic iritis 250.5X for diabetes (etiology) 2. [364.42] for iritis (manifestation) Metabolic manifestation only one code assignment, e.g., diabetic ketoacidosis (250.1X) (Cont’d…)

28. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Disorders of Other Endocrine Glands (…Cont’d) Fifth digit indicates type of diabetes –Adult or juvenile 0, 2: Type II 0 Type II or unspecified type, not stated as uncontrolled 2 Type II or unspecified type uncontrolled 1, 3: Type I 1 Juvenile type, not stated as uncontrolled 3 Juvenile type, uncontrolled (Cont’d…)

29. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Disorders of Other Endocrine Glands ( …Cont’d) Type I—Insulin dependent—pancreas does not produce insulin Type II—non-insulin dependent—(can be on insulin) “Uncontrolled”—must be documented by physician –Can use “out of control” –Cannot assign “uncontrolled” status when documentation states “poorly controlled” (Cont’d…)

30. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Disorders of Other Endocrine Glands (…Cont’d) V58.67 in addition to diabetes code to indicate long-term use of insulin If type is not indicated, code Type II diabetes Patient with Type II diabetes can receive insulin Type I diabetic is insulin dependent

31. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Other Metabolic and Immunity Disorders Section Disorders such as gout and dehydration Disorders often have many names –242.0X Toxic diffuse goiter also known as: Basedow’s disease Graves’ disease Primary thyroid hyperplasia

32. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 ICD-9-CM, Chapter 4 Diseases of Blood and Blood-Forming Organs Short chapter with 10 sections Includes anemia, blood disorders, coagulation defects (Cont’d…)

33. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Chapter 4 (…Cont’d) Often used code, anemia Many different types of anemia: –Hereditary hemolytic (282) –Iron deficiency (280) –Acquired hemolytic (283) Multiple coding often necessary Identify underlying disease condition (Cont’d…)

34. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 Chapter 4 (…Cont’d) Two confusing anemias: anemia of chronic disease –disease causing anemia is chronic –Code 285.2X and then the appropriate code for the chronic disease chronic simple anemia –Anemia (285.9), chronic simple (281.9)

35. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 ICD-9-CM, Chapter 5, Mental, Behaviorial and Neurodevelopmental Disorders Includes codes for –Personality disorders –Stress disorders –Neuroses –Psychoses –Sexual deviation/dysfunction, etc. –Intellectual disabilities (Cont’d…)

36. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 Chapter 5 (…Cont’d) Fifth digit = status of episode Example: 304, Drug dependence has following fifth digits: 0: unspecified (episode) 1: continuous 2: episodic 3: in remission

37. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 ICD-9-CM, Chapter 6 Diseases of Nervous System and Sense Organs –Central Nervous System –Peripheral Nervous System –Disorders of Eye and Adnexa –Diseases of Ear and Mastoid Process

38. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 Pain not elsewhere classified (338) Acute or chronic pain due to: –Trauma –Postoperative –Neoplasm –Psychosocial dysfunction NOT for generalized or localized pain First-listed/primary diagnosis –When definitive diagnosis not established –Pain management is reason for encounter/admission

39. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 ICD-9-CM, Chapter 7—Diseases of Circulatory System Three types of hypertension: –Malignant—accelerated –Benign—continuous, mild (BP↑) controllable, no irreversible vascular changes –Unspecified—NOT indicated as either malignant or benign (.9) Hypertension table located in Index of ICD-9-CM –Under “H,” Hypertension –Locate now

40. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 Section I.C.7.a.1. Hypertension, Essential, or NOS Assign hypertension –arterial –essential –primary –systemic –NOS to 401 Fourth digit to indicate type, 401.X

41. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Section I.C.7.a.2. Hypertension with Heart Disease 402 Category Certain heart conditions when stated “due to hypertension” or implied (“hypertensive”) Add fourth digit for type Use additional code to specify type of heart failure (428)

42. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 42 Section I.C.7.a.3. Hypertensive Chronic Kidney Disease Cause-and-effect relationship assumed in chronic kidney disease with hypertension Category 403, Hypertensive chronic kidney disease, used when: –Category 585 or code 587 are present with hypertension With 403 assign fifth digit 0 stage I-IV or unspecified and 1 for stage V or end stage renal disease

43. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 43 Section I.C.7.a.4. Hypertensive Heart and Chronic Kidney Disease Assign 404 when both hypertensive chronic kidney disease and hypertensive heart disease stated Assume cause-and-effect relationship Assign fifth digit for mention of heart failure, and/or kidney failure stages I-IV or end stage renal disease –Use additional code from category 428, identifying type of heart disease

44. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 44 Stages of Chronic Kidney Disease Stage I: Blood flow through kidney increases, kidney enlarges (585.1) Stage II: (mild) Small amounts of blood protein (albumin) leaks into urine (microalbuminuria) (585.2) Stage III: (moderate) Albumin and other protein losses increase. Patient may develop high BP and kidney’s filter ability (585.3) Stage IV: (severe) Large amounts of urine pass through kidney, blood pressure increases (585.4) Stage V: Ability to filter waste nearly stops (585.5) End stage renal failure (585.6) –When documentation indicates chronic renal disease (CKD) and ESRD, report ESRD Unspecified 585.9

45. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 45 Section I.C.7.a.5. Hypertensive Cerebrovascular Disease Code: Cerebrovascular disease (430-438) first Type of hypertension (401-405) second

46. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 46 Section I.C.7.a.6. Hypertensive Retinopathy Code: Hypertensive retinopathy first (362.11) Type of hypertension (401-405) second first

47. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 47 Section I.C.7.a.7. Hypertension, Secondary Hypertension caused by an underlying condition –Code: 1.Underlying condition first 2.Type of hypertension (405) second

48. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 48 Section I.C.7.a.8. Hypertension, Transient Transient hypertension: Temporary elevation of BP DO NOT assign 401-405 Hypertensive Disease –Hypertension diagnosis NOT established –Instead use: 796.2, Elevated blood pressure 642.3X, Transient hypertension of pregnancy

49. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 49 Section I.C.7.a.9. Hypertension, Controlled Hypertension controlled by therapy –Assign code from 401-405

50. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 50 Section I.C.7.a.10. Hypertension, Uncontrolled Untreated hypertension Uncontrolled hypertension Assign code from 401-405

51. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 51 Section I.C.7.a.11. Elevated Blood Pressure Elevated blood pressure coded 796.2 –Elevated BP reading without hypertension diagnosed –Hypertension NOT stated, NOT coded to 401 (essential hypertension)

52. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 52 ICD-9-CM, Chapter 7—Diseases of Circulatory System Code 410 Acute Myocardial Infarction (MI) requires a fifth digit: “1” Initial episode of care for MI May be reported by more than one facility, if patient transferred “2” Subsequent care Patient re-admitted for testing/treatment within the first eight (8) weeks of initial episode Code 412 reported for old/healed MI –No symptoms

53. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 53 Chapter 8, Diseases of Respiratory System Watch for: “Use additional code to identify infectious organism” –Some codes indicate specific organism and do not need an additional code

54. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 54 Respiratory Failure (RF) Sequencing If RF due to an acute condition (e.g., MI) or acute exacerbation of chronic condition (e.g., COPD) Per new guidelines, if there are no chapter-specific guidelines (OB, poisoning) regarding sequencing, either RF or acute condition may be first-listed diagnosis

55. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 55 Acute Respiratory Infection Section Frequently used codes, such as: –Common cold (460, acute nasopharyngitis) –Sore throat (462, acute pharyngitis) –Acute tonsillitis (463) –Bronchitis (490-491) –Acute upper respiratory infection (465.9, URI) –Influenza (487, flu) Read Guidelines for Chapter 8 for specifics on coding COPD and asthma

56. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 56 Conclusion CHAPTER 11 CHAPTER-SPECIFIC GUIDELINES (ICD-9-CM CHAPTERS 1-8)