CHAPTER 15 USING THE ICD-9-CM.

CHAPTER 15 USING THE ICD-9-CM

Using the ICD-9-CM General Guidelines
Chapter 1, Infectious and Parasitic Diseases Chapter 2, Neoplasms Chapter 3, Endocrine, Nutritional, and Metabolic Diseases, and Immunity Disorders Chapter 4, Diseases of Blood and Blood- Forming Organs Chapter 5, Mental Disorders Chapter 6, Diseases of Nervous System and Sense Organs Chapter 7, Diseases of Circulatory System Chapter 8, Diseases of Respiratory System Chapter 9, Diseases of Digestive System Chapter 10, Diseases of Genitourinary System Chapter 11, Complications of Pregnancy, Childbirth, and Puerperium Chapter 12, Diseases of Skin and Subcutaneous Tissue Chapter 13, Diseases of Musculoskeletal System and Connective Tissue Chapters 14 and 15, Congenital Anomalies; Certain Conditions Originating in Perinatal Period Chapter 16, Symptoms, Signs, and Ill-Defined Conditions Chapter 17, Injury and Poisonings and E Codes Basic Coding Guidelines ICD-10-CM The ICD-9-CM includes 17 chapters. Section I presents the ICD-9-CM conventions, general coding guidelines, and chapter-specific guidelines. Sections II and III outline the selection of diagnoses for inpatient records. Section IV contains the diagnosis guidelines for outpatient services.

Using the ICD-9-CM Guidelines developed by cooperating parties
AHA (American Hospital Association) AHIMA (American Health Information Management Association) CMS (Centers for Medicare and Medicaid Services) NCHS (National Center for Health Statistics) As cooperating parties for ICD-9-CM, these entities developed and approved the guidelines for coding and reporting.

General Guidelines Appendix A of text contains official Guidelines
Inpatient coders use Sections I-III of Guidelines Outpatient coders primarily use Sections I and IV, however… (Cont’d…) In the text, official guidelines that apply to only one setting are identified as “inpatient” or “outpatient.” From which section do inpatient coders code? (Sections 1-111) From which section do outpatient coders code? (Primarily section 1 and IV.)

General Guidelines Basic coding guidelines do NOT cover all situations
(Cont’d…) Basic coding guidelines do NOT cover all situations Outpatient coders also use many inpatient guidelines Slides within presentation labeled “(I)” for inpatient or “(O)” for outpatient Slides that apply to both inpatient and outpatient, labeled “(I/O)” The number that appears to the left of the guideline in the text is the number of the guideline as listed in the Official Guidelines for Coding and Reporting. These are only basic coding guidelines and are not for all situations. When we are going through these slides they will be marked with either an (I) for inpatient, or (O) for outpatient depending on what they pertain to.

Steps to Diagnosis Coding (I/O)
Identify MAIN term(s) in diagnosis Locate MAIN term(s) in Index Review subterms Follow cross-reference instructions (e.g., see, see also) Verify code(s) in Tabular If you begin coding by using these steps, you will develop good coding habits. What is the first step in correct coding of diagnoses? (Identify the main term(s) of the diagnosis you are going to code.) What is the second step in correct coding of diagnoses? (Locate the main term(s) in the index)

Remember (I/O) Read Tabular notes Code to highest specificity (detail)
NEVER CODE FROM INDEX! Also, code the diagnosis until all elements are completely identified. Remember, just as in CPT coding, you never code from the Index of the ICD-9-CM. Always check the cross references and instructions and verify your code in the Tabular.

Guideline Section I.B.3. Level of Detail in Coding (I/O)
Assign diagnosis to highest level of specificity Do NOT use three-digit code if there is fourth Do NOT use four-digit code if there is fifth If not specific, claims bounce! Diagnosis and procedure codes are to be used at the highest number of digits available, according to documentation in the medical record. Diagnosis codes with three digits are included in the ICD-9-CM as the heading of a category of codes that may be further subdivided. A code is invalid if it has not been coded to the full number of digits available for that code.

Section I.A.2. Abbreviations Other (NEC) and Unspecified (NOS) (I/O)
Use ONLY if more specific code NOT available NEC = Not elsewhere classifiable More specific code does NOT exist NOS = Not otherwise specified (Means “unspecified”) Available information NOT specific enough NEC is an abbreviation used in the Index. Both NEC and NOS are abbreviations used in the Tabular List. Third-party payers prefer specific codes. Use the NOS code only if it is believed to be the correct code after a thorough review of medical documentation.

Section I.B.10. Acute and Chronic Conditions (I/O)
Exists alone or together May be separate or combo codes If two codes, code acute first (Cont’d…) What is the difference between acute and chronic? (Acute: having a short and relatively severe course. Chronic: persisting over a long time) If the same condition is described as both acute (or subacute) and chronic and separate subentries with the same indentation level exist in the Alphabetic Index, both should be coded. Sequence the acute or subacute code first.

(…Cont’d) Example, acute and chronic pancreatitis When two separate codes exist, code: Acute pancreatitis 577.0 Chronic pancreatitis 577.1 Place acute first and chronic second 577.0, 577.1 (Cont’d…) When acute and chronic conditions both exist and the index contains separate entries for both, use both codes. Always sequence the acute code first.

(…Cont’d) Combination code: Both acute and chronic condition Diarrhea (acute) (chronic) Acute and subacute bacterial endocarditis 421.0 Otitis acute and subacute 382.9 There are codes that also represent both an acute and chronic condition in one code. What is this type of code called? (A Combination code) Notice that the code definition will tell you what the code entails.

Section I.B.11. Combination Code (I/O)
Always use combination code if one exists Example, encephalomyelitis (manifestation) due to rubella (etiology), A combination code is: A single code used to classify two diagnoses A diagnosis with an associated secondary manifestation. A diagnosis with an associated complication Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading Inclusion and Exclusion notes in the Tabular List. Multiple coding should not be used when the classification provides a combination code that clearly identifies all elements documented in the diagnosis. If the combination code lacks necessary specificity in describing the manifestation or complication, then an additional code may be reported as a secondary code.

Section I.B.9. Multiple Diagnosis Coding (I/O)
Etiology (cause) Manifestation (symptom) Slanted brackets [ ] Example: Retinopathy, diabetic [362.01] Code as shown 250.5X 362.01 (Cont’d…) The etiology/manifestation convention requires two codes to fully describe a single condition that affects multiple body systems. Other instances (single conditions) may require more than one code to fully describe the condition. “Use additional code” indicates that a secondary code should be added. “Code first” notes may be found under certain codes that refer to conditions that may be due to an underlying condition; the underlying condition is sequenced first. “Code, if applicable, any causal condition first” notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable.

Section I.B.9. Multiple Coding for a Single Condition, (I/O)
(…Cont’d) Must check Tabular notes to assign correct fifth digit for diabetes Tabular: 362.0, Diabetic retinopathy, instructs to “Code first diabetes 250.5” 250.5X Cause is diabetes Manifestation is retinopathy Report 250.5X, X = required additional digit There are conditions for which you need two codes to represent one diagnosis. What would the two codes be that you would need to represent one diagnosis? (Possibly, the disease and the underlying cause of the disease-a wound infection due to a bacteria. A disease like diabetes and an effect the diabetes has on the eyes, retinopathy)

Section II.H. Uncertain Diagnosis (I)
If diagnosis at time of discharge states: “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” Code condition as if condition existed until proven otherwise (inpatient facilities code this) Physicians report definitive dx or signs/symptoms (Cont’d…) The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that corresponds most closely with the established diagnosis. The workup, observation, or therapies will be the same whether one is treating the confirmed condition or ruling the condition out

Section II.H. “Cough and fever, probably pneumonia” (I/O)
(…Cont’d) Inpatient: Code pneumonia, do NOT code cough and fever Outpatient: Code cough and fever, do NOT code pneumonia OK to code symptoms in outpatient setting if a definitive diagnosis is not documented Inpatient coders can bill for probable/possible diagnoses but outpatient coders can only bill for confirmed diagnosis. If a patient come into a clinic and has a abdominal pain, and the diagnosis given by the physician is rule out appendicitis, could the outpatient coder code the appendicitis? (No, because they are only ruling it out, it is not a definitive diagnosis yet.) In what setting would the patient have to be in, in order to code the rule out appendicitis? (The patient would have to have been admitted into the hospital.)

Section I.B.13. Impending or Threatened Condition (I)
Code any condition described at time of discharge as impending or threatened Did occur: Code as confirmed Did NOT occur: Code as impending or threatened (MAIN terms) If it did occur, code it as a confirmed diagnosis. If it did not occur, use the Index to determine whether the condition has a subentry term for “impending” or “threatened.” Also, reference the main term entries for Impending and for Threatened. If the subterms are listed, assign the code as given. If the subterms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened.

Selection of Principal Diagnosis (I)
Condition established after study (tests) Chiefly responsible for patient admission What is the difference between the primary and principal diagnosis codes? (Principal diagnosis: Sequenced first in inpatient coding. In an outpatient setting, indicate as the primary diagnosis the main reason for the visit, and sequence the primary diagnosis first.) The principal diagnosis is determined by the circumstances of the patient admission. The coder should list the code for the diagnosis, condition, or problem shown in the medical record to be chiefly responsible for the services provided. Then the coder should list additional codes that describe any coexisting conditions that affect the care of the patient for that encounter.

Selection of First-Listed Diagnosis (O)
Condition for encounter Why patient presented, not necessarily most serious condition noted Documented Chiefly responsible for services provided Also list co-existing conditions In an outpatient setting, coders should indicate the main reason for the visit as the primary diagnosis, as well as subsequent diagnoses to substantiate other services provided, such as laboratory or radiology. Sequence the primary diagnosis first.

Diagnosis and Services (I/O)
Diagnosis and procedure MUST correlate Medical necessity must be established through documentation No correlation = No reimbursement What is the reason for the use of ICD-9 codes? (They establish medical necessity for the documentation.)

Section II.A. Symptoms, Signs, and Ill-Defined Conditions (I)
Chapter 16 Inpatient coders do NOT code when definitive diagnosis has been established These codes are not to be used for principal diagnosis when there is a related definitive diagnosis.

Symptoms, Signs, and Ill-Defined Conditions (O)
Can be the first-listed diagnosis if no more specific diagnosis available Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when the physician has not confirmed an established diagnosis.

Section I.A.3. Codes in Brackets (I/O)
Never sequence as principal diagnosis Although you do not code from the Index, Codes are in correct sequence in Index (Cont’d…) Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. When this combination exists, a “use additional code” note should be used at the etiology code and a “code first” note should be included at the manifestation code. The underlying condition (etiology) should be sequenced first; the code in brackets is always sequenced second.

Section I.A.3. Codes in Brackets, Example (I/O)
(…Cont’d) Index lists: Diabetes, with gangrene 250.7X [785.4] 785.4 = gangrene Tabular: indicates “Code first any associated underlying condition: diabetes (250.7X)….” Code first diabetes, then gangrene 250.7X = diabetes The most commonly used etiology/manifestation combinations are the codes for diabetes mellitus. When is it correct to code 250.7x, Diabetes with gangrene, without 785.4? (Never) Watch closely and let your ICD-9 book guide you to be a great coder. In this example it tells you how to properly code this diagnosis. You are to first code the diabetes and then the underlying condition.

Section II.B. Two or More Interrelated Conditions (I/O)
Two or more interrelated conditions exist Either could be principal diagnosis Either sequenced first (Cont’d…) This is true for both inpatient admissions and outpatient visits. Neither code must be listed as principle so the order does not matter.

Section II.B. Example of Interrelated Conditions (I/O)
(…Cont’d) Mitral valve stenosis and coronary artery disease (two interrelated conditions) Either can be principal diagnosis Either sequenced first MVS and CAD CAD and MVS Resource intensiveness affects choice Mitral valve stenosis is presumed by ICD-9-CM to be of rheumatic origin Interrelated conditions: either diagnosis can be listed as primary. The choice of primary diagnosis usually affects the most resource-intensive procedure.

Section II.C. Two or More Equal Diagnoses (I/O)
Either can be sequenced first Example: Diagnosis of viral gastroenteritis and dehydration if both are treated VG and D D and VG If only dehydration is aggressively treated with IV fluids and the VG is treated with oral meds, sequence dehydration as first-listed When two or more diagnoses equally meet the criteria for principal diagnosis and coding guidelines do not provide sequencing direction, any one of the diagnoses may be sequenced first.

Section II.D. Comparative or Contrasting Conditions (I)
“Either/or” diagnoses Code as confirmed in the inpatient setting If determination CANNOT be made, either can be sequenced first Example: Pneumonia or lung cancer can be either P or LC LC or P If both aggressively treated This is a rare occurrence. When two or more contrasting or comparative diagnoses are documented as “either/or,” they are coded as if the diagnosis were confirmed, and the diagnoses are sequenced according to the circumstances of the admission.

Section II.E. Symptom(s) Followed by Contrasting/Comparative Diagnosis (I)
Symptom code sequenced first Then other diagnoses Example: Patient admitted for chest pain, either gastric reflux or peptic ulcer disease (PUD) Sequence first chest pain Followed by gastric reflux or PUD Rule: Code first underlying condition causing the symptom If it is necessary to code symptom to explain resources used, code also When a symptom is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. The physician will state the diagnosis as “symptoms due to X or Y.” This is different from the previous section, in which the physician stated the diagnosis as “X or Y” instead of listing the symptoms.

Section I.C.18. Observation and Evaluation for Suspected Conditions Not Found (I/O)
V71.01-V71.9 Assigned as principal diagnosis for: Admissions for evaluation Following an accident that would ordinarily result in health problem, BUT there is none Car accident, driver hits head, no apparent injury, admit to R/O head trauma Never a secondary diagnosis There are four primary circumstances for the use of V codes: When a person who is not sick obtains health services, such as vaccination, health screening, or testing to act as an organ donor. When a person with a resolving disease or injury or a chronic condition requiring continuous care receives specific aftercare. When circumstances or problems influence a person’s health status but are not in themselves a current illness or injury. For newborns, to indicate birth status. Can be a first-listed or a secondary code, depending on the circumstances of the encounter.

Section II.F. Original Treatment Plan Not Carried Out (I)
Principal diagnosis becomes Condition that after study was reason for admission as inpatient Treatment does NOT have to be carried out for condition (Cont’d…) The condition that occasioned admission to the hospital should be sequenced as the principal diagnosis, even though treatment may not have been carried out because of unforeseen circumstances.

Section II.F. Example (I)
(Cont’d…) Patient admitted for elective surgery, develops pneumonia, surgery cancelled Code reason for surgery first Code “Surgical or other procedure NOT carried out because of contraindication” (V64.1) Also code pneumonia Always place the reason the patient was admitted to the hospital first, even though treatment may or may not be carried out. If a patient was admitted for elective tonsillectomy due to chronic tonsillitis, but when the patient came in to the hospital was found to have a very high temperature, would the chronic tonsillitis be listed first or the fever? (Tonsillitis)

V Codes Located after 999.9 in Tabular
Two digits before decimal (e.g., V10.1X) Index for V codes is Alphabetic Index to Diseases Main terms: Contraception Counseling Dialysis Status Examination V codes can be located in the Index, similar to any other code. Where is the V code index listed? (The V codes are enclosed in the main index of CPT.) Like other diagnosis codes you would find the main term that you are looking for in the alphabetical index. What are some main terms of V codes? (Status (post), absence, history of, Counseling)

Uses of V Codes (I/O) Not sick BUT receives health care (e.g., vaccination) Services for known disease/injury (e.g., chemotherapy) Codes for “aftercare” (ex., surgery or fracture) (Cont’d…) There are four uses of V codes. When a patient isn’t currently sick but needs to go to the doctor. What would be an example of this? (When a child goes in for immunizations only.) A patient with a known disease who receives health services. What would be an example of this? (A patient who is receiving radiation therapy.)

Uses of V Codes (I/O) (…Cont’d) A circumstance/problem that influences patient’s health BUT NOT current illness/injury Example: Organ transplant status Example: Birth status and outcome of delivery (newborn) Section I.18.e. of Guidelines contains the V Code Table Identifies how V codes can be listed (first, first/additional, additional only) When there is not a current illness or injury. What would be an example of this? (Patient is status post a procedure) To indicate birth status or outcome of surgery. What would be an example of this? (Outcome of delivery)

History V Code Categories in Tabular
Condition no longer present or being treated V12 Personal history of certain other diseases V13 Personal history of other diseases V14 Personal history of allergy to medicinal agents V15 Other personal history presenting hazards to health V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V18 Family history of certain other specific diseases V19 Family history of other conditions “History of” codes are separated by whether it is personal history or family history. Are there only “History of” neoplasm codes? (No) What other “History of” codes are there? (ASHD, asthma, gout, mental disorders)

Special Note About “History of” (I/O)
Index to Disease, MAIN term “History” Entries between “family” and “visual loss V19.0” = “family history of” (FHO) Entries before “family” and after “visual loss” = “personal history of” (PHO) Personal history = V10-V15 Family history = V16-V19 If the patient record states that there is a “history of” a disease, such as diabetes, it does not mean that the patient no longer has the disease; but that the patient’s medical history includes the disease. A V code is not assigned to indicate a previous history of diabetes; rather, the code for the current disease (250.0X) is used. Ask students to use a highlighter and mark their Index where family history begins and ends.

Section I.B.12. Late Effects (I/O)
Ex., followed by code 906.6 Late effect is a residual of (remaining from) previous illness/injury e.g., Scar produced by previous burn Residual coded first (scar) Late effect cause (burn) coded second 906.6 No time limit Generally requires 2 codes (Cont’d…) Late effects codes are not in a separate chapter in the Tabular List. Instead, the coder must identify a case as a late effect. Sometimes, an acute illness or injury leaves a patient with a problem that remains after the illness or injury has resolved. The code for the current injury or illness cannot be coded at the same time as the code for the late effect, except in the case of cerebrovascular disease.

Late Effects Late effect codes not in separate chapter
(…Cont’d) Late effect codes not in separate chapter Rather throughout Tabular Reference the term “Late” in the Index There is no time limit on developing a residual There may be more than one residual Example: Patient had a stroke and has residual paralysis on dominant side (hemiparesis, ) and aphasia, Late effect means original injury has healed and dealing with “residual” condition In the index, reference the term “Late” to locate these codes. When coding “late effects of stroke” you need to know the effect of the stroke on the patient.

ICD-9-CM, Chapter 1 (I/O) Infectious and Parasitic Diseases
Divided based on etiology (cause of disease) Many combination codes Example: candidiasis infection of mouth, which reports both organism and condition with one code In this chapter, there are many instances of multiple coding and combination coding. How are these codes divided? (Mainly by the etiology or cause of disease) What type of infection is candidiasis? (Fungal)

Multiple Codes (I/O) Sequencing must be considered
UTI due to Escherichia coli 599.0 (UTI) etiology 041.4 (E. coli) organism 041 category is secondary-code only Multiple coding is acceptable when it takes more than one code to fully describe the condition. Which comes first, the disease, disorder, or the cause? (The disease or disorder)

Section I.C.1.a. Human Immunodeficiency Virus (I/O)
Code HIV or HIV-related illness ONLY if stated as confirmed in diagnostic statement 042 HIV or HIV-related illness V08 Asymptomatic HIV status Nonspecific HIV serology Once an HIV diagnosis, cannot code V08 Only confirmed cases of HIV infection/illness should be coded because the diagnosis stays in the patient’s record forever. If a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions. V08, Asymptomatic HIV infection, is to be applied when the patient without any documentation of symptoms is listed as HIV positive, known HIV, HIV test positive or similar terminology.

Section I.C.1.a.2.f. Previously Diagnosed HIV-Related Illness (I/O)
Code prior diagnosis HIV-related disease 042 (HIV) NEVER assign these patients to: V08 (asymptomatic) or (Nonspecific serologic evidence of HIV) Patients previously diagnosed with any HIV-related illness should never be assigned code or V08.

Section I.C.1.a.2. HIV Sequencing (I)
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 principal diagnosis Then 042 (HIV) (Cont’d…) A patient is admitted for injuries resulting from a car crash. While undergoing treatment, an HIV-related illness (such as pneumonia) is diagnosed. What is the proper coding sequence? (The injuries from the car crash are coded first. 042 is coded next, followed by diagnosis codes for all HIV-related conditions.)

Section I.C.1.a.2. HIV Sequencing (O)
(…Cont’d) Sequence Reason most responsible for encounter, if HIV (042) Any additional diagnosis that impacts treatment If the visit is for a patient’s HIV status, code 042 first followed by any additional diagnoses that may exist. If the patient goes to the physician due to a sore throat and happens to be HIV positive, code the sore throat first and the HIV second.

Section I.C.1.a.2.g. HIV and Pregnancy Complications (I/O)
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…) Codes from Chapter 15 always take sequencing priority. Why are HIV-related conditions coded differently during pregnancy, childbirth, and the puerperium? (Because you aren’t coding just for the mother but for the status of the child also)

Section I.C.1.a.2.g. HIV and Pregnancy (I/O)
(…Cont’d) Asymptomatic HIV during pregnancy, childbirth, or puerperium 647.6X (Other specified infections and parasitic diseases) and V08 (Asymptomatic HIV infection status) Both codes should be assigned. Why should both codes be assigned? (Only coding 647.6X does not give the full description)

Section I.C.1.a.2.e. Inconclusive Laboratory Test for HIV (I/O)
(Inconclusive serologic test for HIV) Assign this code to patients with inconclusive HIV serology with no definitive diagnosis of the illness. What is inconclusive serology? (When there is no definitive diagnosis of HIV.)

Section I.C.1.a.2.h. HIV Screening (I/O)
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) Code V73.89 if the patient is being seen to determine his/her HIV status. Use V69.5 as a secondary code if the patient is asymptomatic but is in a known risk group for HIV. When is the counseling code used? V65.44 is used when a patient returns to learn his/her HIV test results and the results are negative. It is also used for a positive test result if the patient receives counseling. If the patient has a positive test result and is symptomatic, use 042 followed by the appropriate diagnosis codes.

Caution (I/O) Incorrectly applying these HIV coding rules can cause patient hardship Insurance claims for patients with HIV usually need patient’s written agreement to disclose Be careful to report HIV only when diagnosis is confirmed. Patient’s typically need to sign a written agreement allowing you to disclose their HIV status to the insurance company.

Section I.C.1.b. Septicemia, Septic Shock and SIRS (I)
Septicemia : systemic disease of microorganisms or their toxins in the blood (blood poisoning) Septic shock : overwhelming infection due to severe 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…) It is important to know the correct definitions of the septic terms since they are so close in nature. Septicemia is infection in the blood. Septic Shock is when the infection is so bad the body systems start to shut down. SIRS code always follows the code for septic shock.

Section I.C.1.b. Septicemia, Septic Shock and SIRS (I)
(…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 , Ectopic and Molar Pregnancy Septic shock is never primary or first-listed diagnosis When the diagnosis of septicemia with shock or the diagnosis of general sepsis with septic shock is documented, code and list the septicemia first, and report the septic shock code as a secondary condition.

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

ICD-9-CM, Chapter 2 Neoplasm (I/O)
• Two steps for coding neoplasms: Index: Locate histologic type of neoplasm (e.g., sarcoma, melanoma) Review all instructions Locate code identified (usually in Neoplasm Table in Index) by body site • Neoplasms Table divided into columns: Malignant (primary, secondary, ca in situ) Benign Uncertain behavior Unspecified This chapter classifies diseases according to etiology, or cause. Neoplastic conditions can affect all parts of the body. First, locate the morphologic or histologic type of the neoplasm in the Index. Then, follow the instructions or verify the code listed. Usually, the coder is instructed to turn to the Neoplasm Table in the Index to find the code. Coders can identify the M code (or morphology code): A four-digit alphanumeric code in which the fifth digit indicates the behavior. M codes used in some inpatient settings are optional and are not required on insurance forms.

Section I.C.2. Neoplasms Treatment directed at malignancy: Neoplasm is first-listed diagnosis Except for chemotherapy or radiotherapy: Therapy (treatment) Neoplasm Chemotherapy: V58.11—reason patient presents for treatment, #1 diagnosis Radiotherapy: V58.0—reason patient presents for treatment, #1 diagnosis (Cont’d…) Certain benign neoplasms may be found in specific body system chapters. To properly code a neoplasm, it is necessary to determine from the medical documentation whether the neoplasm is benign, in situ, malignant, or of uncertain histologic behavior. If malignant, any secondary sites should also be determined.

Section I.C.2. Neoplasms (I/O)
(…Cont’d) Surgical removal of neoplasm and subsequent chemotherapy or radiotherapy Code malignancy as first-listed diagnosis Surgery to determine extent of malignancy Code neoplasm as long as patient is receiving treatment or medication following excision (Cont’d…) If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.

V10, “Personal history of malignant neoplasm” if Neoplasm was previously destroyed No longer being treated (Cont’d…) V10 can be used as a code regardless of whether a neoplasm was destroyed or removed. The patient must be free of disease and no longer under any treatment for their cancer. This includes chemotherapy and/or radiation therapy.

(…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 not treated code personal history of (Cont’d…) If treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis. The primary site of neoplasm would be coded as a secondary diagnosis.

Section I.C.2. Neoplasms (I)
(…Cont’d) Admission for symptoms of primary or secondary neoplasm Malignancy principal diagnosis Do NOT code symptoms or signs First-listed is site receiving treatment If both primary and metastatic are treated, code primary as first-listed (Cont’d…) Symptoms, signs, and ill-defined conditions cannot be used to replace the malignancy as the principal or first-listed diagnosis. These signs and symptoms can be coded as additional diagnoses.

Section I.C.2. Neoplasm (I/O)
(…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…) When admission/encounter occurs for management of anemia or dehydration associated with malignancy, chemotherapy, or radiotherapy, and treatment is provided only for anemia or dehydration, code the anemia or dehydration as the principal diagnosis, followed by the appropriate code for the malignancy.

Section I.C.2. Neoplasm (I/O)
(…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…) Designate the complication as the principal diagnosis if treatment is directed at resolving the complication. Be sure to list the malignancy as a secondary diagnosis.

V Codes and Neoplasms (I/O)
Patient receiving chemotherapy or radiotherapy post-op removal of neoplasm Code: Therapy Active neoplasm still being treated Do NOT report H/O (history of) neoplasm When a primary malignancy has been excised or eradicated and there is no further treatment and no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

ICD-9-CM, Chapter 3 (I/O) Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders The Endocrine System consists of glands that are located throughout the body and are responsible for secreting hormones into the bloodstream. What are some examples of Endocrine Disorders/Diseases? (Diabetes, goiters, hyperthyroidism, hypothyroidism, Vitamin deficiencies, dehydration)

Disorders of Other Endocrine Glands (I/O)
Diabetes Mellitus 250 coded frequently Subterms often have two codes Example: Diabetic iritis 250.5X for diabetes (etiology) [364.42] for iritis (manifestation) Metabolic manifestation only one code assignment, ex., diabetic ketoacidosis (250.1X) (Cont’d…) Many of the subterms under diabetes list two codes. The 250.X code is followed by an italicized code in brackets because multiple coding is common for diabetes; in this condition, both the etiology and the manifestation are coded.

(…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…) There are four five-digit subclassifications for use with category 250. NIDDM refers to non-insulin-dependent diabetes mellitus. IDDM refers to insulin-dependent diabetes mellitus. Health care providers should document the type of diabetes mellitus, including whether or not the diabetes is controlled or uncontrolled, because on this basis, the correct 5th digit is selected. Just because a patient is receiving insulin does not mean that he or she is insulin dependent.

Type I—Insulin dependent—pancreas does not function at all 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”

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 The diabetes codes do not indicate if the patient uses insulin or not. If it is documented the patient is on insulin use, the code V58.67 in addition to the diagnosis code.

Other Metabolic and Immunity Disorders Section (I/O)
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 Though diabetes is probably the most common of endocrine disorders, there are many other metabolic and immunity disorders.

ICD-9-CM, Chapter 4 (I/O) Diseases of Blood and Blood-Forming Organs
Short chapter with 10 sections Includes anemia, blood disorders, coagulation defects (Cont’d…) This is the chapter where codes for blood disorders will be found. These are not only disorders of the blood but also of the blood forming organs.

Chapter 4 (I/O) Often used code, anemia
(…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 Anemia is the most common blood disease. Under the main term of anemia are many subterms that relate to the type or cause of the anemia. The unspecified anemia (285.9) should only be used if a more specific type of anemia is not given. If you continuously see your physician only stating anemia, a consultation may be important to have with them and taking in your diagnosis book and showing the variety of codes for anemia may make them be more specific. Many time a physician, not knowing the coding language, does not understand the extent of codes we have to use.

ICD-9-CM, Chapter 5, Mental Disorders (I/O)
Includes codes for Personality disorders Stress disorders Neuroses Psychoses Sexual deviation/dysfunction, etc. (Cont’d…) This chapter includes four sections: organic psychotic conditions; other psychoses; neurotic, personality, and other nonpsychotic mental disorders; and mental retardation. Be sure to code only diagnoses that are documented in the medical record. If physicians are not specific in their diagnostic statements, obtain clarification from them.

Chapter 5 (I/O) Fifth digit = status of episode
(…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 A five-digit subclassification is provided for categories to indicate the patient’s pattern of alcohol or drug use. Which 5th digit would you use if the physician did not state the level of dependence? (0) Would it be correct to code the fifth digit of 1 if the physician does not state this in his documentation? (No, this would not only be fraudulent coding, it could also have a negative effect on the patient if he actually has been in remission.)

ICD-9-CM, Chapter 6 (I/O) Diseases of Nervous System and Sense Organs
Central Nervous System Peripheral Nervous System Disorders of Eye Diseases of Ear This chapter uses some combination codes in which one code identifies both the manifestation and the etiology. The chapter also includes some conditions that are manifestations of other diseases. These categories appear in italics in the Tabular List and instruct the coder to code the underlying disease process first.

Pain Not Elsewhere Classified (338)
Acute or chronic pain due to: Trauma Postoperative Neoplasm Psychosocial dysfunction NOT for generalized or localized pain Principal/primary diagnosis When definitive diagnosis not established Pain management is reason for encounter/admission

ICD-9-CM, Chapter 7—Diseases of Circulatory System (I/O)
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 This chapter contains codes for diseases of the heart and blood vessels. Hypertension is one of the most common conditions coded in this chapter. Uncontrolled hypertension is considered malignant. The Hypertension Table is located in the Index and is shown in Fig. 15–2 of the text. The first category identifies the hypertensive condition, such as accelerated, antepartum, cardiovascular disease, cardiorenal, and cerebrovascular disease. The remaining three columns—malignant, benign, and unspecified—constitute the subcategories of hypertensive disease.

Section I.C.7.a.1. Hypertension, Essential, or NOS (I/O)
Assign hypertension arterial essential primary systemic NOS to 401 Fourth digit to indicate type, 401.X Assign hypertension (arterial) (essential) (primary) (systemic) (NOS) to category code 401. Also, assign the appropriate fourth digit to indicate malignant, benign, or unspecified. Do not use malignant or benign unless the documentation supports this designation.

Section I.C.7.a.2. Hypertension With Heart Disease (I/O)
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) Hypertensive heart disease refers to secondary effects on the heart of prolonged, sustained, or systemic hypertension. Heart conditions are assigned to a code from category 402 when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code from category 428 to identify type of heart failure in those patients with heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure.

Section I.C.7.a.3. Hypertensive Chronic Kidney Disease (I/O)
Cause-and-effect relationship assumed in chronic kidney disease with hypertension Category 403, Hypertensive chronic kidney disease, used when following present: Chronic kidney disease (585.X) Renal failure, unspecified (586) Renal sclerosis, unspecified (587) With 403 assign fifth digit 0 stage I-IV or unspecified and 1 for stage V or end stage renal disease Assign codes from category 403, Hypertensive Renal Disease, when conditions classified to categories are present. A fifth digit of 0 represents Renal Failure Stages I-IV or unspecified ( and 585.9). A fifth digit of 1 represents Renal Failure Stage V or End Stage Renal Disease ( ). Use additional code to identify the stage of chronic kidney disease ( )

Section I.C.7.a.4. Hypertensive Heart and Chronic Kidney Disease (I/O)
Assign 404 when both hypertensive chronic kidney disease and hypertensive heart disease stated Assume cause-and-effect relationship Assign fifth digit for mention of kidney, heart failure, and/or stages I-IV or end stage renal disease Use additional code to specify stage of chronic kidney disease Assign codes from combination category 404, Hypertensive renal and heart disease, when both hypertensive renal disease and hypertensive heart disease are stated in the diagnosis. Assign a fifth digit to identify with/without heart failure and the stage of the renal failure. Use additional code to identify the stage of chronic renal disease ( ) A relationship between the hypertension and the renal disease can be assumed.

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 A fourth digit of 0-9 should be placed on the 585 Category to indicate the stage of renal dysfunction. If the physician does not state the stage of renal dysfunction, query the physician.

Section I.C.7.a.5. Hypertensive Cerebrovascular Disease (I/O)
Code: Cerebrovascular disease ( ) first Type of hypertension (405) second Hypertensive cerebrovascular disease refuse to secondary effects on the vessels of the brain from prolonged sustained or systemic hypertension. Both codes are required: One to identify the underlying etiology and one to identify the type of hypertension

Section I.C.7.a.6. Hypertensive Retinopathy (I/O)
Code: Hypertensive retinopathy first (362.11) Type of hypertension (405) second Two codes are necessary to identify this condition: first, the code from subcategory (hypertensive retinopathy), and then, the appropriate hypertension code.

Section I.C.7.a.7. Hypertension, Secondary (I/O)
Hypertension caused by an underlying condition Code: Underlying condition first Type of hypertension (405) second Again, two codes are required: one to identify the underlying etiology and one to identify the type of hypertension. As you can see this guideline applies to many areas in diagnosis coding.

Section I.C.7.a.8. Hypertension, Transient (I/O)
Transient hypertension: Temporary elevation of BP DO NOT assign Hypertensive Disease Hypertension diagnosis NOT established Instead use: 796.2, Elevated blood pressure 642.3X, Transient hypertension of pregnancy Assign code 796.2, Elevated blood pressure reading without diagnosis of hypertension, unless the patient has an established diagnosis of hypertension.

Section I.C.7.a.9. Hypertension, Controlled (I/O)
Hypertension controlled by therapy Assign code from This diagnosis refers to an existing state of hypertension that is controlled by therapy. What would tell the physician that the patient’s hypertension is controlled? (Routine and concurrent readings that are of an adequate level, no underlying symptoms (headaches, blurred vision, dizziness))

Section I.C.7.a.10. Hypertension, Uncontrolled (I/O)
Untreated hypertension Uncontrolled hypertension Assign code from Uncontrolled hypertension may refer to untreated hypertension or to hypertension not responding to the current therapeutic regimen. Should you assign a code from the 404s if the documentation does not state malignant hypertension? (No)

Section I.C.7.a.11. Elevated Blood Pressure (I/O)
Elevated blood pressure coded 796.2 Elevated BP reading without hypertension is diagnosis Hypertension NOT stated, NOT coded to 401 (essential hypertension) For a statement of elevated blood pressure without further specificity, the coder can assign code 796.2, rather than a code from category 401

Chapter 8, Diseases of Respiratory System (I/O)
Watch for: “Use additional code to identify infectious organism” Some codes indicate specific organism and do not need an additional code Chapter 8 includes diseases and disorders of the respiratory tract, starting with the nasal passages and following the path to the lungs. A note at the beginning of the chapter states, “Use additional code to identify infectious organism.” The organism is already identified in some codes.

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 Always code the acute condition first followed by the chronic conditions. If it’s a chronic condition with an acute exacerbation with another acute condition, code the acute condition first (MI), than the acute exacerbation of a chronic condition second. Per new guidelines, respiratory failure and acute condition can be listed as a first-listed diagnosis.

Acute Respiratory Infection Section (I/O)
Frequently used codes, such as: Common cold (46028, acute nasopharyngitis) Sore throat (462, acute pharyngitis) Acute tonsillitis (463) Bronchitis ( ) Acute upper respiratory infection (465, URI) Influenza (487, flu) Read Guidelines for Chapter 8 for specifics on coding COPD and asthma Acute respiratory conditions are very common conditions. Name some common respiratory infections. (a cold, tonsillitis, bronchitis, asthma, influenza)

Chapter 9 (I/O) Diseases of Digestive System
Mouth to anus and accessory organs Extensive subcategories 574 Cholelithiasis (10 subcategories) Each has fifth digit subclassification 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.

Chapter 10 (I/O) Diseases of Genitourinary System Commonly used codes
Urinary tract infection (599.0) Inflammation of prostate (601.X) Disorders of menstruation ( ) 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.

Chapter 11, Complications of Pregnancy, Childbirth, and Puerperium (I/O)
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.

Section I.C.11.a. General Rules (I/O)
Not all encounters are pregnancy related Example, pregnant woman, broken ankle Broken ankle V22.2 Pregnant state incidental must be documented in medical record 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

Section I.C.11.e. Complications of Pregnancy, Childbirth, and Puerperium (I/O)
Chapter 11 codes Mother’s medical record (600 series codes) Not on newborn medical record (Newborn, 700 series codes) (Cont’d…) 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.

Section I.C.11.e. Complications of Pregnancy, Childbirth, and Puerperium (I)
(…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.

Section I.C.11.b. Selection of Principal Diagnosis—Obstetric (I)
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.

Section I.C.11.b. Selection of Primary Diagnosis (O)
(…Cont’d) Routine prenatal visits no complications: V22.0, Supervision, normal first pregnancy or V22.1, Supervision, other normal pregnancy Always first-listed 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.

Section I.C.11.a.4. Fifth Digit (I/O)
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.

Section I.C.11.h. Normal Delivery, 650 (I)
No complications, principal diagnosis = 650 With complications = NOT 650 V27.0 (Single liveborn) Only outcome for 650 (Normal Delivery) 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.

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 classification 3 Antepartum condition or complication 4 Postpartum condition or complication The 4th digit represents the status of the pregnancy. Which 5th digit would be used if the patient has delivered with no complications? (1)

Section I.C.11.k.1. Fifth Digit (I/O)
Appropriate fifth digit 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 are applicable (2 and 4) Not all fifth digits will be applicable to every code. Read Notes and cues carefully.

Section I.C.11.h. Delivery Procedure Codes (I)
If delivered prior to admission In ambulance At home In ED DO NOT CODE delivery Code any postpartum repairs 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.

Section I.C.11.i. Postpartum Period (I/O)
After delivery and continues for 6 weeks 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.”

Section I.C.11.k. Abortions (I/O)
Codes 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.)

Section I.C.11.k.4. Abortions With Liveborn Fetus (I/O)
Attempted abortion results in liveborn fetus: (Early onset of delivery) appropriately Use V27 (Outcome of delivery) Attempted abortion 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.

Chapter 12, Diseases of Skin and Subcutaneous Tissue (I/O)
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)

Chapter 12 (I/O) 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 out to fully describe the condition.

Chapter 13, Diseases of Musculoskeletal System and Connective Tissue (I/O)
Bone Bursa Cartilage Fascia Ligaments Muscle Synovia Tendons 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.

Chapter 13 Sections (I/O)
Arthopathies (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 5th 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.

Chapters 14 and 15 (I/O) 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.

Section I.C.15.b. Use of Codes V30-V39 (I)
V30-V39 liveborn infant(s) Example: V30, Single liveborn V31, Liveborn twins Inpatient: Principal diagnosis Note: V30 ONLY used once, hospital where baby delivered (transfer cases) 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.

Section I.C.15.h. Coding Perinatal Additional Diagnosis (I)
Code newborn conditions that require: Treatment Further investigation Additional resource Prolonged length of stay (LOS) Implications for future care (Cont’d…) All clinically significant conditions noted on a routine newborn examination should be coded.

Section I.C.15.h. Coding Perinatal Additional Diagnosis (I)
(…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.

Section I.C.15.i. Prematurity and Fetal Growth Retardation (I)
Codes for newborns from categories 764 (Slow fetal growth and fetal malnutrition) and 765 (Disorders relating to short gestation and unspecified low birthweight) (Cont’d…) What is the difference between categories 764 and 765? (Category 764 is for slow fetal growth; malnutrition and 765 is for short gestation and low birthweight.)

Section I.C.15.i. Prematurity and Fetal Growth Retardation (I)
(…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 ( ) 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.

Chapter 16, Symptoms, Signs, and Ill-Defined Conditions (I/O)
Do NOT code a sign or symptom: Definitive diagnosis made (symptoms are part of disease) Only used if no specific diagnosis stated 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 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.

Chapter 17 Injury and Poisoning, Section Examples (I/O)
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.

Section I.C.17. Multiple Injuries and Burns (I/O)
Sequence most severe injury first (physician determined) When coding multiple burns, assign a separate code for each burn site. Category 946, Burns of multiple specified sites, should be used only when the locations of the burns are not documented.

Section I.C.17.c. Current Burns (I/O)
Sequence highest degree burn first Current burns ( ) classified by Depth (severity) Extent (% body surface) Site And if necessary, agent (Cont’d…) Sequence first the code that reflects the highest degree of burn when more than one burn is present.

Section I.C.17.c. Burns (I/O)
(…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.”

Section I.C.17.c.1. Sequence and Different Degree (I/O)
Do NOT code a sign/symptom if definitive diagnosis documented Symptoms are part of disease Only use if no specific diagnosis made If a patient is seen for a cough (786.2) and the physician diagnosis is bronchitis (490), you would only report 490 since the cough (786.2) is a symptom of the bronchitis.

Section I.C.17.c. Burns Classified (I/O)
According to extent body surface involved Burn site NOT specified Additional data required 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.

Section I.C.17.c.6. Category 948 (I/O)
Fourth digits = % 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.

Rule of Nines (…Cont’d) Figure: 15.5
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: 15.5

Section I.C.17.d. Debridement of Wounds, Infection, or Burn (I)
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.

Section I.C.17. Coding for Multiple Injuries (I/O)
Separate code for each injury Most serious injury first Superficial 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.

Section I.C.17.a.2. Vessel and Nerve Damage (I/O)
Code primary injury first Use additional code if nerve damage minor Primary injury = nerve damage Code nerve damage first When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury code is sequenced first.

Section 1.C.17.b.1. Acute Fracture vs. Aftercare
Active treatment of fracture ( ) Active treatment may be: Physician evaluation ER encounter Surgical treatment Closed treatment After active treatment completed use aftercare codes Aftercare involving internal fixation (V54.0) Aftercare for healing traumatic fracture (V54.1X) Other orthopedic aftercare (V54.8X) Unspecified orthopedic aftercare (V54.9)

Section I.C.17.b.2. Multiple Fractures (I/O)
Same coding principles as multiple injuries Code multiple fractures, by site Sequenced by severity Codes describe accidents, injury, open wounds, etc. (Cont’d…) 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

Fractures (I/O) 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.

E Codes (I/O) 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? (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)

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.

Intent Intent Unknown Unspecified Questionable Code As Undetermined*
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.

Section I.C.19.c. Table of Drugs and Chemicals (I/O)
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.

Section I.C.19.d. Two or More Substances Involved (I/O)
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.

Section I.C.19.f. Unknown or Suspected Intent (I/O)
Unspecified Questionable Undetermined E980-E989 As in Slide 131, you need a definitive cause to code a definitive code. If undetermined, use external cause codes E980-E989.

Section I.C.19.g. Undetermined Cause (I/O)
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.

Section I.C.19.h. Late Effects of External Cause (I/O)
Should be used with late effect of a previous injury/poisoning Should NOT be used with related current of 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.

Section IV Diagnostic Coding (O)
Physician’s office Hospital-based outpatient services Part of Official Guidelines for Coding and Reporting, Section IV Outpatient guidelines do not address specific sequencing or diseases as inpatient guidelines do. Follow the inpatient coding guidelines in situations in which there are no clear outpatient coding guidelines. In the outpatient setting, the term “first-listed diagnosis [primary]” is used instead of “principal diagnosis.”

Diagnostic Coding Guideline A (O)
Term first-listed diagnosis, rather than principal diagnosis Outpatient Surgery: Reason for surgery Observation Stay: Medical condition that occasioned admission Primary diagnosis is synonymous with first-listed diagnosis. Either term can replace the term principle diagnosis.

Diagnostic Coding Guideline B (O)
Use codes through V86.1 to code: Diagnosis Symptoms Conditions Problems Complaints Or other reason(s) for visit You will use all different codes from to V89.09. Many clinics are specialized so you may use some codes more than others but it is important to be familiar with all. If your facility is more specialized (cardiology) other than family practice you may only use a minimum of diagnosis codes but if you follow the guidelines you would be able to properly code any diagnosis.

Diagnostic Guideline C (O)
Documentation should describe patient's condition, using terminology that includes: Specific diagnoses Symptoms Problems Reasons for encounter There are ICD-9-CM codes to describe all of these items. If no specific diagnosis is given by the physician what should you code as the diagnosis? (the symptoms the patient came in with or the reason for the encounter)

Diagnostic Guideline D (O)
Selection of codes through (Chapters 1-17) frequently used to describe reason for encounter These codes are from the section of ICD-9-CM for the classification of disease and injuries.

Diagnostic Guideline E (O)
Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when An established diagnosis has NOT been established by physician Chapter 16 contains many, but not all, codes for symptoms. This is the chapter that you would refer to when the there is no definitive diagnosis given. These codes would still be referenced in the index prior to the tabular section of your coding book.

Diagnostic Guideline F (O)
V codes deal with encounters for circumstances other than disease or injury Example: Well-baby checkup Encounters for reasons other than a disease or injury. These have been discussed earlier. What are some other encounters that would be coded with V codes? (postoperative visit, immunization only, birth control counseling)

Diagnostic Guideline G (O)
Codes have either 3, 4, or 5 digits 4 and/or 5 digit codes provide greater specificity (detail) (Cont’d…) Codes with three digits are included as the heading for a category of codes. Never code a three digit code if it requires a fourth or fifth digit. Why should you never code a three digit code if forth or fifth digits are required for that code? (You should always code to the greatest level of specificity. This would also, ultimately, be denied by the third party payer as an incorrect diagnosis and delay reimbursement.)

Diagnostic Guideline G (O)
(…Cont’d) 3-digit code used ONLY if no 4- or 5-digit Where 4 and/or 5 digits provided, must be assigned Diagnoses NOT coded to full digits available invalid Claims bounce! A three-digit code is to be used only if it is not further subdivided. A three-digit code has the heading of a category code (example: 462).

Diagnostic Guideline H (O)
List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided List additional codes that describe any coexisting conditions Assign V72.5 and/or V72.6 for routine Lab/Radiology test ordered without signs, symptoms, or associated diagnosis List first the reason for the encounter and than and coexisting conditions. If a patient comes into the clinic and their chief complaint is a severe cough for greater than a week. Their associated signs and symptoms are extreme fatigue and sore throat. No definitive diagnosis is given. Which symptom would be the first coded, as it was the main reason the patient came into the clinic? (Cough) What would be the coexisting conditions? (fatigue and sore throat)

Diagnostic Guideline I (O)
Do NOT code diagnoses documented as probable, suspected, questionable, ruled out, or working diagnoses Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit Note that this differs from the coding practices used by hospital medical record departments for coding the diagnosis of acute care, short-term hospital inpatients.

Diagnostic Guideline J (O)
Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s) A patient who has a chronic disease and is seen at the physician’s office multiple times, the same diagnosis can be used for each encounter. What might be some examples of this? (Hypertension, Diabetes, Arteriosclerotic heart disease, Asthma, COPD)

Diagnostic Guideline K (O)
Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management Do NOT code conditions previously treated, no longer existing (Cont’d…) All diagnoses that co-exist with primary diagnosis should be coded. If a patient was previously diagnosed with pneumonia, and now the patient comes into the clinic for an asthma check, and the physician lists in his assessment that they are status post pneumonia, but they no longer have symptoms or are being treated, would the pneumonia be coded out as a diagnosis? Why or why not? (No because even though pneumonia pertains to the lung and the patient is in for an asthma check, the patient no longer has pneumonia or is being treated for it so this should not be coded)

Diagnostic Guideline K (O)
(…Cont’d) “History of” codes (V10-V19) may be used as secondary codes if: Impacts current care or treatment What are some examples of situations that would require use of a history code? (Personal history of malignant neoplasm or Personal history of allergy. Family history of malignant neoplasm or Family history of certain chronic disabling diseases.)

Diagnostic Guidelines L and M (O)
For patients receiving diagnostic or therapeutic services ONLY Sequence first Diagnosis Condition Problem Other reason shown in medical record to be chiefly responsible for encounter (Cont’d…) Do not code related signs and symptoms as additional diagnoses. How does this coding guideline differ from the inpatient guideline? (In the outpatient setting, related signs and symptoms are not coded as additional diagnoses. In the inpatient setting, abnormal findings on test results are coded.)

Diagnostic Guidelines L and M (O)
(…Cont’d) Codes for other diagnoses (e.g., chronic conditions) May be sequenced as secondary diagnoses Exception: Patients receiving chemotherapy (V58.11), radiation therapy (V58.0), or rehabilitation V code first diagnosis or problem for which service being performed second For outpatient encounters for diagnostic tests that have been interpreted by a physician with the final report available at the time of coding, code any documented confirmed or definitive diagnoses. Diagnosis is listed second only when the patient is receiving chemotherapy, radiation therapy, or rehabilitation when the V code must be listed first.

Diagnostic Guideline N (O)
For patients receiving preoperative evaluations ONLY Code from category V72.8 (Other specified examinations) Assign secondary code for reason for surgery Code also any findings related to preoperative evaluation A patient receiving only a preoperative evaluation should first be coded with a code from the V72.8 category. The secondary code would be the reason the patient is having the procedure or surgery. If the patient was found to have a fever on the preoperative evaluation, should this be coded for this visit? (Yes, because it was found on evaluation and may require further looking into, or delay the procedure or surgery.)

Diagnostic Guideline O, Further Note (O)
Code diagnosis which required ambulatory surgery Pre- and post-op diagnosis different Code the post-op diagnosis The postoperative diagnosis is the most definitive.

Diagnostic Guideline P (O)
Code routine prenatal visits with no complications: V22.0, (Supervision of normal first pregnancy) V22.1, (Supervision of other normal pregnancy) DO NOT use these codes with pregnancy complication codes Routine outpatient prenatal visits with no complications are coded with V22.0. A normal first pregnancy is V22.1.

ICD-10-CM ICD-10-CM scheduled to replace ICD-9-CM
Target implementation date 2010 Each world government is responsible for adapting the ICD-10 to suit its own country’s needs. In the United States, the Centers for Medicare and Medicaid Services is responsible for developing the procedure classification entitled The ICD-10-PCS (which stands for Procedure Coding System). The National Center for Health Statistics is responsible for the disease classification system (Volumes 1 and 2) entitled ICD-10-CM.

Improvements in ICD-10-CM
More relevant ambulatory and managed care encounter codes Expanded injury codes Combination diagnosis/symptom codes Six digits, maximum (Cont’d…) The ICD-10-CM will replace ICD-9-CM, Volumes 1 and 2. Extensive expansion of injury codes allows for greater specificity. The creation of combination diagnosis/symptom codes will reduce the number of codes needed to fully describe a condition. New drafts of ICD-10-CM have included up to seven digits, but no final information on the number of digits has been released by the government.

Improvements More fourth and fifth digits added Updated diabetes codes
(…Cont’d) More fourth and fifth digits added Updated diabetes codes Greater overall specificity Diabetes mellitus codes will also have greater specificity.

ICD-10-CM Structure 21 Chapters V and E codes incorporated
Addition of chapters for Eye and Adnexa Ear and Mastoid Process The supplementary classifications found in the ICD-9-CM are excluded.

Crosswalk ICD-9-CM code cross-walked to new ICD-10-CM code
Figure: 15.7 As part of the conversion, a cross-walk has been developed. This converts the ICD-9-CM codes to ICD-10-CM codes. Sometimes, more than one ICD-10-CM code cross-walks from the ICD-9-CM code; possible matches are noted in a “best match” column. Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. ICD-9-CM code cross-walked to new ICD-10-CM code

Index Main terms and subterms Figure: 15.8 The Index is alphabetic.
The Index presents the main terms in bold type with subterms indented under the main term. Sometimes, only four digits of the code are given; coders must refer to the Tabular List. Figure: 15.8 Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Tabular Figure: 15.9 The 21 chapters of the Tabular are arranged in numeric order after the first letter assigned to the chapter. Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Each section begins with unique letter and codes arranged in numerical order

ICD-10-PCS Will replace Volume 3, Procedures of ICD-9-CM
Currently being piloted Four major objectives guided the development of the ICD-10-PCS: completeness, expandability, multiaxial nature, and standardized terminology. The ICD-10-PCS has a seven-character alphanumeric code structure. Characters 2 through 7 have a standard meaning within each section but may have different meanings across sections. If a character is not applicable to a specific procedure, the letter Z is used. The Tabular List provides the remaining characters needed to complete the code given in the Index.

Conclusion CHAPTER 15 USING THE ICD-9-CM

CHAPTER 15 USING THE ICD-9-CM.

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CHAPTER 15 USING THE ICD-9-CM.

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