1. The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 2 Introduction to ICD-9-CM Book Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

2. Introduction ·The ICD-9-CM book contains all of the codes you will need to report the reason or reasons WHY the patient came to see this health care professional for a specific encounter. 2 - 2

3. Format of ICD-9-CM ·Volume 1 is the Tabular List of Diseases. ·All ICD-9-CM codes are in numerical order starting with 001 to 999.9, then V01–V83.02, and then E800–E999. 2 - 3

4. Format of ICD-9-CM ·Volume 2 is the Alphabetic Index to Diseases. ·All code descriptions from A to Z ·Condition ·Eponym ·Other descriptors 2 - 4

5. Format of ICD-9-CM ·Volume 2, Section 2, contains the Table of Drugs and Chemicals. ·An alphabetic listing of pharmaceuticals and chemicals that may harm an individual is also included. 2 - 5

6. Format of ICD-9-CM ·Volume 2, Section 3, contains the Index to External Causes. ·An alphabetic listing of the causes of injury and poisoning is also included. 2 - 6

7. The Coding Process ·Abstracting the Physician’s Notes: Abstract the key words relating to the reason or reasons WHY the patient came to see the physician for this visit. 2 - 7

8. The Coding Process ·The Alphabetic Index: Find the key words abstracted from the physician’s notes in the ICD-9-CM alphabetic index. 2 - 8

9. The Coding Process ·The Tabular Listing: Find the code suggested by the alphabetic index in the tabular listing. Read up to the THREE-DIGIT number in this subsection. 2 - 9

10. The Coding Process ·Read ALL notations and directions in the subsection until you find the best match to the words used by the physician in the documentation of the encounter. 2 - 10

11. The Coding Process ·NEVER, NEVER, NEVER code directly from the alphabetic index. ·ALWAYS read all notations and directions in the tabular listing that are shown in the subsection. 2 - 11

12. Types of Codes ·Confirmed, current diagnoses are reported with ICD-9-CM codes 001–999.9. ·For outpatient encounters, ONLY code confirmed diagnoses. 2 - 12

13. Types of Codes ·V codes are used ·when a healthy person goes to a physician. ·when a person requires continuous care. ·when a person is exposed to an illness without showing any signs or symptoms ·for regularly planned encounters. 2 - 13

14. Types of Codes ·E codes are used to explain HOW and WHERE a patient has ·an adverse reaction to a prescribed medication. ·been poisoned. ·been injured. 2 - 14

15. Late Effects ·Scarring, as the result of a burn, laceration, wound, or other injury ·Nonunion or malunion of a fracture ·When specifically stated by the physician as a late effect 2 - 15

16. Late Effects ·The treatment of a late effect requires at least TWO codes: ·A code for the problem (the effect: scar, hemiplegia, etc.) ·A late effect code identifying the original condition 2 - 16

17. Terrorist Events ·The cause of the injury may only be coded as an act of terrorism when identified as such by the FBI or other agency of the federal government. 2 - 17

18. Present on Admission ·Present on admission (POA) indicators are required for inpatient (acute care hospital) claims only. ·POA indicators are used to clearly identify conditions documented at the time of admission. 2 - 18

19. Chapter Summary ·The ICD-9-CM book will guide you to the best, most appropriate code. Just look and read. 2 - 19