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61 Cards in this Set
- Front
- Back
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Section I |
Conventions, general coding guidelines and chapter specific guidelines |
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A: Conventions for the ICD-9-CM |
1) Format 2) Abbreviations a) Index abbreviations b) Tabular abbreviations 3) Punctuation 4) Includes and excludes notes and inclusion terms 5) Other and unspecified codes a) "other" codes b) "unspecified" codes 6) Etiology/manifestation convention ("code first", "use additional code", and "in diseases classified elsewhere" notes) 7) "and" 8) "with" 9) "see" and "see also" |
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B: General Coding Guidelines |
1) Use both Alphabetic index and Tabular list 2) locate each term in the alphabetic index 3) Level of detail in coding 4) Code or Codes from 001.0 through V91.99 5) selection of codes from 001.0 through 999.9 6) signs & symptoms Conditions that are an integral part of a disease process 8) conditions that are not an integral part of a disease process 9) Multiple coding for a single condition 10) Acute & Chronic Conditions 11) Combination Code 12) Late Effects 13) Impending or threatened condition Reporting same diagnosis code more than once 15) Admissions/encounters for rehabilitation 16) Documentation for BMI and Pressure Ulcer Stages 17) Syndromes 18) Documentation of complications of care |
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C: Chapter-specific Coding Guidelines |
1) Chapter 1: Infectious and parasitic Diseases (001-139) |
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1) Chapter 1 |
a) Human immunodeficiency Virus (HIV) infections
b) septicemia, systemic inflammatory response syndrome (SIRS), Sepsis, severe sepsis and septic shock c) Methicillin resistant Staphylococcus aureaus (MRSA) Conditions |
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2) Chapter 2: Neoplasms (140-239) |
a) Treatment directed at the malignancy b) Treatment of secondary site c) Coding and sequencing of complications d) Primary malignancy previously excised e) Admissions/Encountersinolving chemotherapy, immunotherapy and radiation therapy f) Admission/encounter to determine extent of malignancy g) Symptoms, signs, and ill-defined conditions listed in Chapter 16 associated with Neoplasms Admission/encounter for pain control/management Malignant neoplasm associated with transplanted organ |
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3) Chapter 3: Endocrine, nutritional, and metabolic diseases and immunity disorders (240-279) |
a) Diabetes mellitus |
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4: Chapter 4: Diseases of blood and blood forming organs (280-289) |
a) Anemia of chronic disease |
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5: Chapter 5:Mental Disorders (290-319) |
reserved for future guideline expansion |
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6: Chapter 6: Diseases of nervous system and sense organs (320-389) |
a) Pain - Category 338 b) Glaucoma |
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7: Chapter 7: Diseases of circulatory system (390-459) |
a) Hypertension b) Cerebral infarction/stroke/from cerebrovascular accident (CVA) c) Postoperative cerebrovascular accident d) Late effects of cerebrovascular disease e) Acute myocardial infarction (AMI) |
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8: Chapter 8: Diseases of respiratory system (460-519) |
a) Chronic Obstructive Pulmonary Disease (COPD) and asthma b) Chronic Obstructive Pulmonary Disease (COPD) and Bronchitis c) Acute respiratory failure d) Influenza due to certain identified viruses |
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9: Chapter 9: Diseases of Digestive system (520-579) |
reserved for future guideline expansion |
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10: Chapter 10: Diseases of genitourinary system (580-629 |
a) Chronic kidney disease |
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11: Chapter 11: Complications of pregnancy, childbirth, and puerperium (630-679) |
a) General rules for obstetric cases b) Selection of OB principal or first-listed diagnosis c) Fetal conditions affecting the management of the mother d) HIV infection in pregnancy, childbirth and the puerperium e) Current conditions complicating pregnancy f) Diabetes mellitus in pregnancy g) Gestational diabetes h) Normal delivery, Code 650 i) The postpartum and peripartum periods j) Code 677, late effect of complication of pregnancy k) abortions |
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12: Chapter 12: Diseases skin and subcutaneous tissue (680-709) |
a) Pressure ulcer stage codes |
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13: Chapter 13: Diseases of Musculoskeletal and connective Tissue (710-739) |
a) Coding of pathologic fractures |
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14: Chapter 14: Congenital Anomalies (740-759) |
a) Codes in categories 740-759, congenital anomalies |
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15: Chapter 15: Newborn (perinatal) guidelines (760-779) |
a) General perinatal rules b) use of codes V30-V39 c) Newborn transfers d) Use of category V29 e) Use of other V codes on perinatal records f) Maternal causes of perinatal morbidity g) Congenital anomalies in newborns h) Coding additional perinatal diagnoses i) Prematurity and fetal growth retardation j) Newborn sepsis |
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16: Chapter 16: Signs, symptoms and Ill-defined conditions (780-799) |
reserved for future guideline expansion |
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17: Chapter 17: Injury and poisoning (800-999) |
a) Coding of injuries b) Coding of traumatic fractures c) Coding of burns d) Coding of debridement of wound, infection, or burn e) Adverse effects, poisoning and toxic effects f) Complications of care g) SIRS due to non-infectious process |
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18: Classification of factors influencing health status and contact with health service (supplemental V01-V91) |
a) Introduction b) V codes use in any healthcare setting c) V codes indicate a reason for an encounter d) categories of V codes e) V codes that may only be principal/First-listed diagnosis |
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19: Supplemental classification External causes of injury and poisoning (E-Codes, E000-E999) |
a) General E coding guidelines b) Place of occurrence guideline c) Adverse effects of drugs, medicinal and biological substances guidelines d) Child and adult abuse guideline e) Unknown or suspected intent guideline f) Undetermined cause g) Late effects of external cause guidelines h) Misadventures and complications of care guidelines i) Terrorism Guidelines j) Activity code guidelines k) External cause status |
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Section II Selection of principal diagnosis |
A) Codes for symptoms, signs, and ill-defined conditions B) Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis C) Two or more diagnoses that equally meet the definition for principal diagnosis D) Two or more comparative or contrasting conditions E) A symptom(s) followed by contrasting/comparative diagnoses F) Original treatment plan not carried out G) Complication of surgery and other medical care H) Uncertain diagnosis I) Admission from observation unit 1) Admission following medical observation 2) Admission following post-operative observation j) Admission from outpatient surgery |
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Section III Reporting additional diagnoses |
A) Previous conditions B) Abnormal findings C) Uncertain diagnosis |
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Section IV Diagnostic coding and reporting guidelines for outpatient services |
A) Selection of first-listed condition 1) Outpatient surgery 2) Observation stay B) Codes from 001.0 through V91.99 C) Accurate reporting of ICD-9-CM diagnosis codes D) Selection of codes from 001.0 through 999.9 E) Codes that describe symptoms and signs F) Encounters for circumstances other than a disease or injury G) Level of detail in coding 1) ICD-9-CM codes with 3,4, or 5 digits 2) Use of full number of digits required for a code H) ICD-9-CM code for the diagnois, condition, problem, or other reason for encounter/visit I) Uncertain diagnosis J) Chronic diseases K) Code all documented conditions that coexist L) Patients receiving diagnostic services only M) Patients receiving therapeutic services only N) Patients receiving preoperative evaluations only O) Ambulatory surgery P) Routine outpatient prenatal visits |
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Appendix I: Present on Admission Reporting Guidelines |
Section I. Conventions, general coding guidelines and chapter specific guidelines |
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Section I |
The conventions for the ICD-9-CM are the general rules for use of the classification independent of the guidelines. these conventions are incorporated within the index and tabular of the ICD-9-CM as instructional notes. |
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The conventions for the ICD-9-CM are: |
1) Format: The ICD-9-CM uses an indented format for ease in reference 2) Abbreviations a) Index abbreviations b) Tabular abbreviations 3) Punctuation [] Brackets () Parentheses : Colons 4) Includes and excludes notes and inclusion terms Includes: Excludes: Inclusion terms: 5) Other and unspecified codes a) "other" codes b) "unspecified" codes 6) Etiology/manifestation convention ("code first", "use additional code" and "indiseases classified elsewhere" notes) 7) "and" 8) "with" 9) "See" and "See also" |
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1) Format |
The ICD-9-CM uses a indented format for ease |
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2) Abbreviations |
A) index abbreviations NEC "Not elsewhere classifiable" This abbreviation in the index represents "other specified" when a specific code is not available for a condition the index directs the coder to the "other specified" code in the tabular. b) Tabular abbreviations NEC "Not elsewhere classifiable" This abbreviation in the tabular represents "other specified". When a specific code is not available for a condition the tabular includes an NEC entry under a code to identify the code as the "other specified" code. (see section I.A.5.a "other" codes"). NOS "Not otherwise specified" This abbreviation is the equivalent of unspecified (see section I.A.5.b., "Unspecified" codes) |
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3) Punctuation |
[] Brackets are used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the index to identify manifestation codes. (see section I.A.6. "Etiology/manifestations") () Parentheses are use in both the index and tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. : Colons are used in the Tabular list after an incomplete term which needs one or more of the modifiers following the colon to make it assignable to a given category. |
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4) Includes and excludes notes and inclusion terms |
Includes: this not appears immediately under a three-digit code title to further define, or give examples of, the content of the category. Excludes: An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. In some cases the codes for the excluded terms should not be used in conjunction with the code from which it is excluded. An example of this is a congenital condition excluded from an acquired form of the same condition. The congenital and acquired codes should not be used together. In other cases, the excluded terms may be used together with an excluded code. An example of this is when fractures of different bones are coded to different codes. Both codes may be used together if both types of fractures are present. Inclusion terms: List of terms is included under certain four and five digit codes. These terms are the conditions for which that code number is to be used. The terms may be synonyms of the code title, or, in the case of "other specified" codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the index may also be assigned to a code. |
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5) Other and unspecified codes |
a) "other" codes Codes titled "other" or "other specified" (usually a code with a 4th digit 8 or fifth-digit 9 for diagnosis codes) are for use when the information in the medical record provides detail for which a specific code does not exist. Index entries with NEC in the line designate "other" codes in the tabular. These index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code. b) "Unspecified" codes Codes (usually a code with a 4th digit 9 or 5th digit 0 for diagnosis codes) titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code |
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6) Etiology/manifestation convention ("code first," use additional code" and "in diseases /classified elsewhere" notes) |
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
In most cases the manifestation codes will have in the code title, "in diseases classified elsewhere." Codes with this title are a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. "In diseases classified elsewhere" codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. There are manifestation codes that don't have "in diseases classified elsewhere" in the title. For such codes a "use additional code" note will still be present and the rules for sequencing apply. In addition to the notes in the tabular, these conditions also have a specific index entry structure. In the index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second. The most commonly used etiology/manifestation combinations are the codes for diabetes mellitus, category 250. For each code under category 250 there is use additional codes notes for the manifestation that is specific for that particular diabetic manifestation Should a patient have more than one manifestation of diabetes, more than one code from category 250 may be used with as many manifestation codes as are needed to fully describe the patient's complete diabetic condition. The category 250 diabetes codes should be sequenced first, followed by the manifestation codes. "Code first" and "Use additional code" notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination. See-Section I.B.9. "Multiple coding for a single condition" |
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7) "And" |
The word "and" should be interpreted to mean either "and" or "or" when it appears in a title |
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8) "With" |
The word "with" should be interreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular list. The word "with" in the alphabetic index is sequenced immediately following the main term, not in alphabetical order. |
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9) "see" and "See also" |
The "see" instruction following a main term in the index indicates that another term should be referenced. It is necessary to go to the main term referenced with the "see" note to locate the correct code. A "see also" instruction following a main term in the index instructs that there is another main term that may also be referenced that may provide additional index entries that may be useful. It is not necessary to follow the "see also" note when the original main term provides the necessary code. |
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B: General Coding Guidelines |
1) Use of both alphabetic index & tabular index 2) Locate each term in the alphabetic index 3) Level of detail in coding 4) Code or codes from 001.0 through V91.99 5) Selection of codes 001.0 through 999.9 6) Signs and symptoms 7) Conditions that are an integral part of a disease process 8) Conditions that are not an integral part of a disease process 9) Multiple coding for a single condition 10) Acute and chronic conditions 11) Combination code 12) Late Effects 13) Impending or threatening condition 14) Reporting same diagnosis code more than once 15) Admissions/Encounters for rehabilitation 16) Documentation for BMI and Pressure Ulcer Stages 17) Syndromes 18) Documentation of complications of care |
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1) Use of both Alphabetic index and Tabular list |
Use both the alphabetic index and tabular list when locating and assigning a code. Reliance on only the alphabetic index or the tabular list leads to errors in code assignments and less specificity in code selection |
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2) Locate each term in the alphabetic index |
Locate each term in the alphabetic index and verify the code selected in the tabular list. Read and be guided by instructional notations that appear in both the alphabetic index and the tabular list. |
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3) Level of detail in coding |
Diagnosis and procedure codes are to be used at their highest number of digits available. ICD-9-CM diagnosis codes are composed of codes with 3,4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail. A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code. For example, Acute myocardial infarction, code 410, has fourth digits that describe the location of the infarction (eg., 410.2, of inferolateral wall), and fifth digits that identify the episode of care. It would be incorrect to report a code in category 410 without a fourth and fifth digit. ICD-9-CM Volume 3 Procedure codes are composed of codes with either 3 or 4 digits. Codes with two digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of third and/or fourth digits, which provide greater detail. |
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4) Code or Codes from 001.0 - V91.99 |
The appropriate code or codes from 001.0-V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaintsor other reason(s) for the encounter/visit. |
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5) Selection of codes 001.0-999.9 |
The selection of codes 001.0-999.9 will frequently be used to describe the reason for the admission/encounter. These codes are from the section of ICD-9-CM, for the classification of diseases and injuries (e.g., infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc). |
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6) Signs and symptoms |
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 16 of the ICD-9-CM, Symptoms, Signs, and Ill-defined conditions (codes 780.0 - 799.9) contain many, but not all codes for symptoms. |
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7) Conditions that are an integral part of a disease process |
Signs & symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification |
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8) Conditions that are not an integral part of a disease process |
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present. |
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9) Multiple coding for a single condition |
In addition o the etiology/manifestation convention that requires two codes to fully describe a single condition that affects multiple body systems, there are other single conditions that also require more than one code. "Use additional code" notes are found in the tabular at codes that are not part of an etiology/manifestation pair where a secondary code is useful to fully describe a condition. The sequencing rule is the same as the etiology/manifestation pair - "Use additional code" indicates that a secondary code should be added. For example, for infections that are not included in chapter 1, a secondary code from category 041, Bacterial infection in conditions classified elsewhere and of unspecified site, may be required to identify the bacterial organism causing the infection. A "Use additional code" note will normally be found at the infectious disease code, indicating a need for the organism code to be added as a secondary code. "Code first" notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When a "code first" note is present and an underlying condition is should be 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. If a causal condition is known, the code for that condition should be sequenced as the principal or first-listed diagnosis. Multiple codes may be needed for late effects, complication codes and obstetric codes to more fully describe a condition. See the specific guidelines for these conditions for further instruction. |
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10) Acute & Chronic Conditions |
If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the alphabetic index at the same indentation level, code both and sequence the acute (subacute) code first. |
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11) Combination Code |
A combination code is a single code used to classify: - Two diagnoses, or - A diagnosis with an associated secondary process (manifestation) - A diagnosis with an associated complication Combination codes are identified by referring to subterm entries in the alphabetic index and by reading the inclusion and exclusion notes in the tabular list. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the alphabetic index so directs. Multiple coding should not be used when the classification provides a combination code that clearly identifies all of the elements necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code. |
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12) Late Effects |
A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebrovascular accident cases, or it may occur late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. Exceptions to the above guidelines are those instances the late effect code has been expanded (at the fourth and fifth-digit levels) to include the manifestation(s) or the classification instructs otherwise. The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect. |
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13) Impending or threatening condition |
Code any condition described at the time of discharge a "impending" or "threatened" as follows: If it did occur, code as confirmed diagnosis If it did not occur, reference the Alphabetic index to determine if the condition has a subentry term for "impending" or "threatened" and also reference main term entries for "Impending" and for " Threatened." If the subterms are listed, code the existing underlying condition(s) and not the condition described as impending or threatened. |
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14) Reporting Same Diagnosis Code More Than Once |
Each unique ICD-9-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same ICD-9-CM diagnosis code |
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15) Admissions/Encounters for rehabilitation |
When the purpose for the admission/encounter is rehabilitation, sequence the appropriate V code from category V57, Care involving use of rehabilitation procedures, as the principal/first-listed diagnosis. The code for the condition for which the service is being performed should be reported as an additional diagnosis. Only one code from category V57 is required. Code V57.89. Other specified rehabilitation procedures, should be assigned if more than one type of rehabilitation is performed during a single encounter. A procedure code should be reported to identify each type of rehabilitation therapy actually performed. |
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16) Documentation for BMI and Pressure Ulcer Stages |
For the Body Mass Index (BMI) and pressure ulcer stage codes, code assignment may be based on medical record documentation from clinicians who are not eh patient's provider (i.e. physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietition often documents the BMI and nurses often documents the pressure ulcer) must be documented by the patient's provider If there is conflicting medical record documentation, either from the same clinician or different clinitians, the patient's attending provider should be queried for clarification. The BMI and pressure ulcer stage codes should only be reported as secondary diagnoses. As with all other secondary diagnosis codes, the BMI and Pressure Ulcer stage codes should only be assigned hen they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses). |
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17) Syndromes |
Follow the alphabetic index guidance when coding syndromes. In the absence of index guidance, assign codes for the documented manifestations of the syndrome.
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18) Documentation of complications of care |
Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complication. There must be a cause-and-effect relationship between the care provided and condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented. |
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Chapter-Specific Coding Guidelines |
In addition to general coding guidelines, there are guidelines for specific diagnoses and/or conditions in the classification. Unless otherwise indicated, these guidelines apply to all health care settings. Please refer to Section II for guidelines on the selection of principal diagnosis. |
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1. Chapter 1: Infectious and Parasitic Diseases (001-139) |
a) Human Immunodeficiency Virus (HIV) Infections b) Septicemia, systemic inflammatory response syndrome (SIRS), Sepsis, severe sepsis, and septic shock |
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I:C:1:a:1 C: Chapter specific coding 1: Chapter 1: Infectious & parasitic diseases a: Human Immunodeficiency Virus (HIV) Infections 1: Code only confirmed cases |
code only confirmed cases of HIV infection/illness. This is an exception to the hospital inpatient guideline section II, H. In this context, "confirmation" does not require documentation of provider's diagnostic statement that the patient is HIV positive, or has an HIV-Related illness is sufficient. |
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1:C:1:a:2 2: Selection and sequencing of HIV codes |
(a) Patient admitted for HIV-related condition |
