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ICD-9-CM coding guidelines

Report health statistics, to classify mortality and morbidity data for the indexing of medical records, and for medical care review

The ICD-9-CM manual is used, by medical personnel for the following::

Clinical Modifications:

More precise codes to describe illnesses.

eponyms, nouns, syndromes, or adjectives

Diagnoses are listed, in ICD-9-CM, as the folowing four word types:

Eponyms

A disease named after an individual
Lou Gehrig's disease (Amyotrophic Lateral Sclerosis/ motor neuron disease)
Whitmore's bacillus
Raynaud's disease

Nouns

Name of a person, place or thing
Disease
Cyst
Atrophy
Contusion (Bruise)
Syndrome

Syndrome

Raynaud's Syndrome
Barrett's esophagus are examples of ?

Adjectives

Enlarged
Large
Small
Blue
examples of?

Volume I:

This Volume of ICD-9-CM contains:
Tabular List/17 chapters
Numeric listing of codes and their descriptors by chapter.
Supplementary Classification of Factors Influencing Health Status and Contact with Health Services or V Codes (V01-V91)
Supplementary Classification of External Causes of Injury and Poisoning or E Codes (E000-E999)
Appendix A
Appendix C

Volume II: (Alphabetic Index)

This Volume of ICD-9-CM contains:
Alphabetic Index to Diseases and Injuries
Table of Drugs and Chemicals
Index to External Causes of Injury (E Codes)
Hypertension Table
Neoplasm Table

Volume III

ICD-9-CM Procedures
Alphabetic Index to Procedures
Procedures - Tabular List

Note: Physician's Office ICD-9-CM does not have this.

Chapters
Sections
Categories
Subcategories
Subclassifications

5 major divisions of ICD-9-CM:

Chapter

A main division in the ICD-9 manual. Printed in bold uppercase letters and is preceded by codes ranging from 001-999 (Range of sections and categories/RT)

Sections

Each chapter is divided into _____________?
which are groups of three digit categories.

Category

a basic code or one code that represents one or a single condition. One (3 digits) Example:

003 Other Salmonella infections

Subcategory

a more specified disease or condition/indented under a three digit category. The three digit category has been expanded to (4 digits). Example:
003.0 Salmonella gastroenteritis

Subclassification

a more specific disease or condition indented under a four digit subcategory. The fourth digit has been expanded to (5 digits)

Example: 003.21 Salmonella Meningitis

Conventions of ICD-9-CM

These consist of abbreviations, symbols, footnotes, boldface and italicized type and punctuation marks.
They are incorporated within the alphabetic indices & tabular lists of ICD-9-CM as instructional notes.

NEC

"Not elsewhere classified."

Abbreviation for when a code is not available for a specific condition, coder is directed to "other"or "other specified" condition.
Example: Pneumoconiosis
dust ? abbrev? 504

NOS

"Not otherwise specified"

This abbreviation is equivalent to unspecified doctor could not or did not specify further in medical record)

Brackets [ ]
Example 1:
482.2 Pneumonia due to Hemophilus influenzae [H. influenza]

Example 2: 715.0 Osteoarthritis, generalized
[0, 4, 9]

Punctuation that encloses synonyms, alternative terminology or explanatory phrases.

Are also used beneath specific codes, to enclose valid 5th digits, for a subcategory:

Parentheses
Example 1: Alphabetic Index:
Pneumonia (acute) (alpenstich) (benign) (bilateral) (brain)...486

Example 2: 321.1 Meningitis in other fungal diseases
Code first underlying disease (110.0-118)

Punctuation that encloses supplementary words, which are, non-essential modifiers

In Tabular this punctuation may enclose a range of codes appropriate to a related set of conditions:

non-essential modifiers

Words that may be present or absent, in the disease description, without affecting the code assignment.

Colons
Example 1:
443.0 Raynaud's syndrome
Raynaud's:
disease
phenomenon

Example 2: Colon use with inclusion note: See protozoal 007

Punctuation used in the tabular list, after an incomplete term, which needs one or more of the modifiers that follows, in order to make it assignable to a given category.

Also used in both inclusion and exclusion notes.

Instructional Notes

(In Alphabetical & Tabular List):
Notes that contain Includes and excludes notes and inclusion terms located at the beginning of chapter or section, and before or after a category or subcategory. Notes that appear immediately under a three digit code title to further define, or give examples of, the content of the category. Example for section: 001-0039 Infectious and parasitic diseases; example for category: 007 Other Protozozl or see 216

Inclusion notes

Contains terms or conditions that may be coded under the number that is referenced (Synonyms or "other specified terms" that are close enough to be coded to the condition that has been referenced).
These terms are listed under certain four and five digit codes.

Example: Skin of Scrotum and Trunk 216.9

Exclusion notes (Excludes:)

Notes of three types indicating that either:

1.) terms contained within the note are coded to different categories,
2.) terms in the note cannot be coded with the term from which it is excluded.
- example: See hydrocephalus acquired and congenital). pg 1273 in ICD-9-CM,
-or-
3.) Indicates that some conditions may need to be coded together (in other words two codes may be needed because a single dx contains two conditions which are exclusive and therefore coded to different categories)

-example: Arteriosclerotic Cardiovascuar Disease [ASCVD] 429.2 requires additional code to id presence of arteriosclerosis 440.9 which, in turn, excludes ASCVD. thus both codes are required.

Code First Underlying Condition

In tabular list, this designation most commonly represents what is known as the "Manifestation/Etiology" sequencing rule. When a particular condition is due to another underlying causal condition, the underlying condition (etiology) code is sequenced first, followed by the code for the manifestation.

In the alphabetic index, the underlying code is listed first, followed by the manifestation code, which is italicized in brackets. A manifestation code can never be sequenced as the first-listed or principal diagnosis.

"Manifestation/Etiology" sequencing rule

Rule stating that when a particular condition is due to another underlying causal condition, the underlying condition (etiology) code is sequenced first, followed by the code for the manifestation.

Code if applicable, any causal condition first

(Tabular List):
A code with this note indicates this code may be assigned as a first-listed or principal diagnosis, when the causal condition is unknown or not applicable. If the causal condition is known, then the code for that condition should be sequenced, as the principal or first-listed diagnosis.
Example:
590.0 Chronic pyelonephritis
Code, if applicable, any causal condition first (See page 1578 mid page)

Use Additional Code

This designation is used to signal the coder that another code may be necessary to fully define the disease process or condition. If the condition, that is indicated in the note, is present in the documentation, it should always be assigned. A common example involves the assignment of an additional code to specify an infectious organism:
Example:
599.0 Urinary tract infection, site not specified

Use additional code to identify organism, such as Escherichia coli [E. coli] (041.4

General notes

These notes may be found in both the alphabetic index and the tabular list. These notes typically provide information related to a specific section or subsection.
Example:
In the fractures section of the tabular list, (See page 1781 of ICD-9-CM, near the middle of the page) the following note appears:
Note: A fracture not documented as closed or open should be designated (coded) as closed.

Cross Reference Notes

These types of notes are located in the alphabetic indices to instruct the coder to look elsewhere before assigning a final code.
Four types include:
See
See Also
See Category
See Condition

See

_________ indicates that the coder must refer to an alternative term. This is a mandatory instruction

See Also

This designation indicates there is an additional indexed entry where the coder may find pertinent information related to the documented condition. It isn't necessary to refer to the additional entry, if the information presented under the initial indexed entry contains all that is necessary for specific code assignment.

See condition

This note instructs the coder to refer to a main term and not anatomical site for the condition or diagnosis. This note is encountered when referencing an anatomical (body) site, and sometimes adjectives.

See Category

(Alphabetic Index): A variation of the "SEE" cross reference. Refers the coder to a specific category.

"And"

Means either "and" or "or" when it appears in a title. Interpret as: "and/or"

"Due To"

Words indicating that a causal relationship exist between two conditions or diagnoses.
Used in the both the alphabetic and tabular indices.
Causal relationships are assumed with conditions, such as, hypertension and renal failure, and disorders of the mitral and aortic valves (etiology unknown) and rheumatic heart disease.

With" and Associated Terms Incuding:
"With"
"With mention of"
"Associated with"
"In"

These terms do no necessarily indicate a causal relationship, but they occur together much of the time and the classification system indicates this relationship.
Example: Pneumonia, in psittacosis 073.0 should be interpreted as pneumonia due to psittacosis, or, another example: Pneumonia, in anthrax 022.1 [484.5]

"With"

This word, in either a code title in the alphabetic index, or an instructional note in the tabular list, means associated with or due to (except for diabetes).

Boldface Font

Font convention used for all codes and titles in the tabular list(s) and main terms in the alphabetic indices.

Italicized Font

Font convention used for all exclusion notes, and to identify codes that should be used to describe the first-listed or principal diagnosis.

UHDDS

Abbreviation for the Uniform Hospital Discharge Data Set

Uniform Hospital Discharge Data Set UHDDS

The __________ was started in 1974 to improve uniformity and comparability of hospital discharge data.
Includes all non-outpatient settings (acute care, short-term care, long-term care, home health agencies, etc.)
Includes specific data that pertains to patients and their episodes of care.

Principal diagnosis

Other significant diagnoses
-Coexist at the time of admission
-Develop after admission

All significant procedures

Required Data Items of the UHDDS

Principal Diagnosis

The condition "established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"

- may change following studies during the course of the hospital stay.

Most significant diagnosis

The condition having the most impact on the patient's health, length of stay, resource consumption (The most resource intensive condition). This diagnosis may or may not be the principal diagnosis. This could be a secondary diagnosis

either code may be sequenced first as the principle diagnosis

Two or more diagnoses equally meet the definition for principle diagnosis:
When two or more diagnoses equally meet the definition for principal diagnosis as determined by the circumstances of admission and treatment provided , and 1.) there are no other general or disease specific coding guidelines that direct sequencing, 2.) no instructions in the Alphabetic Index and/or Tabular List that direct sequencing, which diagnostic code is listed first as the principle diagnosis?

The condition towards which the most care was directed or the condition that required the inpatient care should be designated as principle diagnosis

Two or more diagnoses equally meet the definition for principle diagnosis:
When two or more conditions are present on admission and treatment is totally or primarily directed toward one condition, or, when only one condition would have required inpatient care, how should coding be sequenced?

a.) code both dx as confirmed
b.) designate principle dx according to circumstances of admission, diagnostic workup, and tx provided (i.e. to which diagnosis was care primarily directed?). If no further determination can be made from this, either may be designated as principle dx.

Two or more comparable or contrasting conditions:
When two or more comparable or contrasting conditions are documented as either/or (or similar terminology), a.) what is the correct way to code the diagnoses coded? b.) which diagnosis is sequenced as principle diagnosis?

The symptom - ."fatigue" - is coded first as principle diagnoses with additional codes assigned for both associated conditions - "depressive reaction" and "hypothyroidism"

A symptom followed by contrasting/comparable diagnoses:
The correct coding for a symptom followed by contrasting/comparative diagnoses when the symptom code is not integral to each of the conditions (code for conditions do not include the symptom) e.g. "fatigue due to either depressive reaction or hypothyroidism"

In this case the diagnoses are coded as contrasting/comparative diagnoses. The symptom "bleeding" is not coded because the codes for both diagnoses include any associated bleeding.

A symptom followed by contrasting/comparable diagnoses (contd.):
Correct coding for a symptom followed by contrasting/comparative diagnoses when the symptom code is integral to each of the conditions (the codes for both conditions include the symptom) e.g. "gastrointestinal bleeding due to either acute gastritis or angiodysplasia"

The diagnosis that occasioned admission to the hospital is still designated as the principle diagnosis even though the planned treatment was not carried out.

Original treatment plan not carried out:
Correct coding for when treatment for a condition that occasioned admission to the hospital is not carried out due to unforeseen circumstances.

Do not code

How should diagnoses that have no impact on patient care during the hospital stay be handled?

1.) Clinical evaluation
2.) Therapeutic treatment
3.) Further evaluation by diagnostic studies,procedures or consultation
4.) Extended length of hospital stay
5.) Increased nursing care and/or monitoring

For UHDDS reporting purposes the definition of "other" diagnoses includes only those conditions that affect the episode of hospital care in terms of the following: (5 factors)

No. The physical examination is a routine part of every hospital admission and is required within 24 hours of hospital stay for the hospital to maintain Joint Commission Accreditation

Does a physical examination alone qualify as further evaluation or clinical evaluation?

Only code the condition relevent to the current episode of care. e.g. Myocardial infarction is coded, cholecystectomy and pneumonia are not reported as they have no bearing on current episode of care.

Note: in some cases history codes (V10-V19) may be used as secondary codes if past condition has some significant impact on current treatment.

Previous conditions stated as diagnoses:
Correct coding when physician include in the diagnostic statement historical information or status post procedures performed on a previous admission that have no bearing on the current stay? e.g. patient admitted with acute myocardial infarction. Patient history notes that patient was status post cholecystectomy and previously hospitalized for pneumonia.

Physician should be consulted as to whether the diagnoses meet reporting criteria. If so, physician will need to add necessary documentation. If not, diagnoses are not coded as they have no bearing on current episode of care.

Other diagnosis with no documentations supporting reportability:

Conditions are only reported when they have a significant impact on the course of care in terms of creating the need for: alternative measures or increase in nursing care, additional diagnostic or therapeutic services, close monitoring of medications, or modifications in nursing care plans.

Chronic conditions that are not the thrust of current treatment are only coded when?

hypertension, Parkinson's disease, COPD, diabetes mellitus etc.

Certain chronic conditions such as (but not limited to) ____? should be coded even in the absence of documented intervention because they affect the patient for the rest of his/her life and almost always require some form of continuous clinical evaluation or monitoring during hospitalization.

These are not coded as additional diagnoses. e.g. joint pain is not coded because it is a characteristic part of rheumatoid arthritis.

Correct coding of conditions that are an integral part of a disease process - e.g. a patient admitted with severe joint pain and rheumatoid arthritis?

Condition should be coded when present. e.g. coma should be coded as an additional diagnosis as it is not implicit in a CVA and not always present.

Correct reporting of conditions that are not an integral part of a disease process - e.g. Cerebrovascular thrombosis with coma?

Only when the physician has not been able to arrive at a related diagnosis but indicates that the abnormal finding is clinically significant in the diagnostic statement.
In some cases it may be necessary to query the physician for further information or documentation. In the example, a Mobitz II block would be significant and warrant a query.

When should codes from 790 - 796 for nonspecific abnormal findings be assigned?
e.g. in the absence of a cardiac problem, which electrocardiography finding would be likely to be clinically significant and warrant asking the physician whether it should be reported - bundle branch block or Mobitz II block?

False. A code should never be assigned on the basis of an abnomal finding alone.

True or False? In some cases, coding on the basis of a single laboratory finding is acceptable.

False. The Admitting diagnosis is not an element of the UHDDS but often must be reported for some payers and for quality-of-care studies. It is often not the same as the principle diagnosis as it is the diagnosis given by the physician at the time of admission and may not agree with the principle diagnosis on discharge. It should not be changed to conform with the principle diagnosis.

True or False? The admitting diagnosis is a formal part of the UHDDS and is essentially the same as the principle diagnosis.

1.) A significant finding (symptom or sign) representing patient distress or an abnormal finding on outpatient examination.
2.) a possible diagnosis based on significant findings (a working diagnosis)
3.) a diagnosis established on an ambulatory care basis or during a previous hospital admission.
4.) an injury or poisoning.
5.) a reason or condition not actually an illness or injury, such as a followup examination or pregnancy in labor.

Admitting diagnoses may be reported as one of the following 5 items?

True. Report in this setting if is documented as "chief complaint" if no definite condition or problem is identified.

True of False? UHDDS definition of principe diagnosis does not apply to the coding of outpatient encounters.

true

True/false an infection following surgery can be considered a complication.

True

True of False The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital in an admission following medical or postoperative observation would be the principle diagnosis.

Priciple diagnosis will be the:
1.) Complication e.g. inffection etc.
2.) Reason for outpatient surgery
3.) Unrelated condition.

Correct designation for admission following outpatient surgery if:
1.) Reason for the inpatient admission is a complication (e.g. infection)
2.) No other complication or condition is documented as the reason for inpatient admission.
3.) Reason for inpatient admission is unrelated to the sugery.

Volume II

Table of Drugs and Chemicals are in which volume of ICD-9?

Volume II

Alphabetic Index to External Causes of Injury (E Codes) are in which volume of ICD-9?

Volume II

Hypertension and Neoplasm Tables are in which volume of ICD-9?

Volume I

Numeric or Tabular list of V and E codes are in which volume of ICD-9?

Volume I

Appendix A and Appendix C are in which volume of ICD-9?

V codes

Supplementary Classification of Factors Influencing Health Status and Contact with Health Services are more commonly called__________?

E codes

Supplementary Classification of External Causes of Injury and Poisoning or E Codes are more commonly called__________?

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