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Step By Step-Chapter 8

Terms in this set (29)

SECTION 1 A: CONVENTIONS FOR THE ICD-9-CM
SECTION 1 A: CONVENTIONS FOR THE ICD-9-CM
1. Format:
The ICD-9-CM uses an indented format for ease in reference
2. Abbreviations
a. Index abbreviations
b. Tabular abbreviations
a. Index abbreviations - NEC "Not elsewhere classifiable"
b. Tabular abbreviations - NEC "Not elsewhere classifiable"
"other specified" code in a. and b..
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.

( ) Parentheses are used 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.
4. Includes and Excludes Notes and Inclusion terms
Includes: This note 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: List of terms is included under certain four and five digit codes. These terms are the condition 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.
5. Other and Unspecified codes
a. "Other" codes
b. "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) titles "unspecified" are
for use when the information in the medical record is
insufficient to assign a more specific code.
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 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. Whenever 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 code. 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 do not 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.
7. "And"
The word "and" should be interpreted to mean either "and" or
"or" when it appears in a title.
8. "With"
The word "with" should be interpreted 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.
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 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.
SECTION 1 B: GENERAL CODING GUIDELINES
SECTION 1 B: GENERAL CODING GUIDELINES
1. Use of Both Alphabetic Index and Tabular List
Use both the Alphabetic Index and the Tabular List when locating and assigning a code. If you don't, it leads to errors in code assignment and less specificity in code selection.
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.
3. Level of Detail in Coding
Diagnosis and procedure codes are to be used at their highest number of digits available.
4. Code or codes from 001.0 through V91.99
The appropriate code or codes from 001.0 through V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter visit.
5. Selection of codes 001.00 through 999.9
The selection of codes 001.0 through 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.).
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 be established (confirmed) by the provider. (Codes 780.0 - 799.9) contain many, but not all codes for symptoms.
7. Conditions that are an integral part of a disease
process
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
8. Conditions that are not an integral of a disease
process
Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.
9. Multiple coding for a single condition
"Use additional code" - indicates that a secondary coded
should be added.
"Code first" - may be due to an underlying cause. When "code
first in present and an underlying condition is
present the underlying condition should be
sequenced first.
"Code, if applicable, any causal condition first" - indicates
that this code may be assigned as a
principal diagnosis when the casual
condition is unknown or not applicable. If
casual condition is known, then the code
for that condition should be sequenced as
the 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.
10. Acute and 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.
11. Combination Code
A combination code is a single code used to classify:
- Two diagnosis, 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 documented in the diagnosis. When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code.
12. Late Effects
A late effect is the residual effect (condition produced) after the acute phase of a illness or injury has terminated. There is not 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 months or years later., such as that due to a previous injury. Coding of 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.
13. Impending or Threatened Condition
Code any condition described at the time of discharge as "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 for "Threatened"
If the subterms are not listed, code the existing underlying
condition(s) and not the condition described as impending
or threatened.
14. Reporting Same Diagnosis Code 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 code.
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.
16. Documentation for BMI and Pressure Ulcer Stages
BMI code assignment may be based on medical record documentation from the clinicians who are not patient's provider.The associated diagnosis (such as overweight, obesity, or pressure ulcer) must be documented by the patient's provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient's attending provider should be queried for clarification.
The BMI and pressure ulcer stage codes should only be reported as secondary diagnosis. As with all other secondary diagnosis codes, the BMI and pressure ulcer stage codes should only be assigned when they meet the definition of a reportable additional diagnosis (see Section III, Reporting Additional Diagnoses).
17. Syndromes
Follow the Alphabetic Index guidance when coding syndromes. In the absence of index guidance, assign codes for the documented manifestations of the syndromes.
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 complications. There must be a cause-and-effect relationship between the care provided and the condition, and in 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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