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CHAPTER 2

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CHAPTER 2

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  1. CHAPTER 2 AN OVERVIEW OF ICD-9-CM

  2. An Overview of the ICD-9-CM • Classification System • Morbidity (illness) • Mortality (death) • ICD = International Classification of Diseases • WHO’s ICD-9 used globally • World Health Organization • ICD-9-CM = 9th Revision; CM, Clinical Modification • Continuity of data (Cont’d…)

  3. Overview (…Cont’d) • 1977: US develops ICD-9-CM version • More code subsets define medical care • ICD-9-CM data comparable to global data in ICD-9 • Updated October 1 of each year • Must use new codes as of October 1 • Also updates April 1 with no grace period

  4. Medicare • Medicare Catastrophic Act of 1988 • Required use of ICD-9-CM codes for diagnosis • Act later repealed, but codes still used • Effective 2003, all claims must have valid diagnosis • Excludes ambulance suppliers

  5. Uses of ICD-9-CM • Facilities track facilityuse through codes • Fiscal entities track health care costs (Cont’d…)

  6. Uses of ICD-9-CM (…Cont’d) • Research • Health care quality • Future needs • Newer cancer center built if patient use warrants

  7. Uses of ICD-9-CM • Use and results evident every day • Newscaster reference to number of AIDS cases • Newspaper article about measles epidemic

  8. ICD-9-CM Principles/Practices Four groups function together to maintain ICD-9-CM • Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA) (Cont’d...)

  9. ICD-9-CM Principles/Practices (...Cont’d) • National Center for Health Statistics (NCHS) • American Health Information Management Association (AHIMA) • American Hospital Association (AHA)

  10. ICD-9-CM Documents Medical Necessity • Diagnoses establish medical necessity • Services and diagnoses must correlate • Correct diagnosis codes allow: • Accurate reimbursement • Fewer rejected claims • Reduced risk of sanctions/fines from audit

  11. CMS-1500 (08/05) in Blocks 21 and 24E (Outpatient) Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.

  12. UB04 in Blocks 66-74 (Inpatient) Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.

  13. Ethics • Documentation must support diagnosis • Example: • Services provided • Diagnosis justifies services • If in doubt, check it out; don’t make assumptions

  14. Your Job • Translate documentation into ICD-9-CM codes • Legionnaires’ disease = 482.84 • Assign code to highest level specificity • Medical record must substantiate diagnosis code assignment

  15. Format of the ICD-9-CM • Volume 1, Diseases, Tabular List (diagnosis) (17 chapters) • Volume 2, Diseases, Alphabetic Index (diagnosis) (3 sections) • Volume 3, Procedures, Tabular List and Alphabetic Index (inpatient)

  16. Volume 1, Diseases, Tabular List • Contains code numbers • 001.0-999.9 Diagnosis codes describe condition • V and E codes = supplemental information (Cont’d…)

  17. Volume 1, Diseases, Tabular List (...Cont’d) Divided into: • Chapter • Section • Category • Subcategory • Subclassification

  18. Volume 2, Diseases, Alphabetic Index • Appears first in book (may vary with publishers) • Terms and code numbers verified inVolume 1 • Never code directly from Index! • Read all notes and follow instructions (e.g., see also) • Tables (e.g., Drugs/Chemicals, Hypertension, Neoplasm)

  19. Volume 3, Procedures, Tabular List and Alphabetic Index • Not used for physician services • Index and Tabular List used for procedures and therapies • Inpatient settings only • Procedures and therapies • Maximum 4 digits • 20.41 Simple mastoidectomy

  20. Volume 1, Tabular List • Two major divisions • Classification of Diseases and Injuries (codes 001.0-999.9) • Supplementary Classification (V codes and E codes)

  21. V Codes (V01.0-______) V89.09 • Patient not ill but encounters health services • e.g., Vaccination • Patient presents for treatment • e.g., Chemotherapy • Some V codes are primary only (e.g., V58.11, encounter for chemotherapy) (Cont’d…)

  22. V Codes (V01.0-V89.09) (…Cont’d) • Factors that influence patient’s health status • e.g., Personal history of [PHO] malignant tumor, organ transplant • Birth status and outcome of delivery

  23. Classification of Diseases and Injuries • Main portion of ICD-9-CM • Codes from 001.0-999.9 • Most chapters are organ systems • Digestive System • Respiratory System

  24. Divisions of Classification of Diseases and Injuries • Chapters: 1 through 17 • Section: A group of related conditions

  25. Volume 1, Diseases, Format Figure: 2.5 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.

  26. Category Code • Category: Represent single disease/condition (3 digits) Figure: 2.6 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.

  27. Subcategory Code • Subcategory: More specific (4th digit) Figure: 2.7 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.

  28. Subclassification Code • Subclassification: More specific (5th digit) Referenced from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.

  29. Specificity in ICD-9-CM Codes • Each digit adds to the specificity (detail) Figure: 2.9

  30. Remember • Assign to the highest level possible, based on documentation • If 4-digit code exists, do not report 3-digit code • If5-digit code exists, do not report 4-digit code

  31. Appendices in Volume 1 • There are fiveappendices in official ICD-9-CM • Private publishers may have more

  32. Appendix A, Morphologyof Neoplasms • Used in conjunction with codes from Chapter 2, Neoplasm • Inpatient setting: Cancer registries and claim forms • Not placed on a billing claim form (M codes) (Cont’d…)

  33. Appendix A, Morphology of Neoplasms (…Cont’d) • Begins withM followed by 5 digits • M8400/0, Sweat gland adenoma • First four digits: Histologic type of neoplasm • Fifth digit: Behavior (e.g., 0 = benign)

  34. Appendix B, Glossary of Mental Disorders • Deleted in 2004 • Most psychiatric disorders are classified using: • The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

  35. Appendix C, Drugs American Hospital Formulary Service (AHFS) publishes list of all drugs Tracks drugs nationally; used by pharmacists Each drug coded with up to six-digit code (e.g., 84:04.04) (Cont’d…)

  36. Appendix C, Drugs (…Cont’d) AHFS listing correlated to ICD-9-CM Table of Drugs and Chemicals New drugs not identified by name Rather listed under heading “Drug” in Table of Drugs and Chemicals Example: 84:04.04 antibiotics

  37. Appendix D, Industrial Accidents Three-digit codes that identify occupational hazards Not placed on insurance or billing form Used by state and federal organizations (OSHA) Occupational Safety and Health Administration to summarize industrial accident data

  38. Appendix E, Three-Digit Categories Presented by chapter Categories are labeled 1 through 17 Provides quick overview of ICD-9-CM contents

  39. Volume 2, Sections Section 1, Index to Diseases Section 2, Table of Drugs and Chemicals Section 3, Index to External Causes of Injuries and Poisonings (E Codes) Never primary diagnosis Medicare does not accept for professional billing

  40. Section 1, Index to Diseases Largest part of Volume 2—Index First step in coding, locate main bold term in the Index Subterms indented 2 spaces to the right May have more than one subterm 3 digits = category codes 4 digits = subcategory 5 digits = subclassification codes

  41. A Word of Caution About the Alphabetic Index (Section I, Vol. 2) Some words in Index do not appear in Tabular—saves space Exact word may not be in code Tabular description But found in Alphabetic Index That is why you must locate term in Index and then locate Tabular (follow where Index directs)

  42. Section 2, Table of Drugs and Chemicals Drug name placedalphabetically on left under heading “Substance” Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. (Cont’d…)

  43. Table of Drugs and Chemicals First column: “Poisoning” code for substance involved, wrong substance given or taken First-listed before manifestation condition (Cont’d…) (…Cont’d) Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.

  44. Table of Drugs and Chemicals (…Cont’d) E codes identify how poisoning occurred Example: If analgesics poisoning occurred by accident, E850.9 Correct order poisoning 3 codes required: Identify agent analgesic 965.9 Condition—coma 780.01 Accidental poison E850.9 Correct order adverse effect 2 codes required Condition—coma 780.01 Therapeutic E935.9

  45. Table of Drugs and Chemicals: Headings Accident: Unintentional Therapeutic: Correct dosage, correctly administered, with adverse effects (example, allergic reaction) Suicide attempt: (must be documented) Assault: Intentionally inflicted by another person Undetermined: Unknown intent

  46. E Codes (E000-E999) Supplementary Classification of External Causes of Injury and Poisoning Alpha-numerical designations for injuries and poisonings (Cont’d…)

  47. E Codes (E000-E999) (…Cont’d) Provides additional information about externalcauses Never a principal (inpatient) diagnosis Separate E code index Locate the E Code index in your ICD-9-CM now

  48. Section 3, E Codes Alphabetic Index to External Causes of Injuries and Poisonings Provide additional information about the nature of injury/poisoning and locality Never aprincipal (inpatient) or first-listed(outpatient) diagnosis

  49. Section 3, E Codes (…Cont’d) Separate Index to External Causes Alphabetical, main terms in bold Subterms are indented 2 to right under main term Some words in Index not in Tabular—saves space That is why you must locate the term in the Index, then locate in Tabular

  50. Index to External Causes: Example Main terms are type of accident (Collision) Subterms are circumstances of the accident (motor vehicle) Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.