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CHAPTER 15

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  1. CHAPTER 15 USING THE ICD-9-CM

  2. General Guidelines Chapter 1, Infectious and Parasitic Diseases Chapter 2, Neoplasms Chapter 3, Endocrine, Nutritional, and Metabolic Diseases, and Immunity Disorders Chapter 4, Diseases of Blood and Blood- Forming Organs Chapter 5, Mental Disorders Chapter 6, Diseases of Nervous System and Sense Organs Chapter 7, Diseases of Circulatory System Chapter 8, Diseases of Respiratory System Chapter 9, Diseases of Digestive System Chapter 10, Diseases of Genitourinary System Chapter 11, Complications of Pregnancy, Childbirth, and Puerperium Chapter 12, Diseases of Skin and Subcutaneous Tissue Chapter 13, Diseases of Musculoskeletal System and Connective Tissue Chapters 14 and 15, Congenital Anomalies; Certain Conditions Originating in Perinatal Period Chapter 16, Symptoms, Signs, and Ill-Defined Conditions Chapter 17, Injury and Poisonings and E Codes Basic Coding Guidelines ICD-10-CM Using the ICD-9-CM

  3. Using the ICD-9-CM • Guidelines developed by cooperating parties • AHA (American Hospital Association) • AHIMA (American Health Information Management Association) • CMS (Centers for Medicare and Medicaid Services) • NCHS (National Center for Health Statistics)

  4. General Guidelines • Appendix A of text contains official Guidelines • Inpatient coders use Sections I-III of Guidelines • Outpatient coders primarily use Sections I and IV, however… (Cont’d…)

  5. General Guidelines (Cont’d…) • Basic coding guidelines do NOT cover all situations • Outpatient coders also use many inpatient guidelines • Slides within presentation labeled “(I)” for inpatient or “(O)” for outpatient • Slides that apply to both inpatient and outpatient, labeled “(I/O)”

  6. Steps to Diagnosis Coding (I/O) • Identify MAIN term(s) in diagnosis • Locate MAIN term(s) in Index • Review subterms • Follow cross-reference instructions • (e.g., see, see also) • Verify code(s) in Tabular

  7. Remember (I/O) • Read Tabular notes • Code to highest specificity (detail) • NEVER CODE FROM INDEX!

  8. Guideline Section I.B.3. Level of Detail in Coding (I/O) • Assign diagnosis to highest level of specificity • Do NOT use three-digit code if there is fourth • Do NOT use four-digit code if there is fifth • If not specific, claims bounce!

  9. Section I.A.2. Abbreviations Other (NEC) and Unspecified (NOS) (I/O) • Use ONLY if more specific code NOT available • NEC = Not elsewhere classifiable • More specific code does NOT exist • NOS = Not otherwise specified (Means “unspecified”) • Available information NOT specific enough

  10. Section I.B.10. Acute and Chronic Conditions (I/O) • Exists alone or together • May be separate or combo codes • If two codes, code acute first (Cont’d…)

  11. Section I.B.10. Acute and Chronic Conditions (I/O) (…Cont’d) • Example, acute and chronic pancreatitis • When two separate codes exist, code: • Acute pancreatitis 577.0 • Chronic pancreatitis 577.1 • Place acute first and chronic second • 577.0, 577.1 (Cont’d…)

  12. Section I.B.10. Acute and Chronic Conditions (I/O) (…Cont’d) • Combination code: Both acute and chronic condition • Diarrhea (acute) (chronic) 787.91 • Acute and subacute bacterial endocarditis 421.0 • Otitis acute and subacute 382.9

  13. Section I.B.11. Combination Code (I/O) • Always use combination code if one exists • Example, encephalomyelitis (manifestation) due to rubella (etiology), 056.01

  14. Section I.B.9. Multiple Diagnosis Coding (I/O) • Etiology (cause) • Manifestation (symptom) • Slanted brackets [ ] • Example: Retinopathy, diabetic 250.5 [362.01] • Code as shown • 250.5X • 362.01 (Cont’d…)

  15. Section I.B.9. Multiple Coding for a Single Condition, (I/O) (…Cont’d) • Must check Tabular notes to assign correct fifth digit for diabetes • Tabular: 362.0, Diabetic retinopathy, instructs to “Code first diabetes 250.5” • 250.5X Cause is diabetes • 362.01 Manifestation is retinopathy • Report 250.5X, 362.01 • X = required additional digit

  16. Section II.H. Uncertain Diagnosis (I) • If diagnosis at time of discharge states: • “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” • Code condition as if condition existed until proven otherwise (inpatient facilities code this) • Physicians report definitive dx or signs/symptoms (Cont’d…)

  17. Section II.H. “Cough and fever, probably pneumonia” (I/O) (…Cont’d) • Inpatient: Code pneumonia, do NOT code cough and fever • Outpatient: Code cough and fever, do NOT code pneumonia • OK to code symptoms in outpatient setting if a definitive diagnosis is not documented

  18. Section I.B.13. Impending or Threatened Condition (I) • Code any condition described at time of discharge as impending or threatened • Did occur: Code as confirmed • Did NOT occur: Code as impending or threatened (MAIN terms)

  19. Selection of Principal Diagnosis (I) • Condition established after study (tests) • Chiefly responsible for patient admission

  20. Selection of First-Listed Diagnosis (O) • Condition for encounter • Why patient presented, not necessarily most serious condition noted • Documented • Chiefly responsible for services provided • Also listco-existingconditions

  21. Diagnosis and Services (I/O) • Diagnosis and procedure MUST correlate • Medical necessity must be established through documentation • No correlation = No reimbursement

  22. Section II.A. Symptoms, Signs, and Ill-Defined Conditions (I) • Chapter 16 • Inpatient coders do NOT code when definitive diagnosis has been established

  23. Symptoms, Signs, and Ill-Defined Conditions (O) • Can be the first-listed diagnosis if no more specific diagnosis available

  24. Section I.A.3. Codes in Brackets (I/O) • Never sequence as principal diagnosis • Although you do not code from the Index, • Codes are in correct sequence in Index (Cont’d…)

  25. Section I.A.3. Codes in Brackets, Example (I/O) (…Cont’d) • Index lists: Diabetes, with gangrene 250.7X [785.4] • 785.4 = gangrene • Tabular: 785.4 indicates “Code first any associated underlying condition: diabetes (250.7X)….” • Code first diabetes, then gangrene • 250.7X = diabetes • 785.4 = gangrene

  26. Section II.B. Two or More Interrelated Conditions (I/O) • Two or more interrelated conditions exist • Either could be principal diagnosis • Either sequenced first (Cont’d…)

  27. Section II.B. Example of Interrelated Conditions (I/O) (…Cont’d) • Mitral valve stenosis and coronary artery disease (two interrelated conditions) • Either can be principal diagnosis • Either sequenced first • MVS and CAD • CAD and MVS • Resource intensiveness affects choice • Mitral valve stenosis is presumed by ICD-9-CM to be of rheumatic origin

  28. Section II.C. Two or More Equal Diagnoses (I/O) • Either can be sequenced first • Example: Diagnosis of viral gastroenteritis and dehydration if both are treated • VGandD • D and VG • If only dehydration is aggressively treated with IV fluids and the VG is treated with oral meds, sequence dehydration as first-listed

  29. Section II.D. Comparative or Contrasting Conditions (I) • “Either/or” diagnoses • Code as confirmed in the inpatient setting • If determination CANNOT be made, either can be sequenced first • Example: Pneumonia or lung cancer can be either • P or LC • LC or P • If both aggressively treated

  30. Section II.E. Symptom(s) Followed by Contrasting/Comparative Diagnosis (I) • Symptom code sequenced first • Then other diagnoses • Example: Patient admitted for chest pain, either gastric reflux or peptic ulcer disease (PUD) • Sequence first chest pain • Followed by gastric reflux or PUD • Rule: Code first underlying condition causing the symptom • If it is necessary to code symptom to explain resources used, code also

  31. Section I.C.18. Observation and Evaluation for Suspected Conditions Not Found (I/O) • V71.01-V71.9 • Assigned as principal diagnosis for: • Admissions for evaluation • Following an accident that would ordinarily result in health problem, BUT there is none • Car accident, driver hits head, no apparent injury, admit to R/O head trauma • Never a secondary diagnosis

  32. Section II.F. Original Treatment Plan Not Carried Out (I) • Principal diagnosis becomes • Condition that after study was reason for admission as inpatient • Treatment does NOThave to be carried out for condition (Cont’d…)

  33. Section II.F. Example (I) (Cont’d…) • Patient admitted for elective surgery, develops pneumonia, surgery cancelled • Code reason for surgery first • Code “Surgical or other procedure NOT carried out because of contraindication” (V64.1) • Also code pneumonia

  34. V Codes • Located after 999.9 in Tabular • Two digits before decimal (e.g., V10.1X) • Index for V codes is Alphabetic Index to Diseases • Main terms: • Contraception • Counseling • Dialysis • Status • Examination

  35. Uses of V Codes (I/O) • Not sick BUT receives health care (e.g., vaccination) • Services for known disease/injury (e.g., chemotherapy) • Codes for “aftercare” (ex., surgery or fracture) (Cont’d…)

  36. Uses of V Codes (I/O) (…Cont’d) • A circumstance/problem that influences patient’s health BUT NOTcurrent illness/injury • Example: Organ transplant status • Example: Birth status and outcome of delivery (newborn) • Section I.18.e. of Guidelines contains the V Code Table • Identifies how V codes can be listed (first, first/additional, additional only)

  37. History V Code Categories in Tabular Condition no longer present or being treated • V12 Personal history of certain other diseases • V13 Personal history of other diseases • V14 Personal history of allergy to medicinal agents • V15 Other personal history presenting hazards to health • V16 Family history of malignant neoplasm • V17 Family history of certain chronic disabling diseases • V18 Family history of certain other specific diseases • V19 Family history of other conditions

  38. Special Note About “History of” (I/O) • Index to Disease, MAIN term “History” • Entries between “family” and “visual loss V19.0” = “family history of” (FHO) • Entries before “family” and after “visual loss” = “personal history of” (PHO) • Personal history = V10-V15 • Family history = V16-V19

  39. Section I.B.12. Late Effects (I/O) • Ex., 701.4 followed by code 906.6 • Late effect is a residual of(remaining from) previous illness/injury • e.g., Scar produced by previous burn • Residual coded first (scar) • Late effect cause (burn) coded second906.6 • No time limit • Generally requires 2 codes (Cont’d…)

  40. Late Effects (…Cont’d) • Late effect codes not in separate chapter • Rather throughout Tabular • Reference the term “Late” in the Index • There is no time limit on developing a residual • There may be more than one residual • Example: Patient had a stroke and has residual paralysis on dominant side (hemiparesis, 438.11) and aphasia,438.21 • Late effect means original injury has healed and dealing with “residual” condition

  41. ICD-9-CM, Chapter 1 (I/O) • Infectious and Parasitic Diseases • Divided based on etiology (cause of disease) • Many combination codes • Example: 112.0 candidiasis infection of mouth, which reports both organism and condition with one code

  42. Multiple Codes (I/O) • Sequencing must be considered • UTI due to Escherichia coli • 599.0 (UTI) etiology • 041.4 (E. coli) organism • 041 category is secondary-code only

  43. Section I.C.1.a. Human Immunodeficiency Virus (I/O) • Code HIV or HIV-related illness ONLY if stated asconfirmed in diagnostic statement • 042 HIV or HIV-related illness • V08 Asymptomatic HIV status • 795.71 Nonspecific HIV serology • Once an HIV diagnosis, cannot code V08

  44. Section I.C.1.a.2.f. Previously Diagnosed HIV-Related Illness (I/O) • Code prior diagnosis HIV-related disease 042 (HIV) • NEVER assign these patients to: • V08 (asymptomatic) or • 795.71 (Nonspecificserologic evidence of HIV)

  45. Section I.C.1.a.2. HIV Sequencing (I) • If admitted for HIV-related illness (e.g., pneumonia) • Code 042 (HIV) • Followed by current illness (pneumocystic carinii, 136.3) • If admitted for other than HIV-related illness • Codeprincipal diagnosis • Then 042 (HIV) (Cont’d…)

  46. Section I.C.1.a.2. HIV Sequencing (O) (…Cont’d) • Sequence • Reason most responsible for encounter, if HIV (042) • Any additional diagnosis that impacts treatment

  47. Section I.C.1.a.2.g. HIV and Pregnancy Complications (I/O) • Exception to HIV sequencing • During pregnancy, childbirth, or puerperium, code: • 647.6X (Other specified infections and parasitic diseases) • Followed by 042 (HIV) (stated diagnosis) • Then any HIV-related illness (Cont’d…)

  48. Section I.C.1.a.2.g. HIV and Pregnancy (I/O) (…Cont’d) • Asymptomatic HIV during pregnancy, childbirth, or puerperium • 647.6X (Other specified infections and parasitic diseases) and • V08(Asymptomatic HIV infection status)

  49. Section I.C.1.a.2.e. Inconclusive Laboratory Test for HIV (I/O) • 795.71 (Inconclusive serologic test for HIV)

  50. Section I.C.1.a.2.h. HIV Screening (I/O) • Code V73.89 (Screening for other specified viral disease) • Patient in high-risk group for HIV • V69.5 (Other problems related to lifestyle) • Patients returning for HIV screening results = V65.44 (HIV counseling)