NYU School of Medicine Coding and Reimbursement Seminar Series ICD-9 Coding for Physician Practices

NYU School of MedicineCoding and Reimbursement Seminar SeriesICD-9 Coding for Physician Practices Gretchen L. Segado, MS, CPC Director of Reimbursement Compliance NYU School of Medicine 316 East 30th Street New York, NY 10016 (212) 263-2446 (212) 263-6445 fax Gretchen.Segado@med.nyu.edu Presented by the Office of Reimbursement Compliance

History of ICD-9 CM • Originally developed by the World Health Organization (WHO) to record morbidity and mortality information for statistical purposes • Has been revised and updated to suit a greater variety of needs and to capture additional information. • International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) was issued in 1978

History of ICD-9 CM • In 1988, Medicare Catastrophic Coverage Act required physicians to report medical diagnosis codes on each Medicare payment request. • April 1, 1989, HCFA (now CMS) required diagnosis codes to be reported using ICD-9 CM

Purpose of ICD-9 CM • Classifying morbidity data for reporting; • Compiling and comparing health care data; • Evaluating the appropriateness and timeliness of medical care provided, which can be used in determining "medical necessity"; • Analyzing payments for health care; and, • Conducting epidemiological and clinical research.

Who must use ICD-9 CM? • All physicians and non-physician practitioners are required to use ICD-9 CM diagnosis codes with the exception of • Ambulance providers • Durable medical equipment suppliers • Nonphysician directed • Independently practicing PTs, OTs • Independently practicing psychologists • Audiologists

Other Coding Systems • Morphology of neoplasms “M Codes” are in ICD-O (International Classification of Disease-Oncology) • not acceptable for Medicare • DSM-IV-R for psychiatric illnesses • Cannot be used for Medicare purposes

Diagnosis coding transforms verbal descriptions into numbers. In order to utilize the ICD-9-CM to its fullest level, the coder must: • Understand medical terminology • Have a working knowledge of how to use a medical dictionary; and • Know how the ICD-9-CM text is organized

Three Volumes to ICD-9 CM Volume 1-DiseasesTabular List Volume 2-Diseases Alphabetical List Volume 3-Procedures Used for Hospital Inpatient coding • Physicians only use Volumes 1 & 2 • Diagnosis codes must be valid for the date of service reported

Volume 2: The Alphabetical List • Provides detailed instructions which assist the coder in determining if a diagnosis may require the use of additional or alternate codes. • is found in the front half of the ICD-9-CM. • It is best to consult the Alphabetic List FIRST before deciding whether a three-, four- or five-digit code best represents the patient's disease, sign or symptom.

Volume 2: The Alphabetical List • Organized by "main terms" which are printed in bold-faced type for ease of reference. • Diseases–Influenza or Bronchitis • Conditions–Fatigue, Fracture or Injury • Nouns–Disturbance or Syndrome • Adjective–Double, Large or Kink

Volume 2: The Alphabetical List • Anatomical sites are not used for Main terms. Example: Bronchial asthma will be found under the disease term asthma rather than the anatomical site bronchial. It is located in the Alphabetical Index to Diseases where, in bold-faced type, the entry "Asthma, Asthmatic" appears.

Volume 2: The Alphabetical List Many conditions can be found in more than one place Examples: Obstetrical conditions may be found under the name of the condition and under the entries for Delivery, Pregnancy and Puerperal (after delivery.) Complications of medical and surgical care are indexed under the Name of condition and under Complications. Eponyms (diseases named for persons) • often located alphabetically by the person's name and by the common name. • For example Vincent's disease (trench mouth) can be found under Vincent's, Disease and Trench.

Volume 1: The Tabular List • Contains the Classification of Diseases and Injuries. • Contains the three-, four-, and five- digit codes that are used on the claims form to indicate the patient's disease, signs or symptoms. • The Tabular list is arranged in 17 chapters.

Volume 1: The Tabular List • Arranged in numerical sequence. • Chapter headings are always in BOLD CAPS. • Three-digit code numbers always refer to sections. • Four-digit code numbers refer to categories • Five-digit code numbers denote sub-categories. Note: 5th digits can appear: At the beginning of a chapter At the beginning of a section At the beginning of a 3-digit category Within a 4th-digit sub-category

Coding Conventions • Always use the most recent version of the ICD-9-CM, and other coding manuals such as CPT and the HCPCS for the current year. • If you use an old codebook with outdated codes, your payment may be denied, delayed or underpaid.

Coding Conventions • Notes: further define terms, clarify information or list choices of additional diagnosis • Format: Subterms are indented to the right of the term to which they are linked • Excludes: Terms following the excludes instruction are to be coded elsewhere

Coding Conventions • Abbreviations • NEC Not elsewhere classifiable. The category number for the term including NEC is to be used only when the coder lacks the information necessary to code the term to a more specific category. • NOS Not otherwise specified. This abbreviation is the equivalent of “unspecified.”

Coding Conventions • Punctuation • [ ] Brackets are used to enclose synonyms, alternative wordings, or explanatory phrases. • ( ) Parentheses are used to enclose supplementary words which may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. • : Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers which follow in order to make it assignable to a given category.

Coding Conventions • Format: ICD-9-CM uses an indented format for ease in reference. • Sequencing: Code, if applicable, any causal condition first (A code with this note may be principal if no causal condition is applicable or known)

Instructional Notations • Includes: This note appears immediately under a three-digit code title to further define, or give example of, the contents of the category. • Excludes: Terms following the word “excludes” are to be coded elsewhere. The term excludes means “DO NOT CODE HERE”. • Use additional code: This instruction is placed in the Tabular List in those categories where the user will need to add further information (by using an additional code) to give a more complete picture of the diagnosis or procedure. • Code first underlying disease: This instructional note is used for those codes not intended to be used as a principal diagnosis, or not to be sequenced before the underlying disease. The note requires that the underlying disease (etiology) be recorded first and the particular manifestation recorded secondarily. This note appears only in the Tabular List.

The Golden Rule • Always code the primary reason that the patient is interacting with the medical professional

Correct Steps for Choosing a Diagnosis Code • Review the medical record to extract the pertinent written description of the disease or symptoms • Look up the disease, signs and symptoms or condition in Volume 2, Alphabetic Index and locate the corresponding code • Look up corresponding code in Volume 1 and choose most specific code that accurately describes the patient’s condition

Start with the Alphabetic List • Code the disease, sign, or symptom. • There are only 2 circumstances when it would be appropriate to code directly from the Alphabetic list. • Table of Hypertension • Table of Neoplasms

After Selecting The Appropriate Codes From The Alphabetic List, Go To The Tabular List • Make sure that all appropriate fourth or fifth digits are captured in the code. • This is referred to as "coding to the highest degree of specificity." • If you fail to code to the highest specificity, claims will usually be rejected. • Verify each payer's billing requirements to avoid denied claims.

Coding to the Highest Degree of Specificity means: 1) Code up to the 5th digit whenever possible, 2) Only use a 4-digit code when no 5-digit code exists and, 3) Only use a 3-digit code when no 4- or 5-digit code exists. Most ICD-9-CM books have some sort of indicator, for example: a red dot or a "5," that are placed next to codes which are not considered highest degree of specificity.

Often patients cannot be specific about their symptoms or, the physicians are not specific in their documentation. In this situation, do not automatically use a 4-digit code. There may be a 5 digit code where, one of the digits corresponds to the meaning of "unspecified," "without complication," or some other catch-all phrase. • While it may seem that the addition of the fifth digit does not significantly enhance the meaning of the code, the use of a 4-digit code would be considered incorrect where an appropriate five-digit code exists. • Always check the information following a main term, or indented beneath a main term. This may enhance or change the meaning of the main term and therefore play a vital role in determining the final code selected.

Examples • Chronic obstructive pulmonary disease is assigned code 496, chronic airway obstruction, not elsewhere classified. • There is no 4th or 5th digits for 496

Examples • Essential hypertension, 401, has fourth digits that describe the type of hypertension. • It would be incorrect to report code category 401 without a fourth digit • For this code category, there is a 4th digit provided to use when no information about the type of hypertension is available • 401.9 unspecified site

Examples • Gastric Ulcer, 531 has fourth digits assigned to provide information such as whether there is hemorrhage or perforation • A 5th digit is available to describe whether or not there is an obstruction. • It would be incorrect to leave off the fifth digit

DO NOT!!!!!! • Do not code diagnoses documented as “probable”, “suspected”, “questionable” or “rule out’ as if they are established. • Code the condition(s) to the highest degree of specificity known at the time of the encounter • symptoms, signs, abnormal test results or other reasons for the visit

Diagnosis Coding for Surgical Services • Code the diagnosis for which the surgery was performed • However, when the claim is filed, if the postoperative diagnosis is known to be different from the preoperative diagnosis, select the postoperative diagnosis for coding

Code all exisiting documented conditions that coexist at the time of the encounter and that require or affect patient care • Do not code conditions previously treated and no longer exisiting • Do not code conditions which the patient has unless they are the reason for the service • Coding pre-existing conditions that are no longer being treated may affect medical necessity determinations

The Tabular List Also Contains Two Supplementary Classifications • Supplementary Classification of Factors influencing Health Status and Contact with Health Services, commonly referred to as the "V-codes." • External Causes of Injuries and Poisoning. • These are very rarely used in physician billing as most payer systems, including Medicare, do not accept them for non-hospital claims. “E-codes”

Supplementary Classification:V-Codes V01-V82.9 Factors influencing Health Status & Contact with the Health Service (Circumstances other than a disease of injury classified to categories) "V-codes" are generally used in three instances: • When a physician identifies a circumstance or problem in a person who is not currently sick but has, nonetheless, come in contact with health services (to receive a prophylactic vaccination or routine health check, for example). • When an ill or injured patient requires specific treatment (such as chemotherapy for malignancy or removal of pins or rods). • When a problem or circumstance that influences the patient's health is not itself a current illness but may affect future medical treatment."

Reporting V-Codes • Usually, V codes should only be reported as supplementary codes and should not be reported as the primary reason for the encounter • Diagnostic tests can be reported with a routine diagnosis code (V70.0-70.9 and V72/0-V72.9) HOWEVER • When the only diagnosis code listed is one of the codes listed above, the service will be denied as a routine service • V-Codes will be used frequently by radiologists and pathologists

Examples • A specimen is referred to a pathologist • A time claim is submitted, if there is an established dx (eg malignant neoplasm 195.3) this dx code should be reported first to describe the reason for the service • Dx Code V72.6 laboratory examination should be reported as a secondary code • If the diagnosis had not been established, the pathologist should report at least one of the signs or symptoms

A Physician refers a patient to a radiologist….. • For a chest x-ray with the reason for the exam identified a cough and fever, rule-out pneumonia. The x-ray is normal. • The radiologist reports diagnosis code 786.2 (cough) and/or 786.6(fever) as the reason for the service. Dx code V72.5 (radiological exam not elsewhere classified) can be reported as a secondary code

A Physician refers a patient to a radiologist….. • For a chest x-ray with the reason for the exam identified as cough and fever, rule out pneumonia. The x-ray demonstrates bronchopneumonia. • The dx code 485 (bronchopneumonia) should be reported as the reason for the service • V72.5 can be reported as a secondary code

A Physician refers a patient to a radiologist….. • For a chest x-ray with the reason for the exam identified only as rule out pneumonia. The x-ray is normal • The radiologist should use a code for undiagnosed disease (eg 799.9, other unknown and unspecified cause) to indicate the patient has some condition, but it is not clearly defined. • Diagnosis V72.5 can be reported as a secondary code

Supplementary Classification: E-codes"—E800-E999 • External causes of Injury and Poisoning (environmental events, circumstances and conditions) • "E-codes" are not normally used on Part B claims. However, check with your carrier to determine which, if any E codes they will allow. • Frequently used for accident and worker’s compensation claims

USING THE TABLE OF NEOPLASMS • A neoplasm is defined as an abnormal growth of tissue. • A growth may be a lesion, tumor, cyst or mass. A neoplasm is not always a malignancy. • Growths behave in different ways. Behavior refers to the capacity of the neoplasm to invade surrounding tissue. • It may remain benign (non-cancerous) or become cancerous but remain in one designated area (malignant, cancer in situ).

Categories Of A Neoplasm Depending On Its Behavior • Malignant Primary:Identifies site of original cancerous neoplasm • Malignant Secondary:Identifies secondary cancerous neoplasm appearing at a body site other than the original site. Malignant, secondary should be used for all secondary cancers, even when the primary malignancy appears to have been arrested. • Malignant Cancer in situ:Identifies cancerous neoplasms that are confined, or "noninvasive" in nature.

Categories Of A Neoplasm Depending On Its Behavior • Benign:Identifies neoplasm that is non-cancerous. Benign neoplasms do not invade normal tissue and remain localized at the primary site. • Uncertain Behavior:This means the tumor cells do not look normal but there are not enough changes to designate malignancy. It is borderline, indicating that the pathologist cannot determine whether this growth is benign or malignant or that this behavior is unpredictable. • Unspecified:So many changes have occurred that it is impossible to tell the origin of the tumor. The nature of the neoplasm is undetermined with no way to tell where the cancer began.

Neoplasm Table—An example

Neoplasms are categorized as follows: 140-195.8 Malignant neoplasms of specific sites, stated or presumed to be primary except lymphatic and hematopoietic tissue. 196-198.89 Malignant neoplasms of specified sites, stated or presumed to be secondary. 199-199.1 Malignant neoplasms, without specification of site. 200-208.9 Malignant neoplasms of lymphatic and hematopoietic tissue, stated or presumed to be primary. 210-229.9 Benign neoplasms. 230-234.9 Carcinoma – in-situ. 235-238.9 Neoplasms of uncertain behavior 239-239.9 Neoplasms of unspecified nature.

Examples • Metastatic carcinoma of colon to the lungs • Code: Colon as Primary (e.g 153.9) and Lungs as Secondary (e.g. 197.0) depending on the specificity of the documentation in the record. • If a primary malignant neoplasm previously excised or eradicated by radiation or chemotherapy recurs, code it as primary malignancy of the stated site unless the Index directs otherwise. If you are not sure, check with your payer to see how they would like it coded. • Recurrence of cancer in Mastectomy site. For example, a cancerous Skin lesion recurs at same site where a lesion has been removed. Code: 173.8 (or 173.9 depending upon the documentation in the record). • You should find the same code for the same diagnosis even if you look it up under different headings on the neoplasm table. Example: 230.7 CA in situ of the ileum 230.7 CA in the intestines (small)

V – codes Associated with Neoplasms • V10-V10.9 Personal history of malignant neoplasm • V58.0 Radiotherapy • V58.1 Chemotherapy • V66 Convalescence • V66. 1 following Radiotherapy • V66.2 following Chemotherapy • V67Follow-up Examination • V67. 1 following Radiotherapy • V67.2 following Chemotherapy • V71. 1Observation for suspected malignant neoplasm

Tips for Coding • Code the condition that brought the patient in today. Some patients present with a complaint of pain. This can be a valid reason for office visits. • The first diagnosis code listed should be the primary diagnosis for that day's service. Do not just depend upon what's in the computer system from the last visit. • Never begin your initial search in the Tabular List (Volume 1) – this leads to errors. The range of code choices should always be explored. • Check all indentations to ensure you have coded the most appropriate code. • Do not code "rule-out" or "suspected" diagnoses, or one that is possible or probable. Code based on the patient's symptom or condition, unless you can document a confirmed diagnosis, which can then be utilized.

Tips for Coding • Do not code a diagnosis for a condition a patient no longer has, unless it has a significant importance relative to the claim being billed. For example, do not code for cancer of the uterus (233.2) if the patient has had a hysterectomy. • It is acceptable to use repeatedly a chronic diagnosis as often as necessary. Do not embellish or modify a valid diagnosis on subsequent visits. If you are unsure if a code applies to a chronic illness that can be used in repeated visits, contact your payer for direction. • When a patient undergoes a surgical procedure, code the diagnosis for the procedure that is being performed (e.g. uterine cancer for hysterectomy). • DO NOT USE a code that is not specifically documented in the record. • Do not use mental health diagnosis codes for Medicare when discussing medical issues. Cancer patients often have complaints of fatigue or insomnia, which are sometimes mistakenly referred to as depression. Symptoms of fatigue or insomnia are valid medical diagnoses.

Tips for Coding • Do not use "E-codes" from the ICD-9-CM for Medicare purposes unless the Carrier's payment policy specifically directs you to do so. • Do not use "history of " when treating the patient for current disease. This term usually refers to patients who are confirmed as 'disease free'. This can mean that the tumor area is confirmed pathologically to be free of disease. • Some oncologists prefer not use this until the patient has been out of treatment for a specified period (6 months to one year). Check with your doctor and/or payer before using these codes. • Do use a definitive diagnosis for lab tests—for example V58.1 (Encounter for chemotherapy). Chemotherapy is a reason for checking the patient's lab values, in some instances. • Avoid vague terms like "uncertain behavior". Check to see if there is a Pathology Report before using this diagnosis.

NYU School of Medicine Coding and Reimbursement Seminar Series ICD-9 Coding for Physician Practices