ICD-9-CM Official Guidelines for Coding and Reporting - Office of ...

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Same Diagnosis Code for Two or More Conditions When the same ICD-9-CM diagnosis code applies to two or more conditions during the same encounter (e.g. bilateral condition, or two separate conditions classified to the same ICD-9-CM diagnosis code): Assign “Y” if all conditions represented by the single ICD-9-CM code were present on admission (e.g. bilateral fracture of the same bone, same site, and both fractures were present on admission) Assign “N” if any of the conditions represented by the single ICD-9-CM code was not present on admission (e.g. dehydration with hyponatremia is assigned to code 276.1, but only one of these conditions was present on admission). Obstetrical conditions Whether or not the patient delivers during the current hospitalization does not affect assignment of the POA indicator. The determining factor for POA assignment is whether the pregnancy complication or obstetrical condition described by the code was present at the time of admission or not. If the pregnancy complication or obstetrical condition was present on admission (e.g., patient admitted in preterm labor), assign “Y”. If the pregnancy complication or obstetrical condition was not present on admission (e.g., 2 nd degree laceration during delivery, postpartum hemorrhage that occurred during current hospitalization, fetal distress develops after admission), assign “N”. If the obstetrical code includes more than one diagnosis and any of the diagnoses identified by the code were not present on admission assign “N”. (e.g., Code 642.7, Pre-eclampsia or eclampsia superimposed on preexisting hypertension). If the obstetrical code includes information that is not a diagnosis, do not consider that information in the POA determination. (e.g. Code 652.1x, Breech or other malpresentation successfully converted to cephalic presentation should be reported as present on admission if the fetus was breech on admission but was converted to cephalic presentation after admission (since the conversion to cephalic presentation does not represent a diagnosis, the fact that the conversion occurred after admission has no bearing on the POA determination). Perinatal conditions ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Page 108 of 119
Newborns are not considered to be admitted until after birth. Therefore, any condition present at birth or that developed in utero is considered present at admission and should be assigned “Y”. This includes conditions that occur during delivery (e.g., injury during delivery, meconium aspiration, exposure to streptococcus B in the vaginal canal). Congenital conditions and anomalies Assign “Y” for congenital conditions and anomalies. Congenital conditions are always considered present on admission. External cause of injury codes Assign “Y” for any E code representing an external cause of injury or poisoning that occurred prior to inpatient admission (e.g., patient fell out of bed at home, patient fell out of bed in emergency room prior to admission) Assign “N” for any E code representing an external cause of injury or poisoning that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission) ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Page 109 of 119
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ICD-9-CM Official Guidelines for Co
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f. Admission/encounter to determine
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F. Original treatment plan not carr
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assigned. The terms within the pare
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8. “With” The word “with” i
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causing the infection. A “use add
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qualified healthcare practitioner l
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eceive a principal diagnosis code o
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(v) Either the term sepsis or SIRS
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clear as to whether an acute organ
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Only one code from subcategory 995.
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2. Chapter 2: Neoplasms (140-239) G
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e. Admissions/Encounters involving
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puberty. For this reason type I dia
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(c) (d) Assigning and sequencing se
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See I.C.17.e.1. Adverse effects. 5.
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• If the encounter is for any oth
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This code may be assigned as the pr
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• 3 with heart failure and with C
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2) Codes from category 438 with cod
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of COPD or with acute bronchitis, t
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equates to mild CKD; stage III, cod
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4) When a delivery occurs When a de
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h. Normal Delivery, Code 650 1) Nor
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2, complete, indicates that all pro
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and there is no documentation of th
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When a congenital anomaly does not
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d. Use of category V29 1) Assigning
Page 57 and 58: A code from category 038, Septicemi
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Page 61 and 62: 8) Sequelae with a late effect code
Page 63 and 64: categories E980-E982, for undetermi
Page 65 and 66: instance, the principal diagnosis w
Page 67 and 68: Categories V03-V06 are for encounte
Page 69 and 70: V49.6 Upper limb amputation status
Page 71 and 72: even if no longer present, is impor
Page 73 and 74: Additional codes may be used in add
Page 75 and 76: V58.43 Aftercare, surgery, trauma V
Page 77 and 78: V28 Antenatal screening (See Sectio
Page 79 and 80: 15) Nonspecific V codes Certain V c
Page 81 and 82: Code(s) Description 1 st Dx Only 1
Page 91 and 92: External cause of injury codes (E-c
Page 93 and 94: d. Multiple Cause E Code Coding Gui
Page 95 and 96: i. Misadventures and Complications
Page 97 and 98: were confirmed and the diagnoses ar
Page 99 and 100: Since that time the application of
Page 101 and 102: When a patient presents for outpati
Page 103 and 104: performed during the same encounter
Page 105 and 106: Issues related to inconsistent, mis
Page 107: If the final diagnosis contains a p
Page 111 and 112: V15.4, Other personal history, Psyc
Page 113 and 114: V86 Estrogen receptor status V87.4,
Page 115 and 116: E990-E999, Injury resulting from op
Page 117 and 118: 7. A patient is admitted to the hos
Page 119: 3. Patient admitted in active labor
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