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

ICD-9-CM Official Guidelines for Coding and Reporting ................................................................... 1
Section I. Conventions, general coding guidelines and chapter specific guidelines........................ 6
A. Conventions for the ICD-9-CM...................................................................................................... 6
1. Format:...................................................................................................................................... 6
2. Abbreviations............................................................................................................................ 6
a. Index abbreviations................................................................................................................. 6
b. Tabular abbreviations.............................................................................................................. 6
3. Punctuation ............................................................................................................................... 6
4. Includes and Excludes Notes and Inclusion terms.................................................................... 7
5. Other and Unspecified codes .................................................................................................... 7
a. “Other” codes.......................................................................................................................... 7
b. “Unspecified” codes................................................................................................................ 7
6. Etiology/manifestation convention (“code first”, “use additional code” and “in diseases
classified elsewhere” notes)...................................................................................................... 8
7. “And” ........................................................................................................................................ 8
8. “With”....................................................................................................................................... 9
9. “See” and “See Also”................................................................................................................ 9
B. General Coding Guidelines............................................................................................................. 9
1. Use of Both Alphabetic Index and Tabular List ....................................................................... 9
2. Locate each term in the Alphabetic Index ................................................................................ 9
3. Level of Detail in Coding ......................................................................................................... 9
4. Code or codes from 001.0 through V89.................................................................................. 10
5. Selection of codes 001.0 through 999.9.................................................................................. 10
6. Signs and symptoms ............................................................................................................... 10
7. Conditions that are an integral part of a disease process ........................................................ 10
8. Conditions that are not an integral part of a disease process .................................................. 10
9. Multiple coding for a single condition.................................................................................... 10
10. Acute and Chronic Conditions................................................................................................ 11
11. Combination Code .................................................................................................................. 11
12. Late Effects ............................................................................................................................. 11
13. Impending or Threatened Condition....................................................................................... 12
14. Reporting Same Diagnosis Code More than Once............................................................. 12
15. Admissions/Encounters for Rehabilitation......................................................................... 12
16. Documentation for BMI and Pressure Ulcer Stages.......................................................... 12
C. Chapter-Specific Coding Guidelines ............................................................................................ 13
1. Chapter 1: Infectious and Parasitic Diseases (001-139) ......................................................... 13
a. Human Immunodeficiency Virus (HIV) Infections.............................................................. 13
b. Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis,
Severe Sepsis, and Septic Shock.......................................................................................... 15
c. Methicillin Resistant Staphylococcus aureus (MRSA) Conditions ................................. 21
2. Chapter 2: Neoplasms (140-239)............................................................................................ 23
a. Treatment directed at the malignancy................................................................................... 23
b. Treatment of secondary site.................................................................................................. 23
c. Coding and sequencing of complications ............................................................................. 23
d. Primary malignancy previously excised ............................................................................... 24
e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy .. 25
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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