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

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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 Page 2 of 119
f. Admission/encounter to determine extent of malignancy .................................................... 25 g. Symptoms, signs, and ill-defined conditions listed in Chapter 16 associated with neoplasms ............................................................................................................................................. 26 h. Admission/encounter for pain control/management............................................................. 26 i. Malignant neoplasm associated with transplanted organ............................................... 26 3. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279).............................................................................................................................. 26 a. Diabetes mellitus................................................................................................................... 26 4. Chapter 4: Diseases of Blood and Blood Forming Organs (280-289).................................... 30 a. Anemia of chronic disease.................................................................................................... 30 5. Chapter 5: Mental Disorders (290-319).................................................................................. 31 Reserved for future guideline expansion .............................................................................. 31 6. Chapter 6: Diseases of Nervous System and Sense Organs (320-389) .................................. 31 a. Pain - Category 338 .............................................................................................................. 31 7. Chapter 7: Diseases of Circulatory System (390-459) ........................................................... 35 a. Hypertension......................................................................................................................... 35 b. Cerebral infarction/stroke/cerebrovascular accident (CVA) ................................................ 38 c. Postoperative cerebrovascular accident ................................................................................ 38 d. Late Effects of Cerebrovascular Disease .............................................................................. 38 e. Acute myocardial infarction (AMI)...................................................................................... 39 8. Chapter 8: Diseases of Respiratory System (460-519)........................................................... 40 a. Chronic Obstructive Pulmonary Disease [COPD] and Asthma ........................................... 40 b. Chronic Obstructive Pulmonary Disease [COPD] and Bronchitis ....................................... 41 c. Acute Respiratory Failure..................................................................................................... 41 d. Influenza due to identified avian influenza virus (avian influenza) ..................................... 42 9. Chapter 9: Diseases of Digestive System (520-579) .............................................................. 42 Reserved for future guideline expansion .............................................................................. 42 10. Chapter 10: Diseases of Genitourinary System (580-629) ..................................................... 42 a. Chronic kidney disease ......................................................................................................... 42 11. Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium (630-679) .......... 43 a. General Rules for Obstetric Cases ........................................................................................ 43 b. Selection of OB Principal or First-listed Diagnosis.............................................................. 44 c. Fetal Conditions Affecting the Management of the Mother................................................. 45 d. HIV Infection in Pregnancy, Childbirth and the Puerperium ............................................... 46 e. Current Conditions Complicating Pregnancy ....................................................................... 46 f. Diabetes mellitus in pregnancy............................................................................................. 46 g. Gestational diabetes .............................................................................................................. 46 h. Normal Delivery, Code 650.................................................................................................. 47 i. The Postpartum and Peripartum Periods............................................................................... 47 j. Code 677, Late effect of complication of pregnancy............................................................ 48 k. Abortions............................................................................................................................... 48 12. Chapter 12: Diseases Skin and Subcutaneous Tissue (680-709)............................................ 50 a. Pressure ulcer stage codes.................................................................................................. 50 13. Chapter 13: Diseases of Musculoskeletal and Connective Tissue (710-739)......................... 52 a. Coding of Pathologic Fractures ............................................................................................ 52 14. Chapter 14: Congenital Anomalies (740-759)........................................................................ 52 a. Codes in categories 740-759, Congenital Anomalies........................................................... 52 ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Page 3 of 119
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Page 5 and 6: F. Original treatment plan not carr
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Page 11 and 12: causing the infection. A “use add
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Page 15 and 16: eceive a principal diagnosis code o
Page 17 and 18: (v) Either the term sepsis or SIRS
Page 19 and 20: clear as to whether an acute organ
Page 21 and 22: Only one code from subcategory 995.
Page 23 and 24: 2. Chapter 2: Neoplasms (140-239) G
Page 25 and 26: e. Admissions/Encounters involving
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Page 29 and 30: (c) (d) Assigning and sequencing se
Page 31 and 32: See I.C.17.e.1. Adverse effects. 5.
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Page 41 and 42: of COPD or with acute bronchitis, t
Page 43 and 44: equates to mild CKD; stage III, cod
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When a congenital anomaly does not
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d. Use of category V29 1) Assigning
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A code from category 038, Septicemi
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ut without any detail at the fourth
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8) Sequelae with a late effect code
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categories E980-E982, for undetermi
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instance, the principal diagnosis w
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Categories V03-V06 are for encounte
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V49.6 Upper limb amputation status
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even if no longer present, is impor
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Additional codes may be used in add
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V58.43 Aftercare, surgery, trauma V
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V28 Antenatal screening (See Sectio
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15) Nonspecific V codes Certain V c
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Code(s) Description 1 st Dx Only 1
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External cause of injury codes (E-c
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d. Multiple Cause E Code Coding Gui
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i. Misadventures and Complications
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were confirmed and the diagnoses ar
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Since that time the application of
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When a patient presents for outpati
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performed during the same encounter
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Issues related to inconsistent, mis
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If the final diagnosis contains a p
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Newborns are not considered to be a
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V15.4, Other personal history, Psyc
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V86 Estrogen receptor status V87.4,
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E990-E999, Injury resulting from op
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7. A patient is admitted to the hos
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3. Patient admitted in active labor
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