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

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accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations. If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification. d. Influenza due to identified avian influenza virus (avian influenza) Code only confirmed cases of avian influenza. This is an exception to the hospital inpatient guideline Section II, H. (Uncertain Diagnosis). In this context, “confirmation” does not require documentation of positive laboratory testing specific for avian influenza. However, coding should be based on the provider’s diagnostic statement that the patient has avian influenza. If the provider records “suspected or possible or probable avian influenza,” the appropriate influenza code from category 487 should be assigned. Code 488, Influenza due to identified avian influenza virus, should not be assigned. 9. Chapter 9: Diseases of Digestive System (520-579) Reserved for future guideline expansion 10. Chapter 10: Diseases of Genitourinary System (580-629) a. Chronic kidney disease 1) Stages of chronic kidney disease (CKD) The ICD-9-CM classifies CKD based on severity. The severity of CKD is designated by stages I-V. Stage II, code 585.2, ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Page 42 of 119
equates to mild CKD; stage III, code 585.3, equates to moderate CKD; and stage IV, code 585.4, equates to severe CKD. Code 585.6, End stage renal disease (ESRD), is assigned when the provider has documented end-stage-renal disease (ESRD). If both a stage of CKD and ESRD are documented, assign code 585.6 only. 2) Chronic kidney disease and kidney transplant status Patients who have undergone kidney transplant may still have some form of CKD, because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate 585 code for the patient’s stage of CKD and code V42.0. If a transplant complication such as failure or rejection is documented, see section I.C.17.f.2.b for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider. 3) Chronic kidney disease with other conditions Patients with CKD may also suffer from other serious conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the tabular list. See I.C.3.a.4 for sequencing instructions for diabetes. See I.C.4.a.1 for anemia in CKD. See I.C.7.a.3 for hypertensive chronic kidney disease. See I.C.17.f.2.b, Kidney transplant complications, for instructions on coding of documented rejection or failure. 11. Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium (630-679) a. General Rules for Obstetric Cases 1) Codes from chapter 11 and sequencing priority Obstetric cases require codes from chapter 11, codes in the range 630-679, Complications of Pregnancy, Childbirth, and the Puerperium. Chapter 11 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 11 codes to further specify conditions. Should the provider document that ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2008 Page 43 of 119
Page 1 and 2: ICD-9-CM Official Guidelines for Co
Page 3 and 4: f. Admission/encounter to determine
Page 5 and 6: F. Original treatment plan not carr
Page 7 and 8: assigned. The terms within the pare
Page 9 and 10: 8. “With” The word “with” i
Page 11 and 12: causing the infection. A “use add
Page 13 and 14: qualified healthcare practitioner l
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
Page 27 and 28: puberty. For this reason type I dia
Page 29 and 30: (c) (d) Assigning and sequencing se
Page 31 and 32: See I.C.17.e.1. Adverse effects. 5.
Page 33 and 34: • If the encounter is for any oth
Page 35 and 36: This code may be assigned as the pr
Page 37 and 38: • 3 with heart failure and with C
Page 39 and 40: 2) Codes from category 438 with cod
Page 41: of COPD or with acute bronchitis, t
Page 45 and 46: 4) When a delivery occurs When a de
Page 47 and 48: h. Normal Delivery, Code 650 1) Nor
Page 49 and 50: 2, complete, indicates that all pro
Page 51 and 52: and there is no documentation of th
Page 53 and 54: When a congenital anomaly does not
Page 55 and 56: d. Use of category V29 1) Assigning
Page 57 and 58: A code from category 038, Septicemi
Page 59 and 60: ut without any detail at the fourth
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 and 108:
If the final diagnosis contains a p
Page 109 and 110:
Newborns are not considered to be a
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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