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

F. Original treatment plan not carried out......................................................................................... 97
G. Complications of surgery and other medical care......................................................................... 97
H. Uncertain Diagnosis...................................................................................................................... 97
I. Admission from Observation Unit................................................................................................ 97
1. Admission Following Medical Observation ........................................................................... 97
2. Admission Following Post-Operative Observation ................................................................ 97
J. Admission from Outpatient Surgery............................................................................................. 98
Section III. Reporting Additional Diagnoses....................................................................................... 98
A. Previous conditions....................................................................................................................... 99
B. Abnormal findings ........................................................................................................................ 99
C. Uncertain Diagnosis...................................................................................................................... 99
Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services ........................ 99
A. Selection of first-listed condition................................................................................................ 100
1. Outpatient Surgery................................................................................................................ 100
2. Observation Stay................................................................................................................... 100
B. Codes from 001.0 through V89.09 ............................................................................................. 101
C. Accurate reporting of ICD-9-CM diagnosis codes ..................................................................... 101
D. Selection of codes 001.0 through 999.9...................................................................................... 101
E. Codes that describe symptoms and signs.................................................................................... 101
F. Encounters for circumstances other than a disease or injury...................................................... 101
G. Level of Detail in Coding ........................................................................................................... 101
1. ICD-9-CM codes with 3, 4, or 5 digits ................................................................................. 101
2. Use of full number of digits required for a code................................................................... 102
H. ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit...... 102
I. Uncertain diagnosis..................................................................................................................... 102
J. Chronic diseases.......................................................................................................................... 102
K. Code all documented conditions that coexist.............................................................................. 102
L. Patients receiving diagnostic services only................................................................................. 102
M. Patients receiving therapeutic services only ............................................................................... 103
N. Patients receiving preoperative evaluations only........................................................................ 103
O. Ambulatory surgery .................................................................................................................... 103
P. Routine outpatient prenatal visits................................................................................................ 103
Appendix I: Present on Admission Reporting Guidelines.............................................................. 104
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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