CHAPTER 11
CHAPTER-SPECIFIC GUIDELINES
(ICD-9-CM CHAPTERS 1-8)
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Slide 1
ICD-9-CM, Chapter 1
• Infectious and Parasitic Diseases
– Divided based on etiology
(cause of disease)
– Many combination codes
– Example: 112.0 candidiasis infection of
mouth, which reports both organism and
condition with one code
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Slide 2
Multiple Codes
• Sequencing must be considered
– UTI due to Escherichia coli
• 599.0 (UTI) etiology
• 041.4X (E. coli) organism
– 041 category is a secondary-code only
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Slide 3
Section I.C.1.a,d,e Human
Immunodeficiency Virus
• Code HIV or HIV-related illness ONLY if
stated as confirmed in diagnostic statement
• 042 HIV or HIV-related illness
• V08 Asymptomatic HIV status
• 795.71 Nonspecific HIV serology
• Once an HIV diagnosis cannot code V08
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Slide 4
Section I.C.1.a.2.f. Previously
diagnosed HIV-related illness
• Code prior diagnosis HIV-related disease
042 (HIV)
• NEVER assign these patients to:
– V08 (asymptomatic) or
– 795.71 (Nonspecific serologic evidence
of HIV)
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Slide 5
Section I.C.1.a.2.
Selection and sequencing of
HIV codes
• If admitted for HIV-related illness
(e.g., pneumonia)
– Code 042 (HIV)
– Followed by current illness
(pneumocystic carinii, 136.3)
• If admitted for other than HIV-related illness
– Code first-listed diagnosis
– Then 042 (HIV)
(Cont’d…)
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Slide 6
Section I.C.1.a.2.
Selection and sequencing of
HIV codes
(…Cont’d)
• Sequence
• Reason most responsible for encounter, if
HIV (042)
– Any additional diagnosis that impacts
treatment
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Slide 7
Section I.C.1.a.2.g. HIV infection
in Pregnancy, Childbirth and the
Puerperium
• Exception to HIV sequencing
• During pregnancy, childbirth, or
puerperium, code:
– 647.6X (Other specified infections and
parasitic diseases)
– Followed by 042 (HIV) (stated diagnosis)
– Then any HIV-related illness
(Cont’d…)
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Slide 8
Section I.C.1.a.2.g.
HIV and Pregnancy
(…Cont’d)
• Asymptomatic HIV during pregnancy,
childbirth, or puerperium
– 647.6X (Other specified infections and
parasitic diseases) and
– V08 (Asymptomatic HIV infection status)
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Slide 9
Section I.C.1.a.2.e.
Patients with inconclusive HIV
serology
• 795.71 (Inconclusive serologic test
for HIV)
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Slide 10
Section I.C.1.a.2.h.
Encounters for testing for HIV
• Code V73.89 (Screening for other
specified viral disease)
– Patient in high-risk group for HIV
– V69.5 (Other problems related to lifestyle)
• Patients returning for HIV screening
results = V65.44 (HIV counseling)
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Slide 11
Caution
• Incorrectly applying these HIV coding rules
can cause patient hardship
– Insurance claims for patients with HIV usually
need patient’s written agreement to disclose
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Slide 12
Section I.C.1.b. Septicemia,
Septic Shock and SIRS
• Septicemia: systemic disease of microorganisms
or their toxins in the blood (blood poisoning)
• Septic shock: cardiovascular failure due to
sepsis
• SIRS: Systemic Inflammatory Response
Syndrome is a systemic response to
infection/trauma
• Sepsis refers to SIRS due to infection
• Severe sepsis is sepsis with acute organ
dysfunction
(Cont’d…)
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Slide 13
Section I.C.1.b. Septicemia,
Septic Shock and SIRS
(…Cont’d)
• Code septicemia (038.XX)
• SIRS second (995.9X)
• If documented, septic shock (785.52) should be
reported
• Sepsis and septic shock associated with OB
codes, also use code 630-633, Ectopic and
Molar Pregnancy
• Septic shock is never primary or first-listed
diagnosis
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Slide 14
Sepsis and Severe Sepsis not
associated with noninfectious process
• Infection resulting from Trauma, Other
Serious Injury, Pancreatitis
– Code Trauma/Injury
– SIRS second (995.9X)
– Any acute organ dysfunctions
• When sepsis or severe sepsis is PDx,
sequence systemic infection & sepsis
codes before non-infectious condition
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Slide 15
ICD-9-CM, Chapter 2
Neoplasm
• Two steps for coding neoplasms:
1. Index: Locate histologic type of neoplasm (e.g.,
sarcoma, melanoma)
• Review all instructions
2. Locate code identified (usually in Neoplasm Table
in Index) by body site
• Neoplasms Table divided into columns:
1.
2.
3.
4.
Malignant (primary, secondary, Ca in situ)
Benign
Uncertain behavior
Unspecified
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Slide 16
ICD-9-CM, Chapter 2
Neoplasm
Morphology Codes-Appendix A ICD-9-CM
• Codes are alpha numeric: M + 4 numeric characters, a
slash, followed by 5th digit (indicates behavior)
• Assigned by tumor registry coder
/0= Benign
/1= Uncertain benign/malignant/borderline
/2=Carcinoma in situ
/3= Malignant, primary site
/6= Malignant, secondary/metastatic site
/9= Malignant, uncertain if primary/secondary site
• Not assigned in outpatient setting
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Slide 17
Section I.C.2. Neoplasms
• Treatment directed at malignancy: Neoplasm is
first-listed diagnosis
– Except for chemotherapy or radiotherapy:
1. Therapy (treatment)
2. Neoplasm
• Chemotherapy: V58.11—encounter for reason
the patient presents for treatment, #1 diagnosis
• Radiotherapy: V58.0—encounter for reason the
patient presents for treatment, #1 diagnosis
(Cont’d…)
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Slide 18
Section I.C.2. Neoplasms
(…Cont’d)
• Surgical removal of neoplasm and
subsequent chemotherapy or radiotherapy
– Code malignancy as first-listed diagnosis
• Surgery to determine extent of malignancy
– Code malignancy as first-listed diagnosis
– Code neoplasm as long as patient is receiving
treatment or medication following excision
(Cont’d…)
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Slide 19
Section I.C.2. Neoplasms
(…Cont’d)
• V10, “Personal history of malignant
neoplasm” if
– Neoplasm was previously
destroyed/removed
– No longer being treated
(Cont’d…)
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Slide 20
Section I.C.2. Neoplasms
(…Cont’d)
• If patient receives treatment for secondary
neoplasm (metastasis):
– Secondary neoplasm is first-listed diagnosis
– Even though primary is known
– Code primary neoplasm as secondary
diagnosis or if no longer treated code
personal history of...
(Cont’d…)
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Slide 21
Section I.C.2. Neoplasms
(…Cont’d)
• Admission for symptoms of primary
or secondary neoplasm
– Malignancy first-listed diagnosis
– Do NOT code symptoms or signs
• First-listed is site receiving treatment
• If both primary and mets are treated, code
primary as first-listed
(Cont’d…)
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Slide 22
Section I.C.2. Neoplasms
(…Cont’d)
• Patient treated for anemia or dehydration
due to neoplasm or therapy
• Code
– Anemia or dehydration
– Neoplasm
• Patient admitted for pain control due to
neoplasm, 338.3
(Cont’d…)
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Slide 23
Section I.C.2. Neoplasms
(…Cont’d)
• Patient admitted to repair complication of
surgery for an intestinal malignancy
– Complication first-listed diagnosis
• Complication is reason for encounter
– Malignancy secondary diagnosis
(Cont’d…)
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Slide 24
V Codes and Neoplasms
• Patient receiving chemotherapy or
radiotherapy post-op removal of neoplasm
• Code:
1. Therapy
2. Active neoplasm still being treated
• Do NOT report H/O (history of) neoplasm
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Slide 25
ICD-9-CM, Chapter 3
• Endocrine, Nutritional, and Metabolic
Diseases and Immunity Disorders
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Slide 26
Disorders of Other Endocrine
Glands
• Diabetes Mellitus 250 coded frequently
– Subterms often have two codes
– Example:
1. Diabetic iritis 250.5X for diabetes (etiology)
2. [364.42] for iritis (manifestation)
• Metabolic manifestation only one code
assignment, e.g., diabetic ketoacidosis
(250.1X)
(Cont’d…)
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Slide 27
Disorders of Other Endocrine
Glands
(…Cont’d)
• Fifth digit indicates type of diabetes
– Adult or juvenile
0, 2: Type II
• 0 Type II or unspecified type, not stated as
uncontrolled
• 2 Type II or unspecified type uncontrolled
1, 3: Type I
• 1 Juvenile type, not stated as uncontrolled
• 3 Juvenile type, uncontrolled
(Cont’d…)
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Slide 28
Disorders of Other Endocrine
Glands
( …Cont’d)
• Type I—Insulin dependent—pancreas does not
produce insulin
• Type II—non-insulin dependent—(can be on
insulin)
• “Uncontrolled”—must be documented by
physician
– Can use “out of control”
– Cannot assign “uncontrolled” status when
documentation states “poorly controlled”
(Cont’d…)
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Slide 29
Disorders of Other Endocrine
Glands
(…Cont’d)
• V58.67 in addition to diabetes code to
indicate long-term use of insulin
• If type is not indicated, code Type II
diabetes
• Patient with Type II diabetes can receive
insulin
• Type I diabetic is insulin dependent
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Slide 30
Other Metabolic and Immunity
Disorders Section
• Disorders such as gout and dehydration
• Disorders often have many names
– 242.0X Toxic diffuse goiter also known as:
• Basedow’s disease
• Graves’ disease
• Primary thyroid hyperplasia
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Slide 31
ICD-9-CM, Chapter 4
• Diseases of Blood and Blood-Forming
Organs
• Short chapter with 10 sections
• Includes anemia, blood disorders,
coagulation defects
(Cont’d…)
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Slide 32
Chapter 4
(…Cont’d)
• Often used code, anemia
• Many different types of anemia:
– Hereditary hemolytic (282)
– Iron deficiency (280)
– Acquired hemolytic (283)
• Multiple coding often necessary
• Identify underlying disease condition
(Cont’d…)
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Slide 33
Chapter 4
(…Cont’d)
Two confusing anemias:
• anemia of chronic disease
– disease causing anemia is chronic
– Code 285.2X and then the appropriate code
for the chronic disease
• chronic simple anemia
– Anemia (285.9), chronic simple (281.9)
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Slide 34
ICD-9-CM, Chapter 5, Mental,
Behaviorial and
Neurodevelopmental Disorders
• Includes codes for
– Personality disorders
– Stress disorders
– Neuroses
– Psychoses
– Sexual deviation/dysfunction, etc.
– Intellectual disabilities
(Cont’d…)
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Slide 35
Chapter 5
(…Cont’d)
• Fifth digit = status of episode
• Example: 304, Drug dependence has
following fifth digits:
0: unspecified (episode)
1: continuous
2: episodic
3: in remission
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Slide 36
ICD-9-CM, Chapter 6
• Diseases of Nervous System and Sense
Organs
– Central Nervous System
– Peripheral Nervous System
– Disorders of Eye and Adnexa
– Diseases of Ear and Mastoid Process
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Slide 37
Pain not elsewhere classified (338)
• Acute or chronic pain due to:
– Trauma
– Postoperative
– Neoplasm
– Psychosocial dysfunction
• NOT for generalized or localized pain
• First-listed/primary diagnosis
– When definitive diagnosis not established
– Pain management is reason for encounter/admission
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Slide 38
ICD-9-CM, Chapter 7—Diseases of
Circulatory System
• Three types of hypertension:
– Malignant—accelerated
– Benign—continuous, mild (BP↑) controllable, no
irreversible vascular changes
– Unspecified—NOT indicated as either
malignant or benign (.9)
• Hypertension table located in Index
of ICD-9-CM
– Under “H,” Hypertension
– Locate now
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Slide 39
Section I.C.7.a.1.
Hypertension, Essential, or NOS
• Assign hypertension
– arterial
– essential
– primary
– systemic
– NOS to 401
• Fourth digit to indicate type, 401.X
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Slide 40
Section I.C.7.a.2. Hypertension with
Heart Disease
• 402 Category
• Certain heart conditions when stated “due
to hypertension” or implied
(“hypertensive”)
• Add fourth digit for type
• Use additional code to specify type of
heart failure (428)
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Slide 41
Section I.C.7.a.3. Hypertensive
Chronic Kidney Disease
• Cause-and-effect relationship assumed in
chronic kidney disease with hypertension
• Category 403, Hypertensive chronic kidney
disease, used when:
– Category 585 or code 587 are present with hypertension
• With 403 assign fifth digit 0 stage I-IV or
unspecified and 1 for stage V or end stage
renal disease
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Slide 42
Section I.C.7.a.4. Hypertensive
Heart and Chronic Kidney
Disease
• Assign 404 when both hypertensive
chronic kidney disease and hypertensive
heart disease stated
• Assume cause-and-effect relationship
• Assign fifth digit for mention of heart
failure, and/or kidney failure stages I-IV or
end stage renal disease
– Use additional code from category 428,
identifying type of heart disease
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Slide 43
Stages of Chronic Kidney Disease
• Stage I:
Blood flow through kidney increases, kidney
enlarges (585.1)
• Stage II:
(mild) Small amounts of blood protein (albumin) leaks into
urine (microalbuminuria) (585.2)
• Stage III: (moderate) Albumin and other protein losses
increase. Patient may develop high BP and kidney’s
filter ability (585.3)
• Stage IV: (severe) Large amounts of urine pass through kidney,
blood pressure increases (585.4)
• Stage V:
Ability to filter waste nearly stops (585.5)
• End stage renal failure (585.6)
– When documentation indicates chronic renal disease (CKD)
and ESRD, report ESRD
• Unspecified 585.9
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Slide 44
Section I.C.7.a.5. Hypertensive
Cerebrovascular Disease
Code:
• Cerebrovascular disease (430-438) first
• Type of hypertension (401-405) second
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Slide 45
Section I.C.7.a.6.
Hypertensive Retinopathy
Code:
• Hypertensive retinopathy first (362.11)
• Type of hypertension (401-405) second
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Slide 46
Section I.C.7.a.7.
Hypertension, Secondary
• Hypertension caused by an underlying
condition
– Code:
1. Underlying condition first
2. Type of hypertension (405) second
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Slide 47
Section I.C.7.a.8. Hypertension,
Transient
• Transient hypertension: Temporary
elevation of BP
• DO NOT assign 401-405 Hypertensive
Disease
– Hypertension diagnosis NOT established
– Instead use:
• 796.2, Elevated blood pressure
• 642.3X, Transient hypertension of pregnancy
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Slide 48
Section I.C.7.a.9. Hypertension,
Controlled
• Hypertension controlled by therapy
– Assign code from 401-405
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Slide 49
Section I.C.7.a.10.
Hypertension, Uncontrolled
• Untreated hypertension
• Uncontrolled hypertension
• Assign code from 401-405
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Slide 50
Section I.C.7.a.11. Elevated
Blood Pressure
• Elevated blood pressure coded 796.2
– Elevated BP reading without hypertension
diagnosed
– Hypertension NOT stated, NOT coded to 401
(essential hypertension)
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Slide 51
ICD-9-CM, Chapter 7—Diseases
of Circulatory System
• Code 410 Acute Myocardial Infarction (MI) requires
a fifth digit:
“1” Initial episode of care for MI
• May be reported by more than one facility, if patient
transferred
“2” Subsequent care
• Patient re-admitted for testing/treatment within the
first eight (8) weeks of initial episode
• Code 412 reported for old/healed MI
– No symptoms
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Slide 52
Chapter 8, Diseases of
Respiratory System
• Watch for: “Use additional code to identify
infectious organism”
– Some codes indicate specific organism and
do not need an additional code
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Slide 53
Respiratory Failure (RF)
Sequencing
• If RF due to an acute condition (e.g., MI)
or acute exacerbation of chronic condition
(e.g., COPD)
• Per new guidelines, if there are no
chapter-specific guidelines (OB,
poisoning) regarding sequencing, either
RF or acute condition may be first-listed
diagnosis
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Slide 54
Acute Respiratory Infection
Section
• Frequently used codes, such as:
– Common cold (460, acute nasopharyngitis)
– Sore throat (462, acute pharyngitis)
– Acute tonsillitis (463)
– Bronchitis (490-491)
– Acute upper respiratory infection (465.9, URI)
– Influenza (487, flu)
Read Guidelines for Chapter 8 for specifics on
coding COPD and asthma
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Slide 55
Conclusion
CHAPTER 11
CHAPTER-SPECIFIC GUIDELINES
(ICD-9-CM CHAPTERS 1-8)
Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc.
Slide 56