CHAPTER 6
CHAPTER-SPECIFIC GUIDELINES
(ICD-9-CM CHAPTERS 9-17)
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Slide 1
Chapter 9
• Diseases of Digestive System
– Mouth to anus and accessory organs
– Extensive subcategories
• 574 Cholelithiasis (10 subcategories)
• Each has fifth digit subclassification
– Presence of hemorrhage associated with
diseases in this chapter
• Query provider if documentation is not clear
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Slide 2
Chapter 10
• Diseases of Genitourinary System
• Commonly used codes
– Urinary tract infection (599.0)
– Inflammation of prostate (601.X)
– Disorders of menstruation (626-627) & breast
(610-612)
• Use additional code to identify organism
Use additional codes to identify lower urinary
tract symptom
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Slide 3
Chapter 11, Complications of Pregnancy,
Childbirth, and the Puerperium
• Extensive multiple coding with many fifth
digit assignments and notes
• Chapter 11 codes take precedence over
codes from other chapters
• Admission for pregnancy, complication
– Obstetric complication =
first-listed diagnosis
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Slide 4
Section I.C.11. Complications of
Pregnancy, Childbirth, and Puerperium
• Chapter 11 codes
• Mother’s medical record
(600 series codes)
• Not on newborn medical record
(Newborn, 700 series codes)
(Cont’d…)
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Slide 5
Section I.C.11. Complications of
Pregnancy, Childbirth, and Puerperium
(…Cont’d)
• Mother’s record
– Outcome of delivery code (V27.0-V27.9)
when delivered
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Slide 6
Section I.C.11.a. General
Rules for Obstetric Cases
• Not all encounters are pregnancy related
– Example, pregnant woman, broken ankle
• Broken ankle
• V22.2 Pregnant state incidental must be
documented in medical record treated condition
not affecting pregnancy
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Slide 7
Section I.C.11.a.4. Fifth
Digit
• All categories EXCEPT 650
(Normal delivery)
• Requires fifth digit for:
– Antepartum
– Postpartum
– Delivery
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Slide 8
Codes 640-676.9 Share
Fifth-Digit Subclassification
• Denotes current episode of care
– 0 Unspecified as to episode of care or not
applicable
– 1 Delivered, with or without mention of
antepartum condition
– 2 Delivered, with mention of postpartum
complication
– 3 Antepartum condition or complication
– 4 Postpartum condition or complication
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Slide 9
Section I.C.11.b. Selection of
Principal Diagnosis—Obstetric
• No delivery: Principal diagnosis =
principal complication
• >1 complication, sequence any first
(Cont’d…)
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Slide 10
Section I.C.11.b. Selection of
Primary Diagnosis
(…Cont’d)
• Routine prenatal visits no complications:
– V22.0, Supervision, normal first pregnancy or
– V22.1, Supervision, other normal pregnancy
– Always primary diagnosis
• Prenatal outpatient visits for high-risk
pregnancies:
– V23, Supervision of high-risk pregnancy
(V23.X)
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Slide 11
Section I.C.11.c.1. Fetal
Conditions Affect Mother
• Codes from Categories 655 and 656
• Assign only if known or suspected fetal
abnormality affects management of the
mother
• Requires additional diagnostic studies,
observation, special care or termination
of the pregnancy
• The existence of a fetal condition alone
does not justify reporting these codes
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Slide 12
Section I.C.11.c.2. In Utero
Surgery
• When surgery is performed on the
fetus, report a code from Category 655
identifying the fetal condition
• No code from Chapter 15, perinatal
codes, should be used on the mother’s
record to identify fetal conditions
• Surgery performed in utero on the fetus
is still coded as an obstetric encounter
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Slide 13
Section I.C.11.d. HIV Infection in
Pregnancy, Childbirth, Puerperium
• Patient admitted during this period because of
an HIV-related illness should receive
– a principal code of 647.6x
– followed by 042
• Patient admitted with asymptomatic HIV
status should be reported
– 647.6x
– V08
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Slide 14
Section I.C.11.e. Current Conditions
Complicating Pregnancy
• Assign a code from Category 648.x for
patient with current condition that
affects management of the pregnancy,
childbirth or the puerperium
• Use additional secondary code from
other chapters to identify conditions
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Slide 15
Section I.C.11.f. Diabetes
Mellitus in Pregnancy
• Significant complicating factor in
pregnancy
• Diabetic pregnant patients should be
assigned code 648.0x AND
• A secondary code from Category 250 to
identify type of diabetes
• Code V58.67, Long-term (current) use of
insulin should also be reported if
appropriate
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Slide 16
Section I.C.11.g. Gestational
Diabetes
• Occurs in second and third trimester in
women who were not diabetic prior to
pregnancy
• Can cause complications in pregnancy
similar to those of pre-existing diabetes
• Puts women at greater risk of
developing diabetes after the
pregnancy
(Cont’d…)
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Slide 17
Section I.C.11.g.
Gestational Diabetes
(…Cont’d)
• Report 648.8x
• NEVER report codes 648.0x and 648.8x
together
• Code V58.67, Long-term (current) use
of insulin should also be reported if
gestational diabetes is being treated
with insulin
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Slide 18
Section I.C.11.h. Normal
Delivery, 650
• No complications, principal diagnosis =
650
• With complications = NOT 650
• V27.0 (Single liveborn)
– Only outcome for 650 (Normal Delivery)
• Normal delivery with resolved
antepartum condition = 650
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Slide 19
Section I.C.11.i.1. Postpartum
and Peripartum Periods
• After delivery and continues
for 6 weeks
• Peripartum period
– Last month of pregnancy to five months
postpartum
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Slide 20
Section I.C.11.i.2,3,4 Postpartum
Complications
• Any complication occurring within the
6-week period
• Complications occurring after the 6-week
period may be reported with Chapter 11
codes, if the provider documents they are
pregnancy related
• Complications occurring during the same
admission as delivery are reported with fifth
digit “2”; subsequent admissions/encounters
with fifth digit “4”
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Slide 21
Section I.C.11.i.5 Care
following delivery outside
hospital
• If delivered prior to admission
– In ambulance
– At home
– In ED
• DO NOT CODE delivery
• Code any postpartum care
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Slide 22
Section I.C.11.j. Late Effect of
Complication of Pregnancy
• Category 677
• Reported when an initial complication
of pregnancy requires care or treatment
at a future date
• Category reported any time after initial
postpartum period
• Like all late effects, code is sequenced
following the complicating condition
code
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Slide 23
Section I.C.11.k. Abortions
• Codes 634-637 require fifth digits:
– 0: Unspecified
– 1: Incomplete (POC, product of conception)
NOT expelled
– 2: Complete, all (POC) expelled prior to care
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Slide 24
Section I.C.11.k.1. Fifth Digit
• Appropriate fifth digit listed under
each code
• 640.0, Threatened abortion
– 0: Unspecified episode
– 1: Delivered with or without complication
– 3: Antepartum condition or complication
• Note that NOT all fifth digits are applicable
(2 and 4)
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Slide 25
Section I.C.11.k.4. Abortion
with Liveborn Fetus
• Attempted abortion results in liveborn
fetus:
– 644.21 (Early onset of delivery)
appropriately
• Use V27 (Outcome of delivery)
• Attempted abortion procedure code
also assigned
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Slide 26
Section I.C.11.k.5. Retained
Products of Conception
• Subsequent admissions for retained
products of conception following a
spontaneous or legally induced
abortion are reported with code from:
– 634 Spontaneous abortion
– 635 Legally induced abortion
– With fifth digit “1” (incomplete)
– Appropriate even if patient previously
discharged with diagnosis of “complete”
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Slide 27
Chapter 12, Diseases of Skin
and Subcutaneous Tissue
SKIN
ACCESSORY ORGANS
• Epidermis
• Sweat glands
• Dermis
• Sebaceous glands
• Subcutaneous tissue • Nails
• Infectious
Skin/Subcutaneous
Tissue
• Scar tissue
• Hair and hair follicles
• Other
(Cont’d…)
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Slide 28
Chapter 12
(…Cont’d)
• Multiple codes often necessary
– Example: Cellulitis due to Staph
– Cellulitis 682.9
– Staph 041.1X
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Slide 29
Chapter 13, Diseases of
Musculoskeletal System and
Connective Tissue
• Bone
• Ligaments
• Bursa
• Muscle
• Cartilage
• Synovia
• Fascia
• Tendons
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Slide 30
Chapter 13 Sections
• Arthropathies (joint disease) and
Related Disorders
• Dorsopathies (curvature of spine)
• Rheumatism, Excluding back
• Osteopathies, Chondropathies, and
Acquired Musculoskeletal Deformities
• Newly Diagnosed Pathologic Fractures
• Extensive notes and fifth digits
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Slide 31
Chapter 13, Diseases of
Musculoskeletal System and
Connective Tissue
• Refer to the note at the beginning of the
chapter regarding fifth-digit subclassifications
• Details located there are not repeated
in the categories
• Used for Categories 711-712, 715-716,
718-719, and 730
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Slide 32
Chapters 14 and 15
• Congenital Anomalies
(abnormality at birth) (740-759)
• Conditions Originating in Perinatal
Period
– Perinatal period through 28th day
following birth
– Codes can be used after 28th day if
documented that condition originated
during perinatal period
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Slide 33
Section I.C.15.b. Use of Codes
V30-V39
• V30-V39 liveborn infant(s)
• Example:
– V30, Single liveborn
– V31, Liveborn twins
• Inpatient: Principal diagnosis
• Note: V30 ONLY used once, hospital
where baby delivered
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Slide 34
Section I.C.15.d. Use of
Category V29
• Assign code when healthy
newborn/infant is evaluated for
suspected condition not found
• Do not use when patient has
signs/symptoms of a suspected
problem, code the signs/symptoms
• V29 is used secondary to V30
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Slide 35
Section I.C.15.f. Maternal
Causes of Perinatal Morbidity
• Codes from Categories 760-763 are
assigned only when the maternal
condition actually affected the
fetus/newborn
• The fact that the mother has a medical
condition or experiences a
complication does not justify routine
reporting of these categories
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Slide 36
Section I.C.15.h. Coding
Additional Perinatal Diagnoses
• Code newborn conditions that require:
– Treatment
– Further investigation
– Additional resource
– Prolonged length of stay (LOS)
– Implications for future care
(Cont’d…)
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Slide 37
Section I.C.15.h. Coding
Additional Perinatal Diagnoses
(…Cont’d)
• Insignificant newborn conditions,
signs, symptoms
– Resolve with no treatment
– Need no code
• EVEN IF documented
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Slide 38
Section I.C.15.i. Prematurity
and Fetal Growth Retardation
• Codes for newborns from categories
– 764 (Slow fetal growth and fetal
malnutrition) and
– 765 (Disorders relating to short gestation
and low birthweight)
(Cont’d…)
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Slide 39
Section I.C.15.i. Prematurity
and Fetal Growth Retardation
(…Cont’d)
• Not assigned solely on birthweight or
gestational age of newborn
– Use clinical assessment instead
• Use physician’s assessment of
maturity
• Use additional code for number of
weeks of gestation (765.0 and 765.1)
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Slide 40
Section I.C.15.j. Newborn
Sepsis
• Code 771.81 should be assigned a
secondary code from category 041 to
identify the organism
• Do not report category 038
• Do not assign 995.91, Sepsis, assign
771.81
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Slide 41
Chapter 16, Symptoms, Signs,
and Ill-Defined Conditions
• Do NOT code a sign or symptom if:
– Definitive diagnosis made
(symptoms are part of disease)
• Only used if no specific diagnosis stated
• Signs/symptoms are transient or cause
not determined
• Patient fails to return and provisional
diagnosis is all that is documented
(Cont’d …)
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Slide 42
Chapter 16, Symptoms, Signs,
and Ill-Defined Conditions
(…Cont’d)
• More precise diagnosis not available
for any other reason
• Certain symptoms that may represent
important problems in medical care
exist and might be desirable to classify
them in addition to the known cause
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Slide 43
Chapter 17 Injury and Poisoning,
Section Examples
• Fractures
• Internal Injury
• Dislocations
• Crushing Injury
• Sprains and Strains
• Foreign Body
• Intracranial Injury
• Burns
• Late Effects
• Poisoning
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Slide 44
Section I.C.17.c. Burns
• Sequence highest degree burn first
• Current burns (940-948) classified by
– Depth (severity)
– Extent (% body surface)
– Site
– And if necessary, agent
(Cont’d …)
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Slide 45
Section I.C.17.c. Burns
(…Cont’d)
• Depth of burn is classified as
– First degree: Erythema
– Second degree: Blistering
– Third degree: Full-thickness involvement
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Slide 46
Section I.C.17.c. Burns
Classified
• According to extent body surface involved
• Burn site NOT specified
– Additional data required
• Burns of different degrees/same local site
– Report highest degree only
• Non-healing burns are reported as acute
burns
• Report 958.3 as additional code for infected
burn site
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Slide 47
Section I.C.17.c.6. Category
948
• Fourth digits = % total body surface
involved
• Fifth digits = % body surface involved in
third-degree burns
• Rule of Nines applies
(Cont’d…)
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Slide 48
Rule of Nines
(…Cont’d)
Figure: 6.6
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Slide 49
Section I.C.17.d. Debridement
of Wounds, Infection, or Burn
• Excisional debridement (86.22)
– Cut away
– Performed by physician
• Nonexcisional procedure (86.28)
– Shaved or scraped (includes water scalpel
[jet])
– Performed by physician or
– Nonphysician
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Slide 50
Section I.C.17. Injury and
Poisoning (800-999)
• Separate code for each injury
• Most serious injury first
• Superficial injuries not reported if in same location as
more serious injury
• Wounds
– Without mention of complication
– Complicated
• Documented delayed healing/treatment, foreign
body, primary infection
– With tendon involvement
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Slide 51
Section I.C.17.a.2. Vessel
and Nerve Damage
• Code primary injury first
– Use additional code if nerve/vessel
damage minor
• Primary injury = nerve/vessel damage
• Code nerve/vessel damage first
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Slide 52
Section 1.C.17.b.1. Acute
Fracture vs. Aftercare
• Active treatment of fracture (800-829) may be:
– Physician evaluation
– ER encounter
– Surgical treatment
– Closed treatment
• After active treatment completed, use aftercare
codes
– Aftercare involving internal fixation (V54.X)
– Aftercare for healing traumatic fracture (V54.1X)
– Other orthopedic aftercare (V54.8X)
– Unspecified orthopedic aftercare (V54.9)
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Slide 53
Section I.C.17.b.2. Multiple
Fractures
• Same coding principles as multiple
injuries
• Code multiple fractures, by site
• Sequenced by severity
• Codes describe accidents, injury, open
wounds, etc.
(Cont’d …)
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Slide 54
Fractures
(…Cont’d)
• Not indicated as closed or open = closed
• Same bone fractured AND dislocated
– Code fracture ONLY
(highest level of injury)
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Slide 55
Section I.C.17.e. Adverse Effects,
Poisoning, and Toxic Effects
• Properties of some drugs, medicinal,
and biological substances, or
combinations may cause toxic
reactions
• Classify as Adverse Effect when drug
was correctly prescribed/administered
– Code effect first
– E-code from therapeutic column for drug
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Slide 56
Section I.C.17.e. Adverse Effects,
Poisoning, and Toxic Effects
Poisoning occurs when drugs/chemical
substances are not taken as directed
• Wrong dosage given in error
• Medication given to wrong person
• Medication taken by wrong person
• Medication overdose has occurred
• Medications (prescription or over-the-counter) taken in
combination with alcohol and/or recreational drugs
• Over-the-counter taken in combination with prescription drugs
without provider approval
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Slide 57
Section I.C.17.e. Adverse Effects,
Poisoning, and Toxic Effects
Sequencing of Poisoning:
• Poisoning code from Table of Drugs &
Chemicals first
• Manifestation(s) of the poisoning second
• Corresponding E-code from the Table of
Drugs and Chemicals last
– If intent unknown or questionable, report
intent as undetermined (E980-E989)
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Slide 58
E Codes
• Provides supplemental information
• Never first-listed diagnosis
• Identify:
– Cause of an injury or poisoning,
– Intent (unintentional or intentional), and
– Place it occurred
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Slide 59
General E Code Guidelines
• Use with any code in Vol. 1
• Initial encounter
– Use E code
• Subsequent encounter
– Use late effects E CODES
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Slide 60
Intent
Intent
Code As
• Unknown
• Undetermined*
• Unspecified
• Undetermined*
• Questionable
• Undetermined*
*(E980-E989)
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Slide 61
Section I.C.19.c. Table of
Drugs and Chemicals
• Alphabetic listing with codes
• Do NOT code directly from Table
• Always reference Tabular
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Slide 62
Section I.C.19.c. Two or More
Substances Involved
• If two or more substances involved code:
– Each unless combination code exists
• Code substance more closely related to
principal diagnosis, and
– Include one code from each category
(cause, intent, place)
• Interaction of a drug(s) and alcohol
– Using poisoning and E codes for both
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Slide 63
Section I.C.19.e. Unknown
or Suspected Intent
• Unknown
• Unspecified
Undetermined
• Questionable
E980-E989
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Slide 64
Section I.C.19.f.
Undetermined Cause
• Intent known, cause unknown, use
– E928.9, Unspecified accident
– E958.9, Suicide and self-inflicted injury by
unspecified means
– E968.9, Assault by unspecified
means
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Slide 65
Section I.C.19.g. Late Effects
of External Cause
• Should be used with late effect of a
previous injury/poisoning
• Should NOT be used with related
current injury code
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Slide 66
Conclusion
CHAPTER 6
CHAPTER-SPECIFIC GUIDELINES
(ICD-9-CM CHAPTERS 9-17)
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Slide 67