Chapter 6 - Delmar

Chapter 6

ICD-9-CM Coding

Copyright © 2008 Delmar Learning. All rights reserved.

ICD-9-CM Coding

• International Classification of Diseases

(ICD)

– Used to code and classify mortality (death) data from death certificates

2


ICD-9-CM Coding

• International Classification of Diseases,

Clinical Modification (ICD-9-CM)

– Used to code and classify morbidity

(disease) data from inpatient and outpatient records

3


Overview of ICD-9-CM

• ICD-9-CM is organized into three volumes:

– Volume 1

• Tabular List

– Volume 2

• Index to Diseases

– Volume 3

• Index to Procedures and Tabular List

4


Mandatory

Reporting of ICD-9-CM Codes

• Medicare Catastrophic Coverage Act of

1988

– Mandated reporting of ICD-9-CM diagnosis codes on Medicare claims

5


Mandatory

Reporting of ICD-9-CM Codes

• Medical necessity:

– Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury

6


ICD-9-CM Annual Updates

• CMS enforces regulations pursuant to the Medicare Prescription Drug,

Improvement, and Modernization Act

(MMA)

– Requires all code sets reported on claims be valid at the time services are provided

7



• Compliance means:

– Traditional mid-year (April 1) and end-ofyear (October 1) coding updates

• Must be immediately implemented so that accurate codes are reported on submitted claims

8



• If outdated codes are submitted on claims:

– Providers and health care facilities will incur administrative costs associated with resubmitting corrected claims and delayed reimbursement for services provided

9


Outpatient Coding Guidelines

• Diagnostic Coding and Reporting

Guidelines for Outpatient Services:

Hospital-Based and Physician Office

– Developed by the federal government for use in reporting diagnoses for claims submission

10



• Developed and approved by:

1. American Hospital Association (AHA)

2. American Health Information Management

Association (AHIMA)

3. Centers for Medicare and Medicaid

Services (CMS, formerly HCFA)

4. National Center for Health Statistics

(NCHS)

11



• Although the guidelines were originally developed for use in submitting government claims, insurance companies have also adopted them.

12


Coding Tip

• Most critical rule involves beginning the search for the correct code assignment using the Index to Diseases/of Diseases.

13


Selection of

First-Listed Condition

• In the outpatient setting:

– Term first-listed diagnosis is used

– Determined in accordance with ICD-9-CM’s coding conventions as well as general and disease-specific coding guidelines

14


Selection of First-Listed Condition

• Outpatient treated in one of four settings:

1. Ambulatory Surgery Center (ASC)

– Patient is released prior to a 24-hour stay

2.

Health care provider’s office

15


Selection of First-Listed Condition

• Outpatient treated in one of four settings:

3. Hospital clinic, emergency or outpatient department, or same-day surgery unit

4. Hospital observation setting

• Patient’s length of stay is 23 hours, 59 minutes, and 59 seconds or less

16


Coding Tip

• Outpatient surgery:

– Code reason for surgery as the first-listed diagnosis (reason for the encounter)

• Even if surgery is not performed due to a contradiction

17


Coding Tip

• Observation stay:

– When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis

18


Coding Tip

• Outpatient surgery requires longer stay:

– A patient presents for outpatient surgery and develops complications requiring admission to observation.

– Code the reason for the surgery as the first reported diagnosis, followed by codes for the complications as secondary diagnoses.

19


Coding Tip

• An inpatient is a person admitted to a hospital or long term care facility for treatment with an expected stay of 24 hours or more.

20


Coding Tip

• In medical literature, you may see principal diagnosis referred to as first-listed diagnosis.

• Remember!

– The outpatient setting’s first-listed diagnosis is not the principal diagnosis

21


Coding Tip

• Inpatient principal diagnosis:

– Condition determined after study that resulted in the patient’s admission to the hospital.

• UB-04 secondary diagnoses include comorbidities and complications

22


ICD-9-CM Tabular List of

Diseases (codes 001.0-V86.1)

• Must be used to identify diagnoses, symptoms, conditions, problems, complaints, or any other reason for the encounter/visit.

23


Accurate Reporting of ICD-9-CM Diagnosis Codes

• Documentation should describe patient’s condition using terminology that includes specific diagnoses as well as symptoms, problems, or reasons for the encounter.

24


ICD-9-CM Tabular List of

Diseases (codes 001.0-V86.1)

• Must be used to identify diagnoses, symptoms, conditions, problems, complaints, or any other reason for the encounter/visit.

25


Reason for Encounter

• Codes 001.0

–999.9

– Frequently used to describe reason for encounter

– Codes are from section of ICD-9-CM for the classification of diseases and injuries.

26


Signs and Symptoms

• Codes that describe signs and symptoms are acceptable for reporting purposes when the physician has not documented an established or confirmed diagnosis.

27


Factors Influencing Health Status and

Contact with Health Services (V codes)

• Provides codes to deal with encounters for circumstances other than a disease or injury Codes V01.0-V86.1

28


Level of Detail in Coding

• Codes contain 3, 4, or 5 digits

• Codes with three digits:

– Included in ICD-9-CM as the heading of a category of disease codes

– May be further subdivided into four or five digits

• Provide greater specificity

29


Level of Detail in Coding

• Three-digit disease code is assigned only if it is not further subdivided

• If fourth-digit subcategories or fifth-digit subclassifications are provided:

– They must be assigned

• If not the code is invalid

30


Sequencing

ICD-9-CM Diagnosis

• First code for the diagnosis, condition, problem, or other reason for encounter shown in the medical record to be chiefly responsible for the services provided.

31


Sequencing

ICD-9-CM Diagnosis

• Additional codes that describe coexisting conditions that were treated or medically managed during the encounter.

32


Qualified Diagnoses

• Do not code diagnoses documented as:

– Probable, suspected, questionable, rule out, or working diagnosis, because these are considered qualified diagnoses

• Instead code condition to highest degree of certainty for that encounter

33


Qualified Diagnoses

• Qualified diagnosis:

– Working diagnosis that is not yet proven or established

– Example:

• Suspected pneumonia

• Code the sign or symptom:

– Wheezing, shortness of breath, etc.

34


Chronic Diseases

• If treated on an ongoing basis:

– May be coded and reported as many times as the patient receives treatment and care for the condition

35


Code all Documented

Conditions that Coexist

• Code all that coexist at the time of the encounter, and require or affect patient care, treatment or management.

36


Code all Documented

Conditions that Coexist

• Do not code conditions that were previously treated and no longer exist.

• However, history codes (V10-V19) may be reported as secondary codes.

37


Encounter for

Diagnostic Services

• First, report the diagnosis, condition, problem, or reason for encounter that is documented in the patient record as being chiefly responsible for the outpatient services provided during the encounter.

38


Encounter for

Therapeutic Services

• Sequence first the diagnosis, condition, problem, or other reason for the encounter shown in the medical record to be chiefly responsible for the outpatient services provided.

39


Encounter for

Preoperative Evaluation

• Assign appropriate sub classification code located under subcategory V72.8.

40


ICD-9-CM Coding System

• ICD-9-CM has three volumes:

– Tabular List

– Index to Diseases

– Index to Procedures and Tabular List

41



• Tabular and Index to Diseases

– Used in provider and health facilities to code diagnoses

• Index to Procedures and Tabular List

– Used in hospitals to code inpatient procedures

42



• Publishers make coding easier by placing the Index to Diseases in front of the

Tabular List

43


Supplementary Classifications:

V Codes and E Codes

• V codes are assigned when a circumstance other than a disease or injury is present.

– Examples:

• Removal of cast applied by another physician

(V54.89)

• Exposure to tuberculosis (V10.3)

44


V Codes and E Codes

• Like V codes, E codes are located in the

Tabular List:

– E codes describe external causes of injury, like poisoning, accidents, or other adverse reactions affecting a patient’s health

45


Appendices

• Appendices serve in coding neoplasms, adverse effects of chemicals and drugs, and external causes of disease and injury.

• In addition, the disease category codes are listed as an appendix.

46


Appendices

• Morphology of Neoplasms (M codes) contains a reference to the World Health

Organization publication entitled

International Classification of Diseases for

Oncology.

47


Appendices

• Morphology

– Indicates tissue type of a neoplasm

• Benign

– Not cancerous

• Malignant

– Cancerous

48


Appendices

• Classification of Drugs by AHFS list contains the American Hospital Formulary

Services list number and its ICD-9-CM code number

– Organized in numerical order according to

AHSF list number

49


Appendices

• Classification of industrial accidents according to agency based on employment injury statistics

– Adopted by the International Conference of

Labor Statisticians

• Difficult to locate the E code entry in the

ICD-9-CM Index to External Causes

50


Appendices

• List of three-digit categories contains a breakdown of three-digit category codes organized beneath section headings.

51


Index to Diseases

• Within the ICD-9CM Index to Diseases

– Two official tables that make it easier to code hypertension and neoplasms

52


Great Tools

Within the ICD-9-CM index

• Table of Drugs and Chemicals

• Index to External Causes (E codes)

53


Volume 3: Index to

Procedures and Tabular List

• Included in hospital version of commercial

ICD-9-CM books

• Index to Diseases alphabetical listings of main terms or conditions

54


Volume 3: Index to Procedures and Tabular List

• Main terms

– Printed in boldface type and are followed by the code number

• Subterms (essential modifiers)

– Qualify the main term by listing alternate sites, etiology, or clinical status

55



• Step 1

– Locate main term in the Index to Diseases

56



• Step 2

– If the phrase “ see condition ” is found after the main term:

• A descriptive term (an adjective) or the anatomic site has been referenced instead of the disorder

57



• Referenced instead of the disorder or the disease (the condition) documented in the diagnostic statement.

58



• Step 3

– When the condition listed cannot be found:

• Locate main terms such as syndrome, disease, disorder, derangement of, or abnormal.

• See Table 6-1 that lists special main terms for additional help.

59


Volume 3:Index to Procedures and Tabular List

• Major Topic Headings

– Printed in bold uppercase letters and followed by codes in parentheses

60



• Categories

– Major topics are divided into three-digit categories

• Printed in upper and lower case and are followed by three-digit codes

61



• Subcategories

– Four-digit subcategories are indented and printed in the same way as major category headings.

62



• Subclassifications

– Some fourth digits are more subdivided into subclassifications, which require the task of a fifth digit.

63



• Fifth-digits

– Required when indicated in the code book

64



• Fifth-digit entries are associated with:

– Chapters

– Major topic headings

– Categories

– Subcategories

65


Using the Tabular List

• After reviewing main terms and subterms:

– Locate the first possible code in the Index to

Disease

66



• In the Tabular List:

– Locate code, review code descriptions, review any EXCLUDES notes to determine whether the condition being coded is excluded

• Assign any required fifth digit

67



• Check to be sure the code number is appropriate for age and sex of patient

• Return to Index to Disease for other possible code selections

– If code description does not fit condition or reason for visit

• Enter final code

68


Tabular List

(Disease) Coding Conventions

• Apply to disease and condition codes and to additional classification codes

• Index to Procedures and Tabular List:

– Included only in hospital version of commercial ICD-9-CM books

69


Tabular List


• Principal Procedures

– A procedure performed for best treatment before diagnostic purpose

– One performed to treat a problem

– One that is most closely related to principal diagnosis

70


Tabular List


• Secondary Procedure

– Additional procedures performed during same encounter as the principal procedure

71


Tabular List


• Benign

– Mild and/or controlled hypertension

• Unspecified

– No notation of benign or malignant status

72


Neoplasm Table

• Neoplasms

– New growths or tumors, where cell reproduction is out of control

– Provider should specify whether the tumor is benign or malignant

73


Neoplasm Table

• Another term related with neoplasm is lesion

– Defined as any discontinuity of tissue

74


• Mass

• Cyst

• Dysplasia

• Polyp

• Adenosis

Neoplasm Table

75


Neoplasm Table

• Primary Malignancy

– Original tumor site

– All malignant tumors are considered primary

• Unless otherwise documented as metastatic or secondary

76


Neoplasm Table

• Secondary Malignancy

– Tumor has spread to a secondary site

• Either nearby the primary site or to a distant area of the body

77


Neoplasm Table

• Carcinoma (Ca) in SITU

– Tumor that is localized, limited, encapsulated, and noninvasive

78


Neoplasm Table

• Uncertain behavior

– Pathology impossible to predict subsequent morphology or behavior from the submitted specimen

79


Neoplasm Table

• Unspecified nature

– Neoplasm is identified

• But no more signs of histology or nature of the tumor is in the document diagnosis

80


Neoplasm Table

• Primary Malignancies

– Malignancy is coded as the primary site if the diagnostic statement documents:

• Metastatic from a site

• Spread from a site

• Primary neoplasm of a site

81


Neoplasm Table

• Malignancy for which no specific classification is documented

– Recurrent (repeating) tumor

82


Secondary Malignancies

• Secondary Malignancies

– Metastatic and show that a primary cancer has spread to another

83



• Cancer described as metastatic from a site is primary of that site:

– Assign code to the primary neoplasm

– Assign second code to the secondary neoplasm of the specified site, or unspecified site

84



• Cancer described as metastatic to a site is considered secondary of that site

– Assign one code to the secondary site, and a second code to the specified primary site or unspecified site.

85



• When anatomic sites are recognized as metastatic:

– Assign secondary neoplasm code(s) to those sites

– Assign unspecified site code to the main malignant neoplasm

86



• If the diagnostic statement does not specify whether the neoplasm site is primary or secondary:

– Code site as primary unless the documented site is the following….

87



• Bone, brain, diaphragm, heart, liver, lymph nodes, mediastinum, meninges, peritoneium, pleura,retropertoneum, spinal cord,or classifiable to 195.

88


Re-excision of Tumor

• When a surgeon performs a second excision to widen the margins of the original tumor site

– Ensures that all tumor cells have been removed

89


Coding Tip

• Read notes that apply to condition you are coding

• Never assign a code directly from table or

Index to Diseases

• Be certain codes represent current status of the neoplasm

90


Coding Tip

• Assign a neoplasm code if tumor has been excised

– And patient is still undergoing radiation or chemotherapy

• Assign a V code if tumor is not present

– If patient is not receiving treatment but is returning for follow-ups

91


Coding Tip

• In a pathology report:

– Classification stated overrides morphology classification in the Index to Diseases

• Poisonings occur as a result of an overdose, wrong substance administered or taken, or intoxication.

92


Poisoning and External Cause

• Poisoning

– Codes 960-989

• Assigned according to classification of drug or chemical

93



• Accident

– Codes (E850-E869)

• Accidental overdosing

• Wrong substance given

• Drug inadvertently taken

• Accidents during a medical surgical procedure

94



• Therapeutic use

– Codes E930-E952

• Effect caused by proper substance administered in therapeutic setting

• Suicide attempt

– Codes E950-E952

• Self-inflicted poisoning

95



• Assault

– Codes E961-E962

96



• Undetermined

– Codes E980-E982

• If used it will not state whether poisoning was intentional or accidental.

• E codes are used to explain cause of poisoning or effect

97



• ICD-9-CM contains two supplementary classifications:

– V codes

• Factors influencing health status and contact.

(V01-V82)

– E codes

• External causes of injury and poisoning (E800-

E999)

98


V Codes

• Classification of factors influencing the person’s health status

• These services fall into one of these categories:

– Problems

• Issues that could affect patient’s health status

99


V Codes

• Services

– Patient seen for treatment not caused by illness

• Factual reporting

– Used for statistical purpose

100


V Code and Description

• V01-V06

– Persons with potential health hazards related to communicable diseases

• V07-V09

– Persons with need for isolation, other health hazards, and prophylactic measures

101



• V10-V19

– Person with potential health related to personal or family history

102



• V20-V29

– Persons encountering services in circumstances related to reproduction and development

• V30-V39

– Live born infants according to type of birth

103



• V40-V49

– Person with a condition influencing their health

104



• V50-V59

– Encountering health services for specific procedures and aftercare

• V60-V69

– Encountering health services in other circumstances

105



• V70-V83

– Person without reported diagnosis encountered during examination and investigation of individuals and population

• Code 042

– States that patient is HIV and associated with

AIDS

106



• Code 079.53

– When HIV is identified by provider

• Code 795.71

– When screening for HIV was reported as nonspecific

• V01.7

– Patient exposed to virus but not tested

107



• V08

– Assigned when patient is HIV positive but not showing symptoms

108


Common Closed Fractures

• Comminuted

• Linear

• Spiral

• Impacted

• Simple

• Greenstick

109


Common Open Fracture

• Compressed

• Compound

• Missile

• Puncture

• Fracture with a foreign body

• Infected fracture

110


Late Effect

• Residual effect of a previous acute illness or long-term effect of the disorder

111


Two Codes Needed

• Primary code

– Identifies original illness

• Secondary

– Represents original condition of the late effect

112


Original Condition

• Fracture

• CVA

• Third-degree burn

• Polio

• Laceration

• Breast implant

113


Late Effect

• Malunion

• Hemiplegia

• Deep scarring

• Contractures

• Keloid

• Ruptured implant

114


Burns

• Burns require two codes

– One for site and degree

– Second for percentage of body surface

115


ICD-10: Coding for the Future

• By 2010?

– Tenth revision of the International

Classification of Diseases is expected to replace the ICD-9

116



• ICD-10-CM

– Includes more codes and is designed to collect more data on every type of health care encounter

117



• History of the ICD coding

– ICD coding serves as a statistical tool for international collection and exchange of mortality (death) data

118



• ICD-10 is being modified to:

– Return to or exceed the level of specificity found in ICD-9-CM

• Expand alphabetic Index to Diseases

119



• Provide code titles and language that complement accepted clinical practice

• Remove codes unique to mortality coding

120



• Modifications applied by the NCHS include:

– Increasing ICD-10’s five character structure to six characters

121



• Incorporating common fourth-digit subcategories and fifth-digit sub classifications

• Adding trimesters to obstetric codes

122



• Creating codes that allow for laterality

– Unique code for right arm

• Creating combined diagnostic/symptoms codes

123


ICD-10 Volumes

• ICD-10 published three volumes:

– Volume 1-1992

– Volume 2-1993

– Volume 3-1994

• Volume 1 contains a tabular list of alphabetic disease codes

124


ICD-10 Volumes

• ICD 10 Volume 2: Instruction Manual

– Volume 2 of ICD-10

• Contains rules and guidelines for mortality and morbidity coding

– ICD 10-CM

• Undecided whether a separate volume will be dedicated to rules, or be organized under a different volume

125


ICD-10 Volumes

• ICD-10 volume 3: Alphabetic Index

– Volume 3 of ICD-10 is an index to codes classified in the Tabular List

126


Organizational

Changes in ICD-10 and ICD-10-CM

• ICD-10-CM will seem familiar

– But some classification changes include iatrogenic illness, sequelae, and injury

• Iatrogenic illness results from medical intervention

127


Organizational


• Sequelae

– Late effects from injury or illness

128


Organizational


• In ICD-10 codes appear at the end of each anatomic chapter

– Injury is a wound or some other damage to an organ

129


Organizational


• In ICD-10-CM injuries to the head are subdivided into the following three-digit categories:

– S00

• Superficial injury of head

– S01

• Open wound of head

130


Organizational


• S02

– Fracture of skull and facial bones

• S03

– Dislocation, sprain, and strain of joints and ligaments of head

• S04

– Injury of cranial nerves

131


Organizational


• S05

– Injury of eye and orbit

• S06

– Intracranial injury

• S07

– Crushing head injury

132


Organizational


• S08

– Traumatic amputation of part of head

• S09

– Other and underspecified injuries of head

133


Important Issues

When Comparing ICD-10 and ICD-9

• E codes in the ICD 10

– Classify diseases of endocrine system, not external causes

• In ICD 9, external cause is currently classified as E codes

– However, in ICD-10-CM they will be V codes

134


Important Issues When

Comparing ICD-10 and ICD-9

• V codes in the ICD-9-CM supplemental classification to report factors related to health status

– Changed in ICD-10-CM to U and Z codes

135


Important Issues When

Comparing ICD-10 and ICD-9

• J codes in the HCPCS Level II report drug administration

• In the ICD-10-CM

– J codes report disorder of the respiratory system

136


Implementing ICD-10-CM

• Create a task force

– Create implementation ICD-10-CM responsibilities into work topics and assign each member a job.

137



• Be vigilant

– Assign one member to research articles about ICD-9-CM implementation found in newsletters, the internet, and the Federal

Register.

138



• Alert organization change to ICD-10-CM

– Transition to ICD-10-CM affects all departments

– Open task force meetings to entire organization

• Invite representatives to become part of the working group

139



• Anticipate problems

– Plan for education and training of personal

– Involve computer information systems in the transition to ICD-10-CM

140



• Train physicians

– Required detail in ICD-10-CM emphasizes physician participation

– Patient chart must specify terminology and complete documentation

141



• Review patients’ charts:

– Identify documentation problems relevant to

ICD-10-CM

142



• The United States adopted the ICD-9-CM to facilitate the coding and classification of morbidity disease data from inpatient, outpatient, physician records, and statistical surveys.

143


Chapter 6 - Delmar

Factors Influencing Health Status and

Contact with Health Services (V codes)

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Chapter 6 - Delmar

Factors Influencing Health Status and

Contact with Health Services (V codes)

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