CODING WITH
ICD-9-CM IN
LONG TERM CARE
Mary Ann P. Leonard, RHIA, CRM, RAC-CT
Health Information Professionals
[email protected]
610-291-9210
HISTORY OF ICD-9-CM
Published the revised U.S. version of the
International Classification of Disease, 9th edition,
Clinical Modifications (ICD-9-CM)
1/1/79 use mandated for all health care systems
Revisions published by the American Hospital
Association every 6 months (now focusing on ICD-
10-CM)
Interpretations published by the American Hospital
Association quarterly (Coding Clinic) (now focusing
on ICD-10-CM)
PURPOSE OF ICD-9-CM
To classify morbidity and mortality information for
statistical purposes
To index health care record (information) by
diagnosis and procedure
Not utilized as a nomenclature (naming of disease)
CODING MANUAL FORMAT
Diagnostic Index
Divided into alphabetic and tabular (numeric)
sections
Divided into 17 chapters
Contains 6 appendices
Diagnostic codes consist of 3 digits to the left of
the decimal point and 0 - 2 digits to the right of
the decimal point (XXX.XX)
CODING MANUAL FORMAT
Procedural Index
Divided into alphabetic and tabular (numeric)
sections
Procedure codes consist of 2 digits to the left of
the decimal point and 1 - 2 digits to the right of
the decimal point (XX.XX)
Procedure codes are NOT used in long term care
CONVENTIONS AND TERMS cont
OTHER CONVENTIONS
TYPEFACE
BOLD Used for all codes and titles in the
Tabular List
ITALICS Used for all exclusions notes
and to identify those rubrics which are not
to be used for primary tabulation of disease
TABLES
Hypertension Table
Neoplasm Table
Table of Drugs and Chemicals
CONVENTIONS AND TERMS
MAIN TERMS
identifies the disease condition
always in bold print
arranged alphabetically in the Index by
diagnosis, condition, problem, etc.
anatomical sites will refer to a condition
CONVENTIONS AND TERMS
SUBTERMS
terms listed after the Main Term
in alphabetical order or numerical order
will have anatomical sites
CONVENTIONS AND TERMS cont.
MODIFYING TERMS
listed in parentheses ( ) after the Main term
or subterm
descriptive terms that do not have to be
present for coding
CONVENTIONS AND TERMS cont
CATEGORY CODE
Three digit code that starts the sequence
there are codes that are only three digits
but the number of these is limited (@ 100)
Sample: Multiple Sclerosis 340
Depression 311
Parkinsons Disease 342
CONVENTIONS AND TERMS cont
NEC (Not Elsewhere Classifiable)
used when a more specific category has
not been provided in the Manual
to be avoided if possible
CONVENTIONS AND TERMS cont
NOS (Not Otherwise Specified)
identifies a lack of more specific
information
to be avoided if possible
CONVENTIONS AND TERMS cont
CROSS REFERENCE
see, see also, see category
direction to look elsewhere for information
must be followed
CONVENTIONS AND TERMS cont
NOTES
informational
used to define terms and coding instructions
identifies 5th digits
italicized print
SAMPLE: Note - Complicated includes traumatic amputation with delayed healing, delayed treatment, foreign body, or major infection
CONVENTIONS AND TERMS cont
PUNCTUATION
[ ] Brackets are used to enclose synonyms,
alternative wordings, or explanatory phrase
CONVENTIONS AND TERMS cont
( ) Parentheses used to enclose
supplementary wording which may be present
or absent in the statement of the disease or
procedure without affecting the code number
to which it is assigned
CONVENTIONS AND TERMS cont
: Colons are used in the Tabular List after an incomplete term which needs one
or more of the modifiers which follow in
order to make the it assignable to a given
category
CONVENTIONS AND TERMS cont
{ } Braces are used to enclose a series of
terms, each of which is modified by the
statement appearing at the right of the brace
CONVENTIONS AND TERMS cont
SYMBOLS
The lozenge symbol printed in the
left margin preceding the disease code
denotes a fourth digit rubric unique to ICD-
9-CM
CONVENTIONS AND TERMS cont
The section mark symbol preceding
a code denotes the placement of
applicable subdivisions in that code at the
top of the page
CONVENTIONS AND TERMS cont
INSTRUCTIONAL NOTES
INCLUDES:
This note appears immediately under a
two or three digit title to further define, or
give example of the contents of the
category
CONVENTIONS AND TERMS cont
EXCLUDES
Terms following the word excludes
are to be coded elsewhere as
indicated in each case
CONVENTIONS AND TERMS cont
The word AND should be interpreted to mean either and or or when it appears in a title.
< 2011 Official Guidelines A.7>
Example:
198.5 - Secondary Malignant Neoplasm, Bone and Bone Marrow
CONVENTIONS AND TERMS cont
Omit Code
When Used in the Alphabetic Index
Instructs coder that No Code is to be Assigned.
Omit code is a medical term that should not be coded
as a diagnosis.
Example: Metaplasia cervix omit code
CONVENTIONS AND TERMS cont
See condition
Guides the Coder to refer to Main Term rather
than the Anatomical Site or Adjectives
Describing the Disease.
Examples: Cerebral see condition
Diffuse see condition
CONVENTIONS AND TERMS cont
Use additional code, if desired
Instruction is placed in the Tabular List in
those categories where the user may wish to
add further information (by using an additional
code) to give a more complete picture of the
diagnosis or procedure
CONVENTIONS AND TERMS cont
Code first underlying disease
Instruction is used in those codes not
intended to be used as a principle diagnosis,
or not to be sequenced before the underlying
disease
CONVENTIONS AND TERMS cont
Acute and Chronic Conditions
If the same condition is described as both acute and chronic, and exist as separate entries at the same indentation level in the Alphabetic Index, code as separate entries
If the same condition is described as both acute and chronic but is identified in the Alphabetic Index (and Tabular) as a Combined Code, (one code to represent both conditions) use the one code
CONVENTIONS AND TERMS cont
Multiple coding should not be used when the
classification provides a combination code which
addresses all of the elements
CONVENTIONS AND TERMS cont
Late Effect
A late effect is a residual condition after the acute
phase of an illness or injury has passed
There is no time limit on when a late effect code
can be used
CONVENTIONS AND TERMS cont
Late effects requires two codes:
The residual condition
The cause of the late effect
The residual effect is sequenced first followed by
the cause of the late effect unless identified
otherwise in the Tabular Index
CONVENTIONS AND TERMS cont
Uncertain diagnosis/diagnoses
In acute care, those diagnoses identified as
questionable, possible, ?, suspected, likely, rule
out, etc. are coded as though the condition has
been substantiated
In long term care, uncertain diagnoses are NOT
to be coded
CONVENTIONS AND TERMS cont
Syndromes
Follow the Alphabetic Index guidance when
coding syndromes. In the absence of index
guidance, assign codes for the documented
manifestations of the syndrome.
CONVENTIONS AND TERMS cont
Documentation of complication of care
Code assignment is based on the providers
documentation of the relationship between the condition
and the care or procedure. The guidelines extends to any
complications of care, regardless of the chapter the code
is located in. It is important to note that not all conditions
that occur during or following medical care or surgery is
classified as complications. There must be a cause-and-
effect relationship between the acre provided and the
condition, and an indication in the documentation that it is
a complication. Query the provider for clarification, if the
complication is not clearly documented.
STEPS IN CODING
Locate the main term in the Alphabetic Index
under the disease or condition NEVER
RELY SOLELY ON THE ALPHABETIC
INDEX TO CODE
Select the appropriate code
Refer to the Tabular Index (numeric listing)
Read the information provided in the Tabular
Check for the 4th and 5th digits
Assign the appropriate code
USE OF V CODES
V codes identify encounters with the health care system for diagnostic, monitoring, or other types of interactions
Some of the cate
