ICD-9-CM Diagnostic & Reimbursement for

Physician Services 2010 edition

Chapter 1:Introduction to ICD-9-CM

Coding is…

Classifying data Assigning a representation for that data Telling a story to the insurance company

using numbers instead of letters.

Example: A zip code is the representation of the area in which a person lives.

Purposes of Coding

Retrieval of information◦ By diagnosis (why the patient is in the office)◦ By procedure (what was done to the patient)

Reimbursement- money received from insurance company for correct coding.

Resources for Coding

ICD-9-CM◦ Volumes 1 & 2 are used to code diagnoses in

office and hospital settings◦ Volume 3 is used for hospital procedure coding◦ This book is updated annually in October for all

settings

This is where you look first.

Volume 2 is divided into three major sections:o Index to Diseases and InjuriesoTable of Drugs and ChemicalsoAlphabetic Index to External Causes of

Injury and Poisoning

5

Volume 2: Alphabetic Index

This is where you look second. Volume 1 contains the following major

subdivisions:oClassification of Diseases and InjuriesoSupplementary Classifications

V Codes E Codes

oAppendices

6

Volume 1 Tabular Index

Volume 1 is divided into 17 chapters (000–999).

Each chapter is structured into the following subdivisions:oSectionsoCategoriesoSubcategoriesoSubclassifications

7

Volume 1-Tabular Index

Sections A group of three-digit categories Represent a single disease entity or a group of

similar or closely related conditions Example: Disorders of Thyroid Gland (240–246) Categories Consist of three digits Represent a single disease entity or a group of

similar or closely related conditions Example: Disorders of tooth development and

eruption (520)

8

Sections & Categories

Subcategories Represented by fourth digit 4th digit provides more specificity or information

regarding the condition’s etiology, site, or manifestation

Fifth digit subclassifications The fifth digit adds greater specificity to certain

fourth-digit codes. Fifth-digit assignments and instructions appear at

the beginning of a chapter, section, category, or subcategory in the ICD-9cm book

9

Subcategories & Fifth digit Subclassifications

You must code to the highest level of specificity. Otherwise you won’t get paid!

Third-digit code must only be used when there is no subcategory or subclassification.

Fourth-digit code must only be used when there is no subclassification with it.

Watch for required fourth and fifth digits, there will be a shaded box to the left of the code with a 4 or 5 in the box. Look down to the bottom of the page for the description of the shaded box and what is needed.

10

Coding to specificity

Allow every disease or condition to have a code

Code title includes “other,” “unspecified,” or “other and unspecified.”

Usually designated by fourth-digit 8 or 9

Do NOT use unspecified codes unless you really cannot find another code!

11

Residual Subcategories

Look in your book for the different Appendices.

Morphology of Neoplasms Classification of Drugs by AHFS List Classification of Industrial Accidents

according to Agency List of three-digit categories c/c Exclusion List

12

Appendices

Main terms Subterms Carryover lines Nonessential modifiers Eponyms Neoplasm and hypertension tables Table of Drugs and Chemicals

13

Index to Diseases and Injuries

Main Terms Set flush with the left margin of each column In boldface type Represent:

o Diseases (influenza, bronchitis)o Conditions (fatigue, fracture)o Nouns (disease, syndrome)o Adjectives (double, large, kink)Subterms

Indented under the main term to the right by one standard indentation

Alphabetical order under main term Describe differences in condition such as anatomic site,

cause, or clinical type

14

Main Terms & Subterms

Carryover Lines (page 14) Needed for main terms or subterms because the number of words

that fit on a single line of print is limited in the Alphabetic Index. Indented two standard indents Do not confuse with another subterm

Nonessential Modifiers (page 14-15) Series of terms in parentheses that may follow a main term

or subterm Presence or absence of parenthetical terms has no effect on

code assignment. Word in parentheses may or may not appear in the

diagnostic statement without affecting the code assignment.

15

Carryover Lines

Eponyms The name of a disease, structure, operation, or procedure

usually derived from the name of the person who discovered or described it first

May be found under eponymic name or under “Disease,” “Syndrome,” or “Disorder”

Index Tables Main terms and subterms are arranged in tables instead of

standard columns.o Hypertension Tableo Neoplasm Tableo Table of Drugs and Chemicals

16

Eponyms & Index Tables

Further define or provide an example of code(s) They can appear at the beginning of a chapter or

section. The notes usually list other common phrases

used to describe the same condition but it may not be an exhaustive list.

Because an inclusion list is not repeated, coder must look back to the beginning of the chapter, section, category, or subcategory

Look at page 18 for examples

17

Inclusion Notes

Appear in italicized print in a box Provide a direction to code the particular

condition listed elsewhere, usually with the code listed in the exclusion notes.

May have 3 different meanings.

18

Excludes Notes

1: Code under consideration cannot be assigned if the associated condition specified in the exclusion note is present.o See subcategory 424.3 for an

example2: Condition may have to be

coded elsewhere.o The etiology of the condition

determines whether the code under review or the code suggested in the exclusion note should be assigned.

o One or the other code is used but not both.

o See category 603 for an example.

3: Note indicates additional code may be required to explain the condition.

o The condition in the exclusion note is not included in the code under review.

o If the condition specified in the exclusion note is present, the additional code should be assigned

See codes 280-289 for example.

19

Excludes 3 Meanings

Appear in the Tabular List and Alphabetic Index

Describe needed instruction to assign fifth digits

Provide additional coding instruction Provide definition of terms Alphabetic Index notes are boxed and in

italic type. Tabular notes are located at various levels and are not boxed.

See page 20 for example.

20

Instructional Notes

oCertain conditions require multiple coding with one code for the underlying condition (cause, etiology) and another code for the manifestation(s).

o Instructions on the sequence of codes is listed as well and should be followed.

oThe Alphabetic Index identifies both codes with the second code in brackets.

21

Mandatory Multiple Code Assignment

Mandatory codingo First code is the underlying

condition.o Second code in brackets is the

manifestation.o Both codes are assigned.o Sequence the codes in the order

listed in Alphabetic Index.

Use additional code, if desired. Pg 21o Appears in the Tabular Listo “If desired” should be ignored.o The use of an additional code may

provide more complete information.o The additional code must be

assigned if the health information provides supportive documentation.

Code first underlying condition. Pg 22

o Appears in the Tabular Listo Found under codes that

should not be listed first or as a single code

o The underlying condition and code number(s) appear after the phrase, “Code first.”

o Used with codes that are in italicized print, which indicates that the code is not listed first or appears as a single code

22

Multiple Code Assignment

◦ Appear in the Alphabetic Index◦ Indicate a relationship between conditions

Examples:◦ And – Secondary to◦ Associated with – With◦ Due to – With mention of

Refer to page 23 for example

23

Connecting Words

Not Elsewhere Classified (NEC) o Used with ill-defined terms in the Tabular List to warn the

coder that specified forms of the condition are coded differently

o Can be used with terms for which a more specific code is unavailable, even if the diagnostic statement is very specific.

Not Otherwise Specified (NOS)o Equivalent of unspecifiedo Used in the Tabular Listo Usually included with .9 codeso Diagnostic statement does not contain enough information

to assign a more specific code

24

Abbreviations, Page 23-24

Parentheses ( )oEnclose supplementary words or explanatory

information that may or may not be present in the diagnosis or procedure statement

oWords in parentheses do not affect the code number assigned.

oThese terms are called nonessential modifiers Square Brackets [ ]oOnly used in the Tabular ListoEnclose synonyms, alternative wording,

abbreviations, and explanatory phrases

25

Punctuation, page 24-25

Slanted Brackets [ ] page 25o Appear only in the Alphabetic Indexo Enclose a code that must be used in conjunction with the

code immediately preceding ito Code in the slanted brackets is always listed second.o Code in the slanted brackets is the disease’s

manifestation Colon : o Used in the Tabular Listo Appears after an incomplete term that needs one or

more modifiers or adjectives in order to be assigned to a given category or code

o See Category 204 for an example on page 26

26

More Punctuation

Brace }oAppears in the Tabular Listo Intended to simplify entries and save printing

space by reducing repetitive wordingoConnects a series of terms on the left or the right

with a statement on the other side of the braceoA term on the left must appear with a term on the

right before this code can be used

See page 26 for example.

27

Punctuation (continued)

Section Mark §o Indicates a footnote or reference concerning this

code appears on the page or preceding pagesoNot all codebook publishers use the section mark.

Some have substituted another symbol to alert the coder of special instructions

Lozenge ■o Found immediately preceding a fourth digit to

indicate the code is unique to ICD-9-CM and does not correlate directly to ICD-9

oHas no significance to codingoMay not be found in all codebooks

28

Symbols

1. Identify all main terms.

2. Locate each main term in the Alphabetic Index.

3. Refer to any subterms indented under the main term.

4. Follow cross-reference instructions for codes not located under the main term.

5. Verify the code selected in the Tabular List

6. Read and be guided by any instructional terms in the Tabular List.

7. Assign codes to their highest level of specificity.

29

Basic Steps in ICD-9-CM Coding

Signs and Symptoms

When a definitive diagnosis is not available, the chief complaint should be used for coding

Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,(R/O)” or “working diagnosis.” Code symptoms to the highest degree of certainty for the visit

Chronic diseases requiring ongoing treatment may be reported as many times as the patient receives treatment