1. MEDICAL CODINGMedical coding professionals provide a key stepin the medical process. Every time a patientreceives professional health care in a physiciansoffice, hospital outpatient facility or ambulatorysurgical center (ASC), the provider mustdocument the services provided. The Coder willabstract the information from thedocumentation,assign theappropriatecodes, and create a claim to be paid, whether bya commercial payer, the patient, or CMS.

2. TYPES OF MEDICAL CODING INPATIENT OUTPATIENT AMBULATORY SURGERY INTERVENTIONAL RADIOLOGY HIERARCHIAL CLINICAL CODING MORPHOLOGY CODING etc.. 3. OUTPATIENT CODING Outpatient coding involves coding themedical charts of patients who aredischarged from a healthcare facilitywithin 24 hours. So, outpatient medicalcoders are responsible for charting themedical records of patients who receivetreatments or undergo diagnosticprocedures in clinics, doctor offices orhospital emergency rooms on the same-day basis. 4. INPATIENT CODING This refers to coding the records ofpatients who are required to stay in ahospital or any other healthcare unitfor more than 24 hours, hence thename inpatient coding. Since themedical records of patients who areadmitted to a hospital for treatmenttend to be a lot more complex, thisnaturally makes the job of inpatientmedical coders that much harder. 5. INPATIENT FACILITIES SURGERY NEWBORN CARE MEDICINE THORACIC SURGERY ORTHOPEDICS TRANSPLANT CARE PEDIATRICS ONCOLOGY CARE OBSTETRICS PULMONARY CARE UROLOGY GASTROINTESTINAL NEUROLOGY CARE CARDIOVASCULAR PLASTIC SURGERY FAMILY PRACTICE PSYCHIATRY CRITICAL CARE SKILLED NURSINGMEDICINE CARE 6. INPATIENT CODING Inpatient Medical Records ICD-9-CM (Volume1-2) Diagnosis codes ICD-9-CM (Volume 3) Procedure codes Diagnosis-Related Group (DRG) system AHA Coding Clinic Encoder Tools (WinStrat, 3MEncoder, Trucode etc) 7. ICD-9-CM International Classification of Diseases, 9thRevision, Clinical Modification ICD-9-CM guidelines are a set of rules thathave been developed to accompany andcomplement the official conventions andinstructions provided within the ICD-9-CMitself. The instructions and conventions of theclassification take precedence over guidelines. These guidelines are based on the coding andsequencing instructions in Volumes I, II and IIIof ICD-9-CM, but provide additional instruction. 8. Purpose of GuidelinesThe purpose of coding guidelines is to provide timelydirections for accuracy and consistency in coding and topromote uniformity among hospitals in reporting ICD-9-CM coded clinical information. The task of reexaminingcoding guidelines to ensure that they are clear andcomplete and of developing additional guidelines wherethey are needed has been assigned to a subcommittee ofthe Coding Clinic for ICD-9-CM Editorial Advisory Board.The 7 coding guidelines appearing in this issue havebeen reviewed by the Editorial Advisory Board and havebeen approved by all members of the cooperating parties(American Medical Record Association, Health careFinancing Administration, National Center for HealthStatistics, and the American Hospital Association) to theCentral Office on ICD-9-CM maintained by the AmericanHospital Association. 9. ICD-9-CM The diagnosis codes (Volumes 1-2) havebeen adopted under HIPAA for all healthcaresettings. Volume 3 procedure codes have beenadopted for inpatient procedures reported byhospitals. These guidelines have been developed toassist both the healthcare provider and thecoder in identifying those diagnoses andprocedures that are to be reported. The entire medical record should be reviewedto determine the specific reason for theencounter and the conditions treated. 10. ICD-9-CMThe guidelines are organized into sections.Section I includes the structure and conventionsof the classification and general guidelines thatapply to the entire classification, and chapter-specific guidelines that correspond to thechapters as they are arranged in theclassification. Section II includes guidelines for selection ofprincipal diagnosis for non-outpatient settings. Section III includes guidelines for reportingadditional diagnoses in non-outpatient settings. Section IV is for outpatient coding andreporting. 11. ICD-9-CM : Section I Conventions The conventions for the ICD-9-CM are thegeneral rules for use of the classificationindependent of the guidelines. These conventions are incorporated withinthe index and tabular of the ICD-9-CM asinstructional notes. Abbreviations NEC : Not elsewhere classifiable or otherspecified code NOS : Not otherwise specified orunspecified 12. ICD-9-CM : Section IPunctuation[ ] Brackets are used in the tabular list toenclose synonyms, alternative wording orexplanatory phrases. Brackets are used inthe index to identify manifestation codes. 13. ICD-9-CM : Section IPunctuation ( ) Parentheses are used in both the index and tabular to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers. 14. ICD-9-CM : Section I Punctuation: Colons are used in the Tabular list after anincomplete term which needs one or more ofthe modifiers following the colon to make itassignable to a given category. 15. ICD-9-CM : Section I Includes : This note appears immediately under a three-digit code title to further define, or give examples of, the content of the category. 16. ICD-9-CM : Section I Excludes : An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. In some cases the codes for the excluded terms should not be used in conjunction with the code from which it is excluded. 17. ICD-9-CM : Section I Inclusion Terms : The terms may be synonyms of the code title, or, in the case of other specified codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the index may also be assigned to a code. 18. ICD-9-CM Section IOther Codes Codes titled other or other specified (usually a code with a 4th digit 8 or fifth-digit 9 for diagnosis codes) are for use when the information in the medical record provides detail for which a specific code does not exist. More details : Coding Clinic, January - February 1986 Page: 6 to 7 19. ICD-9-CM Section IUnspecified Codes Codes (usually a code with a 4th digit 9 or 5th digit 0 for diagnosis codes) titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code.More details : Coding Clinic, January - February 1986 Page: 6 to 7 20. ICD-9-CM Section IEtiology/Manifestation Convention ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Code First and Use additional Code 21. ICD-9-CM Section I And The word and should be interpreted to mean eitherand or or when it appears in a title. With The word with should be interpreted to meanassociated with or due to when it appears in acode title, the Alphabetic Index, or an instructionalnote in the Tabular List. 22. ICD-9-CM Section ISee and See Also The see instruction following a main term in the index indicates that another term should be referenced. It is necessary to go to the main term referenced with the see note to locate the correct code. A see also instruction following a main term in the index instructs that there is another main term that may also be referenced that may provide additional index entries that may be useful. 23. ICD-9-CM Section IGeneral Coding Guidelines Use both the Alphabetic Index and the Tabular List when locating and assigning a code. Locate each term in the Alphabetic Index and verify the code selected in the Tabular List. For example, code for the condition combined hyperlipidemia 24. ICD-9-CM Section I Codes that describe symptoms and signs, asopposed to diagnoses, are acceptable forreporting purposes when a related definitivediagnosis has not been established(confirmed) by the provider. Conditions that are not an integral part of adisease process should be reported whenpresent. Multiple codes are necessary to describe acondition completely sometimes (Instructionslike Use additional code, Code first) 25. ICD-9-CM Section IAcute and Chronic conditions If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. Example : Acute and chronic Pyelonephritis 590.10 Acute Pyelonephritis 590.00 Chronic Pyelonephritis 26. ICD-9-CM Section ICombination Code A single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or an associated complication is called a combination code. Combination codes are identified by referring to sub-term entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. Assign only the combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Be guided by directions in the Tabular List for the use of an additional code or codes to provide greater specificity. 27. ICD-9-CM Section ICombination Code Examples Two diagnosesMitral valve stenosis and aortic valve insufficiency, 396.1. Assign only one code A diagnosis with an associated secondary process (manifestation)Acute pharyngitis due to hemolytic streptococcal infection, 034.0. Assign only one code A diagnosis with an associated complicationAppendicitis with peritoneal abscess, 540.1. Assign only one code 28. ICD-9-CM Section ILate Effects A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. 29. ICD-9-CM Section ILate Effects ExampleQue : A patient presented with a personal history of parasitic (worm) invasion of brain. The worm is dead but he is suffering from the after effect, severe headaches. How should this encounter be coded?Answer : Assign code 784.0, Headache, as the first listed code for this case. Assign code 139.8, Late effects of other and unspecified infectious and parasitic diseases, as an additional diagnosis. Do not assign a code for the worm infestation, since the worm is dead and the patient no longer has the condition. 30. ICD-9-CM Section IImpending or Threatened Condition Code any condition described at the time of dischargeas impending or threatened as follows: If it did occur, code as confirmed diagnosis. If it did not occur, reference the Alphabetic Index todetermine if the condition has a subentry term forimpending or threatened and also reference mainterm entries for Impending and for Threatened. If the subterms are listed, assign the given code. If the subterms are not listed, code the existingunderlying condition(s) and not the conditiondescribed as impending or threatened. 31. ICD-9-CM Section IExamples Impending myocardial infarction: The medical record is reviewedto be sure that the myocardial infarction did not occur. On page394, the Alphabetic Index has a subterm entry of "impending"under Infarction, myocardium, with a code assignment of 411.1. Impending gangrene of lower extremities: A review of the medicalrecord provides little, if any, information to further identify thepresence or absence of gangrene. Code the gangrene only if thephysician documents that it is present. 32. ICD-9-CM Section I Each unique ICD-9-CM diagnosis code maybe reported only once for an encounter. The above rule applies to bilateral conditionsor two different conditions classified to thesame ICD-9-CM diagnosis code. When the admission/encounters forRehabilitation, V57 category code shouldsequence first. The code for the condition for which therehab service is being performed should bereported as an additional diagnosis. 33. ICD-9-CM Section IDocumentation for BMI Stages If the BMI has clinical significance for the patient encounter, the specific BMI value may be picked up from the dietitians documentation. The provider must provide documentation of a clinical condition, such as obesity, to justify reporting a code for the body mass index. To meet the criteria for a reportable secondary diagnosis, the BMI would need to have some bearing or relevance in turns of patient care. For reporting purpose, the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: Clinical evaluation; or Therapeutic treatment; or Diagnostic procedures; or Extended length of hospital stay; or Increased nursing care and/or monitoring Once the provider has provided documentation of the clinical condition, such as obesity, the coder can use the dietitians note to assign the appropriate BMI codes from category V85. 34. ICD-9-CM Section IDocumentation of Complications of Care Code assignment is based on the providers documentation of the relationship between the condition and the care or procedure. The guideline 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 are classified as complications. There must be a cause-and-effect relationship between the care 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. 35. ICD-9-CM CHAPTERSChapter 1: Infectious and Parasitic Diseases (001-139)Chapter 2: Neoplasms (140-239)Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279)Chapter 4: Diseases of Blood and Blood Forming Organs (280-289)Chapter 5: Mental Disorders (290-319)Chapter 6: Diseases of Nervous System and Sense Organs (320-389)Chapter 7: Diseases of Circulatory System (390-459)Chapter 8: Diseases of Respiratory System (460-519)Chapter 9: Diseases of Digestive System (520-579)Chapter 10: Diseases of Genitourinary System (580-629)Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium(630-679)Chapter 12: Diseases Skin and Subcutaneous Tissue (680-709)Chapter 13: Diseases of Musculoskeletal and Connective Tissue(710-739)Chapter 14: Congenital Anomalies (740-759)Chapter 15: Newborn (Perinatal) Guidelines (760-779)Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799)Chapter 17: Injury and Poisoning (800-999) 36. CHAPTER SPECIFICCODING GUIDELINES 37. Chapter 1: Infectious and Parasitic Diseases (001-139)Human Immunodeficiency Virus (HIV) InfectionsHIV infection is a condition caused by the humanimmunodeficiency virus (HIV). The condition gradually destroysthe immune system, which makes it harder for the body to fightinfections.Coding Points HIV 1. Code only confirmed cases of HIV infection/illness.The providers diagnostic statement that patient is HIVpositive, or has an HIV-related illness is sufficient. 2. If a patient is admitted for an HIV-related condition, theprincipal diagnosis should be 042, followed byadditional diagnosis codes for all reported HIV-relatedconditions. 38. Coding Points HIV3. If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (e.g., the nature of injury code) should be the principal diagnosis. Other diagnoses would be 042 followed by additional diagnosis codes for all reported HIV-related conditions.4. Whether the patient is newly diagnosed or has had previous admissions/encounters for HIV conditions is irrelevant to the sequencing decision.5. V08 Asymptomatic human immunodeficiency virus [HIV] infection, is to be applied when the patient without any documentation of symptoms is listed as being HIV positive, known HIV, HIV test positive, or similar terminology. 39. Coding Points HIV6. Patients with inconclusive HIV serology, but nodefinitive diagnosis or manifestations of the illness, maybe assigned code 795.71, Inconclusive serologic test forHuman Immunodeficiency Virus [HIV].7. Once a patient has developed an HIV-relatedillness, the patient should always be assigned code 042on every subsequent admission/encounter.8. HIV Infection in Pregnancy, Childbirth and thePuerperium, Codes from Chapter 15 always takesequencing priority(647.6x) followed by 042 and thecode(s) for the HIV-related illness(es). 40. Coding Points HIV9. Encounters for Testing for HIV : use code V73.89Screening for other specified viral disease. If anasymptomatic patient is in a known high risk group forHIV, assign V69.8, Other problem related to life style asan additional code. An additional counseling codeV65.44 may be used if counseling is provided duringthe encounter for the test.11. When a patient returns to be informed of his/her HIVtest results use code V65.44, HIV counseling, if theresults of the test are negative. But if the test is positiveand asymptomatic, assign V08 and 042 forsymptomatic. 41. HIV Codes 042 and V08 42. Sepsis CodingSepticemia systemic disease associated with thepresence of pathological microorganisms or toxinsin the bloodSIRS systemic response toinfection, trauma/burns, or other insult (such ascancer) with symptoms includingfever, tachycardia, tachypnea, and leukocytosisSepsis SIRS due to infectionSevere Sepsis - Sepsis with associated acute organdysfunction, such as kidney or heart failure.Septic Shock Circulatory failure associated withsevere sepsis.Urosepsis - urinary tract infection that has spreadinto the blood 43. Sepsis Coding Coding of SIRS, sepsis and severe sepsisrequires a minimum of 2 codes : underlyingcause followed by 995.9x categorySepsis and Severe sepsis require a code forthe systemic infection (038.xx, 112.5 etc) andeither code 995.91(sepsis) or 995.92 (severesepsis). Severe sepsis requires an additional code(s)for the associated organ dysfunction(s) Severe sepsis sequencing rules : 038.xxfollowed by 995.92 as required by thesequencing rules in the Tabular List 44. Sepsis Coding Always validate the POA indicator for sepsis as Ywhen it reported as principal diagnosis. If a patient admitted with Sepsis, Severe sepsisand a localized infection (such as pneumonia,cellulitis) code for the systemic infection (038.xx,112.5 etc) should be assigned first then code995.91or 995.92 followed by the code for thelocalized infection. Urosepsis term is a nonspecific term. Assign599.0 based on the default for the term in theICD-9-CM index if sepsis documentation notavailable. Streptococcal sepsis 038.0 + 995.91 Streptococcal septicemia 038.0 only 45. Sepsis Coding An acute organ dysfunction must be associated with thesepsis in order to assign the severe sepsis code. For Septic Shock cases, 038.x should be sequencedfirst followed by the codes 995.92 and 785.52(septicshock) or 998.02 (postoperative septic shock) and anyadditional acute organ dysfunctions should also beassigned. 995.92 will be assigned with 785.52 and 998.02 even ifthe term severe sepsis is not documented in themedical record, since septic shock indicates thepresence of severe sepsis. Sepsis due to post-procedural infection codes : 998.59(other postoperative infection) or 674.3x (othercomplications of obstetrical surgical wounds) should becoded first followed by the appropriate sepsis codesand acute organ dysfunction. 46. Sepsis Coding 47. Sepsis Coding 48. Sepsis Coding Sepsis resulting from an indwellingurinary catheter, 996.64 Infection andinflammatory reaction due to internalprosthetic device, implant and graft, Dueto indwelling urinary catheter should besequenced first followed by theappropriate sepsis codes(038.x and995.9x) and E-code. Codes from subcategory 995.9x cannever be assigned as a principaldiagnosis. (coding conventions mustfollow) 49. MRSA Methicillin Resistant StaphylococcusAureus (MRSA) Infection due to MRSA If that infectionhas a combination code that includescausative organism, assign theappropriate code for the condition. If the combination code is not availableassign it as multiple coding i.e. conditionplus the MRSA code. Colonization means that MSSA or MRSAis present on or in the body withoutnecessarily causing illness. 50. MRSA MRSA screen positive or MRSA nasalswab positive (Documentations) V02.54(MRSA colonization), V02.53(MSSA colonization), V02.59(otherbacterial colonization) If a patient is documented as having bothMRSA colonization and infection during ahospital admission, code V02.54, Carrieror suspected carrier, Methicillin resistantStaphylococcus aureus, and a code forthe MRSA infection may both beassigned. 51. Chapter 2: Neoplasms (140-239) To properly code a neoplasm it is necessary todetermine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. Ifmalignant, any secondary (metastatic) sites should alsobe determined. The neoplasm table in the Alphabetic Index should bereferenced first. If the histological term is documented, that term shouldbe referenced first, rather than going immediately to theNeoplasm Table, in order to determine which column inthe Neoplasm Table is appropriate. The tabular should then be referenced to verify that thecorrect code has been selected from the table and thata more specific site code does not exist. 52. Chapter 2: Neoplasms (140-239) If the treatment is directed at the malignancy, designate themalignancy as the principal diagnosis. If a patient admission/encounter is solely for the administration ofchemotherapy, immunotherapy or radiation therapy, assign theappropriate V58.x code as the first-listed or principal diagnosis, andthe diagnosis or problem for which the service is being performed asa secondary diagnosis. When a patient is admitted because of a primary neoplasm withmetastasis and treatment is directed toward the secondary siteonly, the secondary neoplasm is designated as the principaldiagnosis even though the primary malignancy is still present.. The tabular should then be referenced to verify that the correct codehas been selected from the table and that a more specific site codedoes not exist. 53. Chapter 2: Neoplasms (140-239)Malignant neoplasms of the following sites are exceptions, andinstead of coding to an unknown primary or to the morphology, thefollowing sites are always coded as secondary neoplasms of thatsite unless the provider documented as primary site. Bone Brain Diaphragm Heart Liver Lymph nodes Mediastinum Meninges Peritoneum Pleura Retroperitoneum Spinal cord Sites classifiable to 195.0-8 54. Chapter 2: Neoplasms (140-239) When admission/encounter is for management of an anemia associated with themalignancy, and the treatment is only for anemia, the appropriate anemia code(such as code 285.22, Anemia in neoplastic disease) is designated as theprincipal diagnosis and is followed by the appropriate code(s) for the malignancy. If anemia in neoplastic disease and anemia due to anti-neoplastic chemotherapyare both documented, assign codes for both conditions. When the admission/encounter is for management of an anemia associated withchemotherapy, immunotherapy or radiotherapy and the only treatment is for theanemia, the anemia is sequenced first. The appropriate neoplasm code should beassigned as an additional code. When the admission/encounter is for management of dehydration due to themalignancy or the therapy, or a combination of both, and only the dehydration isbeing treated (intravenous rehydration), the dehydration is sequencedfirst, followed by the code(s) for the malignancy. When the admission/encounter is for treatment of a complication resulting from asurgical procedure, designate the complication as the principal or first-listeddiagnosis if treatment is directed at resolving the complication. 55. Chapter 2: Neoplasms (140-239) When a primary malignancy has been previously excised or eradicated from itssite and there is no further treatment directed to that site and there is no evidenceof any existing primary malignancy, a code from category V10, Personal history ofmalignant neoplasm, should be used to indicate the former site of the malignancy. When an episode of care involves the surgical removal of a neoplasm, primary orsecondary site, followed by adjunct chemotherapy or radiation treatment duringthe same episode of care, the neoplasm code should be assigned as principal orfirst-listed diagnosis, using codes in the 140-198 series or where appropriate inthe 200-203 series. If a patient admission/encounter is solely for the administration ofchemotherapy, immunotherapy or radiation therapy assign code V58.0, Encounterfor radiation therapy, or V58.11, Encounter for antineoplastic chemotherapy, orV58.12, Encounter for antineoplastic immunotherapy as the first-listed or principaldiagnosis. If a patient receives more than one of these therapies during the same admissionmore than one of these codes may be assigned, in any sequence. Themalignancy for which the therapy is being administered should be assigned as asecondary diagnosis. 56. Chapter 2: Neoplasms (140-239) When the reason for admission/encounter is to determine the extentof the malignancy, or for a procedure such as paracentesis orthoracentesis, the primary malignancy or appropriate metastatic siteis designated as the principal or first-listed diagnosis, even thoughchemotherapy or radiotherapy is administered. Symptoms, signs, and ill-defined conditions listed in Chapter 16characteristic of, or associated with, an existing primary orsecondary site malignancy cannot be used to replace themalignancy as principal or first-listed diagnosis, regardless of thenumber of admissions or encounters for treatment and care of theneoplasm. A malignant neoplasm of a transplanted organ should be coded as atransplant complication. Assign first the appropriate code fromsubcategory 996.8x, Complications of transplanted organ, followedby code 199.2, Malignant neoplasm associated with transplantedorgan. Use an additional code for the specific malignancy. 57. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases & Immunity Disorders (240-279)Diabetes Mellitus Category 250 to identify complications/manifestations associatedwith diabetes mellitus The following are the fifth-digits for the codes under category 250: 0 type II or unspecified type, not stated as uncontrolled 1 type I, [juvenile type], not stated as uncontrolled 2 type II or unspecified type, uncontrolled 3 type I, [juvenile type], uncontrolled If the type of diabetes mellitus is not documented in the medicalrecord the default is type II. Patients who routinely use insulin, code V58.67, Long-term (current)use of insulin, should also be assigned to indicate that the patientuses insulin. 58. Endocrine, Nutritional, and Metabolic Diseases & Immunity Disorders (240-279)Diabetes and associated complications Diabetic Macular Edema 250.5x sequence first followed by362.07 Diabetic Osteomyelitis 250.8x sequence first followed by 731.8and 730.xx An underdose of insulin due to an insulin pump failure shouldbe assigned 996.57, Mechanical complication due to insulinpump, as the principal or first listed code, followed by theappropriate diabetes mellitus code based on documentation. The principal or first listed code for an encounter due to aninsulin pump malfunction resulting in an overdose ofinsulin, should also be 996.57, Mechanical complication dueto insulin pump, followed by code 962.3, Poisoning byinsulins and anti-diabetic agents, and the appropriatediabetes mellitus code based on documentation. 59. Endocrine, Nutritional, and Metabolic Diseases & Immunity Disorders (240-279) Secondary diabetes (category 249) is always causedby another condition or event (e.g., cysticfibrosis, malignant neoplasm ofpancreas, pancreatectomy, adverse effect of drug, orpoisoning). For postpancreatectomy diabetes mellitus (lack ofinsulin due to the surgical removal of all or part of thepancreas), assign code 251.3, Postsurgicalhypoinsulinemia. Assign a code from subcategory249, Secondary diabetes mellitus and a code fromsubcategory V88.1, Acquired absence of pancreas asadditional codes. Code also any diabetic manifestations(e.g. diabetic nephrosis 581.81).. 60. Chapter 4: Diseases of Blood and Blood Forming Organs (280-289) Subcategory 285.2, Anemia in chronic illness, hascodes for anemia in chronic kidney disease, code285.21; anemia in neoplastic disease, code 285.22; andanemia in other chronic illness, code 285.29. When using a code from subcategory 285 it is alsonecessary to use the code for the chronic conditioncausing the anemia. For example, when assigning code285.21, Anemia in chronic kidney disease, it is alsonecessary to assign a code from category 585, Chronickidney disease, to indicate the stage of chronic kidneydisease. When assigning code 285.22, Anemia in neoplasticdisease, it is also necessary to assign the neoplasmcode that is responsible for the anemia. 61. Chapter 5: Mental Disorders (290-319)Category Section Titles290-294 Organic Psychotic Conditions295-299 Other Psychoses300-316 Neurotic Disorders, PersonalityDisorders, and OtherNon-psychotic Mental Disorders 317-319 Mental Retardation Always follow coding conventions beforereporting. 62. Mental Disorders (290-319)The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by theAmerican Psychiatric Association provides a common language and standard criteria forthe classification of mental disorders. It is used in the United States and in varyingdegrees around the world, by clinicians, researchers, psychiatric drug regulationagencies, health insurance companies, pharmaceutical companies, and policy makers.The current version is the DSM-IV-TR (fourth edition, text revision). It is organized into afive-part axis system, with the first axis incorporating clinical disorders and the secondcovering personality disorders and intellectual disabilities. The remaining axes coverrelated medical, psychosocial and environmental factors, as well as assessments offunctioning for children. Axis I: Clinical disorders, including major mental disorders, learning disorders andsubstance use disorders Axis II: Personality disorders and intellectual disabilities (although developmentaldisorders, such as Autism, were coded on Axis II in the previous edition, these disordersare now included on Axis I) Axis III: Acute medical conditions and physical disorders Axis IV: Psychosocial and environmental factors contributing to the disorder Axis V: Global assessment of functioning or Childrens Global Assessment Scale forchildren and teens under the age of 18 63. Mental Disorders (290-319) Depression (311), Anxiety (300.00) Depression and Anxiety 311, 300.00 should be reported Depression with Anxiety 300.4 should be reported (CC 3Q 2001 P.6) Major Depression has explained in 296 category codes. 294 category (Dementia) codes never be principal diagnosis, alwaysfollow Code First Instruction. Category 305 includes cases where a person, for whom no otherdiagnosis is possible, has come under medical care because of themaladaptive effect of a drug on which he is not dependent and that he hastaken on his own initiative to the detriment of his health or socialfunctioning. Category 305 explains abuse ofalcohol, tobacco, cannabis, hallucinogen, sedative, hypnotic oranxiolytic, opioid , cocaine type drug abuses. Category 303 explains Alcohol dependence. Category 303 305 has 5th digit explained the pattern of use(continuous, episodic, or in remission and unspecified) which assignedonly on the basis of provider documentation (CC 1 Q 2010 P.20) 64. Chapter 6: Diseases of Nervous System & Sense Organs (320-389) Codes in category 338 may be used in conjunctionwith codes from other categories and chapters toprovide more detail about acute or chronic pain andneoplasm-related pain, unless otherwise indicatedbelow. If the pain is not specified as acute or chronic, do notassign codes from category 338, except for post-thoracotomy pain, postoperative pain, neoplasmrelated pain, or central pain syndrome. A code from subcategories 338.1 and 338.2 shouldnot be assigned if the underlying (definitive) diagnosisis known, unless the reason for the encounter is paincontrol/ management and not management of theunderlying condition. 65. Diseases of Nervous System & Sense Organs When pain control or pain management is the reason for theadmission/encounter, category 338 codes are acceptable asprincipal diagnosis. When an admission or encounter is for a procedure aimed attreating the underlying condition (e.g., spinalfusion, kyphoplasty), a code for the underlying condition(e.g., vertebral fracture, spinal stenosis) should be assignedas the principal diagnosis. No code from category 338 shouldbe assigned. When a patient is admitted for the insertion of aneurostimulator for pain control, assign the appropriate paincode as the principal or first listed diagnosis. Codes from category 338 may be used in conjunction withcodes that identify the site of pain (including codes fromchapter 16) if the category 338 code provides additionalinformation. 66. Diseases of Nervous System & Sense Organs Pain associated with devices, implants or grafts left in a surgical site (forexample painful hip prosthesis) is assigned to the appropriate code(s)found in Chapter 17, Injury and Poisoning. Use additional code(s) fromcategory 338 to identify acute or chronic pain due to presence of thedevice, implant or graft (338.18-338.19 or 338.28-338.29). Chronic pain is classified to subcategory 338.2. There is no time framedefining when pain becomes chronic pain. The providers documentationshould be used to guide use of these codes. Code 338.3 is assigned to pain documented as being related, associatedor due to cancer, primary or secondary malignancy, or tumor. This code isassigned regardless of whether the pain is acute or chronic. The underlyingneoplasm should also be reported. Chronic pain syndrome (338.4) code should only be used when theprovider has specifically documented this condition. For types of glaucoma classified into subcategories 365.1-365.6, anadditional code should be assigned from subcategory 365.7 to identify theglaucoma stage. 67. Chapter 7: Diseases of Circulatory System (390-459) Hypertension codes classifies in the Alphabetic Index according to malignant, benign, and unspecified(fourth digits0,1 9). Hypertension with Heart Disease (402 category) Causal relationship must be documented by the provider. Use additional code(s) from category 428 to identify the type of heart failure in those patients with heart failure. The same heart conditions (425.8, 429.0-429.3, 429.8, 429.9) with hypertension, but without a stated causal relationship, are coded separately. 68. Diseases of Circulatory System (390-459)Hypertensive Chronic Kidney Disease (403 category) Unlike hypertension with heart disease, ICD-9-CMpresumes a cause-and-effect relationship and classifieschronic kidney disease (CKD) with hypertension ashypertensive chronic kidney disease. Assign codes from category 403 when conditions classifiedto category 585 or code 587 are present withhypertension(401.x). Fifth digit for category 403 should be assigned as 0 withCKD stage I through IV or unspecified and 1CKD V orESRD (End stage renal disease) 69. Diseases of Circulatory System (390-459)Hypertensive Heart & Chronic Kidney Disease (404 category) Assign codes from combination category 404, Hypertensiveheart and chronic kidney disease, when both hypertensivekidney disease and hypertensive heart disease are stated inthe diagnosis. 70. Diseases of Circulatory System (390-459) Hypertensive Cerebrovascular disease (430-438), cerebrovascular disease sequence first thenappropriate code from categories 401-405, hypertension. Hypertensive Retinopathy First assign362.11, Hypertensive retinopathy followed by 401-405category Secondary Hypertension Two codes; one to identify theunderlying etiology and one from category 405 to identify thehypertension Transient Hypertension 796.2 (Elevated blood pressurereading without the diagnosis of hypertension) or 642.3x(transient hypertension of pregnancy) Accelerated Hypertension should be reported asMalignant type hypertension as Alphabetic Index directs. 71. Diseases of Circulatory System (390-459) Cerebrovascular Accident = Cerebral Infarction = Stroke =434.91 (default code) Additional code(s) should be assigned for any neurologic deficitsassociated with the acute CVA, regardless of whether or not theneurologic deficit resolves prior to discharge. Postoperative cerebrovascular accident should be reported withcode 997.02. A secondary code from the code range 430-432 orfrom a code from subcategories 433 or 434 with a fifth digit of1 should also be used to identify the type of hemorrhage orinfarct. Late effect of CVA includes neurologic deficits that persist afterinitial onset of conditions classifiable to 430-437. The residualeffect should be coded as additional if coding convention (Useadditional code) advises to report it. When history of cerebrovascular disease when no neurologicdeficits are present, reported with V12.54 code. 72. Diseases of Circulatory System (390-459) The ICD-9-CM codes for Acute Myocardial Infarction (AMI) (410 category)identify the site, such as anterolateral wall or true posterior wall. If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts toNSTEMI due to thrombolytic therapy, it is still coded as STEMI. Chronic Myocardial Infarction should be reported with 414.8 (as AlphabeticIndex directs) Fifth digit classification of 410 category 0 = Use when the source document does not contain sufficient information for theassignment of fifth-digit 1 or 2. (It should rarely used) 1 = covers all care provided to a newly diagnosed myocardial infarction patientuntil the patient is discharged from medical care. This includes any transfers toand from other facilities prior to the patients discharge and occurring within theeight-week time frame. 2 = covers care (further observation, evaluation or treatment) rendered after theinitial treatment (discharge), but the myocardial infarction is still less than 8weeks old. 73. Chapter 8: Diseases of Respiratory System (460-519) COPD (496) and Asthma (category 493) Asthma with COPD combination code 493.2x, fifth digitclassifies as 0-unspecified, 1-status asthmaticus, and 2-acute exacerbation. COPD Exacerbation = Decompensated COPD = 491.21 COPD Exacerbation + Acute Bronchitis = 491.22 only (Theacute bronchitis included in code 491.22 supersedes theacute exacerbation). Acute Bronchitis with COPD = 491.22 When hypoxia is associated with COPD, it is appropriate toassign code 799.02, Hypoxemia, as an additional diagnosisif desired. (CC 3Q 2009 P.20) Respiratory insufficiency (518.82) is an integral part ofCOPD and is included in any COPD code. Do not assign518.82 as an additional code. (CC 2Q 1991 P.21) 74. Diseases of Respiratory System (460-519) Acute Respiratory Failure (518.81) may be assigned as aprincipal diagnosis when it is the condition established afterstudy to be chiefly responsible for occasioning theadmission to the hospital, and the selection is supported bythe Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such asobstetrics, poisoning, HIV, newborn) that providesequencing direction take precedence. If both the respiratory failure and the other acute conditionare equally responsible for occasioning the admission to thehospital, and there are no chapter-specific sequencingrules, the guideline regarding two or more diagnoses thatequally meet the definition for principal diagnosis. 75. Diseases of Respiratory System (460-519) Respiratory Failure code fifth digits classified according towhether acute(518.81), chronic(518.82) or acute andchronic(518.84) Code only confirmed cases of avian influenza (codes488.01-488.02, 488.09, Influenza due to identified avianinfluenza virus), 2009 H1N1 influenza virus (codes 488.11-488.12, 488.19), or novel influenza A (codes 488.81-488.82, 488.89, Influenza due to identified novel influenza Avirus). This is an exception to the hospital inpatientguideline Section II, H. (Uncertain Diagnosis). Malignant Pleural Effusion 511.81 should never be aprincipal diagnosis/first-listed code. Follow Code firstinstruction. 76. Chapter 9: Diseases of Digestive System (520-579) The terms Arteriovenous Malformation (AVM) and Angiodysplasia often are used interchangeably by the provider. AVMs may be congenital or acquired Unless specified as congenital, Gastric AVM should be reported as 537.82 (CC 3Q 1996 P.9-10) Angiodysplasia of Intestine 569.84, 569.85(with hemorrhage) If an appendectomy is performed and the pathology report indicates a normal appendix, the principal diagnosis would be the symptom for which the patient was admitted. (CC 1990 2Q P.26) 77. Diseases of Digestive System (520-579) If a patient presents with a GI bleed and then undergoesdiagnostic testing such as EGD to determine the site of thebleed, unless the physician specifies a causal relationshipbetween the findings on this test and the bleed, the code578.x should be assigned. Codes for any other findingssuch as gastritis should be coded as without hemorrhage(CC 2005 3Q P.17-18) Incarcerated incisional hernia with small bowel obstructioncaused by adhesions should be reported with552.21, Incisional hernia with obstruction and 568.0Peritoneal adhesions. (CC 1Q 2012 P.8) Bowel obstruction due to Crohns disease should sequence555.9 Crohns disease as PDx followed by 560.89 otherspecified intestinal obstruction. (CC 2Q 1997 P.3) 78. Diseases of Digestive System (520-579) Diagnosis code for Shock liver should be reported with570. (CC 1Q 2000 P.22) Sequencing rule for coding bleeding esophageal varicesand also has cirrhosis. (CC 1985 Nov-Dec P.14) Do not confuse with esophageal varice and gastricvarice. Gastric varices should be reported with 456.8as Index directs. Sequencing the associated conditionbased on the circumstances of admission. 79. Chapter 10: Diseases of Genitourinary System (580-629) The ICD-9-CM classifies CKD stages based on severity. If both a stage of CKD and ESRD are documented, assign code 585.6 only. The presence of CKD after the kidney transplant status doesnt constitute a transplant complication. 585 category and V42.0 should be reported. 80. Chapter 11: Complications of Pregnancy, Childbirth,& the Puerperium (630-679) Chapter 11 codes have sequencing priority over codes from otherchapters. Should the provider document that the pregnancy is incidental to theencounter, then code V22.2 should be used in place of any chapter11 codes. Categories 640-649, 651-676 have required fifth-digits, whichindicate whether the encounter is antepartum, postpartum andwhether a delivery has also occurred When a delivery occurs, the principal diagnosis should correspond tothe main circumstances or complication of the delivery. In cases ofcesarean delivery, the selection of the principal diagnosis should bethe condition established after study that was responsible for thepatients admission. An outcome of delivery code, V27.0-V27.9, should be included onevery maternal record when a delivery has occurred. When the fetal condition is actually responsible for modifying themanagement of the mother, codes from categories 655 and 656should assigned. 81. Complications of Pregnancy, Childbirth, & the Puerperium (630-679) During pregnancy, childbirth or the puerperium, a patientadmitted because of an HIV-related illness should receive aprincipal diagnosis of 647.6X, Other specified infectious andparasitic diseases in the mother classifiable elsewhere, butcomplicating the pregnancy, childbirth or thepuerperium, followed by 042 (or V08) and the code(s) forthe HIV-related illness(es). DM is pregnancy (648.0x + 250.00) and GestationalDiabetes (648.8x) Code V58.67 Long-term (current) use of insulin, should alsobe assigned if the gestational diabetes is being treated withinsulin. 82. Complications of Pregnancy, Childbirth,& the Puerperium (630-679) 83. Decision process for use of fifth digits for categories 640-674 84. Complications of Pregnancy, Childbirth, & the Puerperium (630-679) Code 670.2x, Puerperal sepsis, should be assignedwith a secondary code to identify the causal organism.Do not assign code 995.91, Sepsis, as code 670.2xdescribes the sepsis. If applicable, use additionalcodes to identify severe sepsis (995.92) and anyassociated acute organ dysfunction. When an attempted termination of pregnancy results ina liveborn fetus assign code 644.21, Early onset ofdelivery, with an appropriate code from categoryV27, Outcome of Delivery. The procedure code for theattempted termination of pregnancy should also beassigned. 85. Common complication codes of Obstetrics (Inpatient) 86. Chapter 12: Diseases Skin and Subcutaneous Tissue (680-709) Two codes are needed to completely describe a pressure ulcer: A code from subcategory 707.0, Pressure ulcer, to identify the site of the pressure ulcer and a code from subcategory 707.2, Pressure ulcer stages. 87. Chapter 13: Diseases of Musculoskeletal &Connective Tissue (710-739) Degenerative Arthritis, Hypertrophic arthritis, DegenerativeJoint disease, Osteoarthritis explained in 715 categorycodes. Localized, in the 715.1 subcategories, includes bilateralinvolvement of the same site.. Pathologic fracture, chronic fracture, spontaneous fractureexplained in 733.1 subcategory. Assign the underlying etiology of pathologic fracture whencoding 733.1, such as osteoporosis, malignancy or otherchronic condition etc. Use additional external cause code, if applicable, to identifythe cause of the musculoskeletal condition (710-739) SeeUse additional code instruction of the chapter classificationin Tabular List of ICD-9-CM. 88. Chapter 14: Congenital Anomalies (740-759) Assign an appropriate code(s) from categories 740-759, Congenital Anomalies, when an anomaly isdocumented. When a congenital anomaly does not have a unique codeassignment, assign additional code(s) for any manifestationsthat may be present. Codes from Chapter 14 may be used throughout the life ofthe patient. Although present at birth, a congenital anomalymay not be identified until later in life. If a congenital anomaly has been corrected, a personalhistory code should be used to identify the history of theanomaly. When classifying renal cysts, if it is not indicated or isunknown whether they are acquired or congenital, ICD-9-CMmakes the assumption that the cyst is congenital. (CC 4Q1990 P.3) 89. Chapter 15: Newborn (Perinatal) Guidelines (760-779) For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth. Chapter 15 code may be used throughout the life of the patient if the condition is still present. If the index does not provide a specific code for a perinatal condition, assign code 779.89, Other specified conditions originating in the perinatal period, followed by the code from another chapter that specifies the condition. If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 15 should be used. If the condition is community-acquired, a code from Chapter 15 should not be assigned. (Refer : CC 1Q 2005 P.10) 90. Newborn (Perinatal) Guidelines (760-779) All clinically significant conditions noted on routine newborn examinationshould be coded. A condition is clinically significant if it requires: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring; or has implications for future health care needs When coding the birth of an infant, assign a code from categories V30-V39, according to the type of birth. A code from this series is assigned as a principaldiagnosis, and assigned only once to a newborn at the time of birth. Assign a code from category V29, Observation and evaluation of newborns andinfants for suspected conditions not found, to identify those instances when ahealthy newborn is evaluated for a suspected condition that is determined afterstudy not to be present. A code for prematurity should not be assigned unless it is documented. Newborn Sepsis Code 771.81, Septicemia [sepsis] of newborn, should be assigned. Do not assign code 995.91, Sepsis, as code 771.81 describes the sepsis. 91. Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799) This section includes symptoms, signs, abnormal results oflaboratory or other investigative procedures, and ill-definedconditions regarding which no diagnosis classifiable elsewhere isrecorded. Signs and symptoms that point rather definitely to a given diagnosisare assigned to some category in the preceding part of theclassification. In general, categories 780-796 include the more ill-defined conditions and symptoms that point with perhaps equalsuspicion to two or more diseases or to two or more systems of thebody, and without the necessary study of the case to make a finaldiagnosis. The Alphabetic Index should be consulted to determine whichsymptoms and signs are to be allocated here and which to morespecific sections of the classification; the residual subcategoriesnumbered .9 are provided for other relevant symptoms whichcannot be allocated elsewhere in the classification. 92. Signs, Symptoms and Ill-Defined Conditions (780-799) The conditions and signs or symptoms included in categories780- 796 consist of: (a) cases for which no more specific diagnosis can be made even after all facts bearing on the case have been investigated; (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnoses in a patient who failed to return for further investigation or care; (d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason;(f) certain symptoms which represent important problems in medical care and which it might be desired to classify in addition to a known cause. 93. Signs, Symptoms and Ill-Defined Conditions (780-799)ILL-DEFINED AND UNKNOWN CAUSES OF MORBIDITY AND MORTALITY (797-799) ILL DEFINED - imperfectly defined; having no clear outline MORBIDITY - an unhealthy or diseased condition MORTALITY - fatal outcome of morbidity (death)The title of this section is fitting because the codes included in this section are ill-defined and of unknown causes, ranging from sudden infant death syndrome(SIDS) to decreased libido. 94. Chapter 17: Injury and Poisoning (800-999) When coding injuries, assign separate codes for each injury unlessa combination code is provided, in which case the combinationcode is assigned. The code for the most serious injury, as determined by the providerand the focus of treatment, is sequenced first. When a primary injury results in minor damage to peripheral nervesor blood vessels, the primary injury is sequenced first withadditional code(s) from categories 950-957, Injury to nerves andspinal cord, and/or 900-904, Injury to blood vessels. When theprimary injury is to the blood vessels or nerves, that injury shouldbe sequenced first. The principles of multiple coding of injuries should be followed incoding fractures. Multiple fractures are sequenced in accordance with the severity ofthe fracture. The provider should be asked to list the fracturediagnoses in the order of severity. 95. Injury and Poisoning (800-999) Current burns (940-948) are classified by depth, extent and byagent (E code). Sequence first the code that reflects the highest degree of burnwhen more than one burn is present. Non-healing burns are coded as acute burns. Necrosis of burnedskin should be coded as a non-healed burn. Assign code 958.3, Posttraumatic wound infection, not elsewhereclassified, as an additional code for any documented infected burnsite. When coding burns, assign separate codes for each burn site. Encounters for the treatment of the late effects of burns (i.e., scarsor joint contractures) should be coded to the residual condition(sequelae) followed by the appropriate late effect code (906.5-906.9). A late effect E code may also be used, if desired. 96. Injury and Poisoning (800-999) 97. Injury and Poisoning (800-999) Adverse effects of therapeutic substances correctly prescribedand properly administered (toxicity, synergistic reaction, sideeffect, and idiosyncratic reaction) may be due to (1) differencesamong patients, such as age, sex, disease, and geneticfactors, and (2) drug-related factors, such as type of drug, route ofadministration, duration of therapy, dosage, and bioavailability.Code the reaction plus the appropriate code from the E930-E949series. Poisoning (960-979) Errors made in drug prescription or in the administration of the drug byprovider, nurse, patient, or other person, use the appropriate poisoning code fromthe 960-979 series. If an overdose of a drug was intentionally taken or administered and resulted indrug toxicity, it would be coded as a poisoning (960-979 series). If a non-prescribed drug or medicinal agent was taken in combination with acorrectly prescribed and properly administered drug, any drug toxicity or otherreaction resulting from the interaction of the two drugs would be classified as apoisoning. 98. Injury and Poisoning (800-999) Poisoning (960-979) When a reaction results from the interaction of a drug(s) and alcohol, this wouldbe classified as poisoning. When coding a poisoning or reaction to the improper use of a medication(e.g., wrong dose, wrong substance, wrong route of administration) the poisoningcode is sequenced first, followed by a code for the manifestation. Complication of care (996-999) An additional code identifying the complication should be assigned with codes incategories 996-999, Complications of Surgical and Medical Care NEC, when theadditional code provides greater specificity as to the nature of the condition. If thecomplication code fully describes the condition, no additional code is necessary. Transplant Complications (996.8x) A transplant complication code is only assigned if the complication affects thefunction of the transplanted organ. Two codes are required to fully describe atransplant complication, the appropriate code from subcategory 996.8 and asecondary code that identifies the complication. 99. Injury and Poisoning (800-999) Ventilator Associated Pneumonia (VAP) Code 997.31, Ventilator associated pneumonia, should be assigned only whenthe provider has documentedventilator associated pneumonia (VAP). Anadditional code to identify the organism (e.g., Pseudomonas aeruginosa, code041.7) should also be assigned. Do not assign an additional code from categories480-484 to identify the type of pneumonia. SIRS due to Non-infectious Process The systemic inflammatory response syndrome (SIRS) can develop as a result ofcertain non-infectious disease processes, such as trauma, malignantneoplasm, or pancreatitis. When SIRS is documented with a noninfectiouscondition, and no subsequent infection is documented, the code for theunderlying condition, such as an injury, should be assigned, followed by code995.93, Systemic inflammatory response syndrome due to noninfectious processwithout acute organ dysfunction, or 995.94, Systemic inflammatory responsesyndrome due to non-infectious process with acute organ dysfunction. 100. Classification of Factors Influencing Health Status andContact with Health Service (Supplemental V01-V91) V codes are for use in any healthcare setting. V codes may be usedas either a first listed (principal diagnosis code in the inpatientsetting) or secondary code, depending on the circumstances of theencounter. Certain V codes may only be used as first listed, othersonly as secondary codes. Categories of V codes include :Contact/Exposure(V01), Inoculations and Vaccinations (V03-V06), Status codes (V02, V08, V42-V45, V45.87, V45.88, V46, V49, V58.6x etc..), History codes (V12-V19, V10, V87 etc), Screening (V28, V73-V82), Observation(V29, V71, V89.0), Aftercare (V51-V58.89), Follow up(V24, V67), Donor (V59), Counselling(V25.0, V26.3, V26.4, V61.x, V65.x), Obstetrics and relatedconditions (V22-V28, V91), Newborn (V20, V29, V30-V39), Routineadministrative examinations (V20.2, V70, V72), Prophylactic organremoval (V50.4), Miscellaneous codes (V07, V50, V66 etc..), Non-specific codes (V11, V40, V41 etc). 101. Supplemental Classification of External Causes of Injury andPoisoning (E-codes, E800-E999) External causes of injury and poisoning codes (categories E000 and E800-E999)are intended to provide data for injury research and evaluation of injury preventionstrategies. Activity codes (categories E001-E030) are intended to be used to describe theactivity of a person seeking care for injuries as well as other health conditions, whenthe injury or other health condition resulted from an activity or the activity contributedto a condition. E codes capture how the injury, poisoning, or adverse effect happened (cause), theintent (unintentional or accidental; or intentional, such as suicide or assault), thepersons status (e.g. civilian, military), the associated activity and the place wherethe event occurred. Some major categories of E codes include: transport accidents poisoning and adverse effects of drugs, medicinal substances and biologicals accidental falls accidents caused by fire and flames accidents due to natural and environmental factors late effects of accidents, assaults or self injury assaults or purposely inflicted injury suicide or self inflicted injury 102. Supplemental Classification of External Causes of Injury andPoisoning (E-codes, E800-E999) An E code from categories E800-E999 may be used with any code in the range of 001-V91, which indicates an injury, poisoning, or adverse effect due to an external cause. Use the full range of E codes (E800 E999) to completely describe the cause, the intentand the place of occurrence, if applicable, for all injuries, poisonings, and adverse effectsof drugs. Assign as many E codes as necessary to fully explain each cause. The selection of the appropriate E code is guided by the Index to External Causes, whichis located after the alphabetical index to diseases and by Inclusion and Exclusion notes inthe Tabular List. Use an additional code from category E849 to indicate the Place of Occurrence. Do notuse E849.9 if the place of occurrence is not stated. A late effect E code should never be used with a related current nature of injury code. Assign a code from category E001-E030 to describe the activity that caused orcontributed to the injury or other health condition. Do not assign E030, Unspecifiedactivity, if the activity is not stated. Assign a code from category E000, External cause status, to indicate the work status ofthe person at the time the event occurred. Do not assign a code from category E000 if no other E codes are applicable for theencounter. Do not assign code E000.9, Unspecified external cause status, if the status isnot stated. 103. ICD-9-CM : Section IISelection of Principal Diagnosis The circumstances of inpatient admission always govern the selection ofprincipal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set(UHDDS) as that condition established after study to be chiefly responsible foroccasioning the admission of the patient to the hospital for care. In determining principal diagnosis the coding conventions in the ICD-9-CM, Volumes I and II take precedence over these official coding guidelines. Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are notto be used as principal diagnosis when a related definitive diagnosis has beenestablished. When there are two or more interrelated conditions (such as diseases in thesame ICD-9-CM chapter or manifestations characteristically associated with acertain disease) potentially meeting the definition of principal diagnosis, eithercondition may be sequenced first, unless the circumstances of theadmission, the therapy provided, the Tabular List, or the Alphabetic Indexindicate otherwise. 104. ICD-9-CM : Section IISelection of Principal Diagnosis When two or more diagnoses equally meet the criteria for principaldiagnosis as determined by the circumstances of admission, diagnosticworkup and/or therapy provided, and the Alphabetic Index, Tabular List, oranother coding guidelines does not provide sequencing direction, any oneof the diagnoses may be sequenced first. When two or more contrasting or comparative diagnoses are documentedas either/or (or similar terminology), they are coded as if the diagnoseswere confirmed and the diagnoses are sequenced according to thecircumstances of the admission. If no further determination can be madeas to which diagnosis should be principal, either diagnosis may besequenced first. When a symptom(s) is followed by contrasting/comparative diagnoses, thesymptom code is sequenced first. All the contrasting/comparativediagnoses should be coded as additional diagnoses. 105. ICD-9-CM : Section IISelection of Principal Diagnosis Sequence as the principal diagnosis the condition, which after studyoccasioned the admission to the hospital, even though treatment may nothave been carried out due to unforeseen circumstances. When the admission is for treatment of a complication resulting fromsurgery or other medical care, the complication code is sequenced as theprincipal diagnosis. If the complication is classified to the 996-999 seriesand the code lacks the necessary specificity in describing thecomplication, an additional code for the specific complication should beassigned. If the diagnosis documented at the time of discharge is qualified asprobable, suspected, likely, questionable, possible, or still to beruled out, or other similar terms indicating uncertainty, code the conditionas if it existed or was established. The bases for these guidelines are thediagnostic workup, arrangements for further workup or observation, andinitial therapeutic approach that correspond most closely with theestablished diagnosis. (This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals. ) 106. ICD-9-CM : Section IIAdmission from Observation Unit When a patient is admitted to an observation unit for a medicalcondition, which either worsens or does not improve, and issubsequently admitted as an inpatient of the same hospital for thissame medical condition, the principal diagnosis would be the medicalcondition which led to the hospital admission. When a patient is admitted to an observation unit to monitor acondition (or complication) that develops following outpatientsurgery, and then is subsequently admitted as an inpatient of the samehospital, hospitals should apply the Uniform Hospital Discharge DataSet (UHDDS) definition of principal diagnosis as "that conditionestablished after study to be chiefly responsible for occasioning theadmission of the patient to the hospital for care." 107. ICD-9-CM : Section IIAdmission from Outpatient Surgery When a patient receives surgery in the hospitals outpatient surgerydepartment and is subsequently admitted for continuing inpatientcare at the same hospital, the following guidelines should befollowed in selecting the principal diagnosis for the inpatientadmission: If the reason for the inpatient admission is a complication, assign thecomplication as the principal diagnosis. If no complication, or other condition, is documented as the reason forthe inpatient admission, assign the reason for the outpatient surgery asthe principal diagnosis. If the reason for the inpatient admission is another condition unrelated tothe surgery, assign the unrelated condition as the principal diagnosis. 108. ICD-9-CM : Section IIIReporting Additional Diagnoses For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring. Definition All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded. 109. ICD-9-CM : Section IIIPrevious ConditionsIf the provider has included a diagnosis in the final diagnosticstatement, such as the discharge summary or the face sheet, it shouldordinarily be coded. Some providers include in the diagnostic statementresolved conditions or diagnoses and status-post procedures fromprevious admission that have no bearing on the current stay. Suchconditions are not to be reported and are coded only if required by hospitalpolicy.Abnormal FindingsAbnormal findings (laboratory, x-ray, pathologic, and other diagnosticresults) are not coded and reported unless the provider indicates theirclinical significance.Uncertain DiagnosesIf the diagnosis documented at the time of discharge is qualified asprobable, suspected, likely, questionable, possible, or still to beruled out or other similar terms indicating uncertainty, code the conditionas if it existed or was established. 110. ICD-9-CM : Section IV Diagnostic Coding and ReportingGuidelines for Outpatient Services In determining the first-listed diagnosis the coding conventions of ICD-9-CM, as well as the general and disease specific guidelines takeprecedence over the outpatient guidelines. The most critical rule involves beginning the search for the correct codeassignment through the Alphabetic Index. When a patient presents for outpatient surgery, code the reason for thesurgery as the first-listed diagnosis (reason for the encounter), even if thesurgery is not performed due to a contraindication. When a patient is admitted for observation for a medical condition, assigna code for the medical condition as the first-listed diagnosis. Do not code diagnoses documented as probable, suspected,questionable, rule out, or working diagnosis or other similar termsindicating uncertainty. Rather, code the condition(s) to the highest degreeof certainty for that encounter/visit, such as symptoms, signs, abnormaltest results, or other reason for the visit. 111. ICD-9-CM : Section IVDiagnostic Coding and Reporting Guidelines for Outpatient Services Chronic diseases treated on an ongoing basis may be coded andreported as many times as the patient receives treatment and care forthe condition(s). Code all documented conditions that coexist at the time of theencounter/visit, and require or affect patient care treatment ormanagement. History codes (V10-V19) may be used as secondary codes if thehistorical condition or family history has an impact on current care orinfluences treatment. For patients receiving diagnostic services only during anencounter/visit, sequence first the diagnosis, condition, problem, orother reason for encounter/visit shown in the medical record to bechiefly responsible for the outpatient services provided during theencounter/visit. 112. ICD-9-CM : Section IV Diagnostic Coding and ReportingGuidelines for Outpatient Services For patients receiving therapeutic services only during anencounter/visit, sequence first the diagnosis, condition, problem, or otherreason for encounter/visit shown in the medical record to be chieflyresponsible for the outpatient services provided during the encounter/visit. For patients receiving preoperative evaluations only, sequence first a codefrom category V72.8, Other specified examinations, to describe the pre-opconsultations. For ambulatory surgery, code the diagnosis for which the surgery wasperformed. If the postoperative diagnosis is known to be different from thepreoperative diagnosis at the time the diagnosis is confirmed, select thepostoperative diagnosis for coding, since it is the most definitive. For routine outpatient prenatal visits when no complications arepresent, codes V22.0, Supervision of normal first pregnancy, orV22.1, Supervision of other normal pregnancy, should be used as theprincipal diagnosis. 113. Present on Admission (POA) The POA guidelines are not intended to provide guidance on when acondition should be coded, but rather, how to apply the POA indicator tothe final set of diagnosis codes that have been assigned in accordancewith Sections I, II, and III of the official coding guidelines. Subsequent tothe assignment of the ICD-9-CM codes, the POA indicator should then beassigned to those conditions that have been coded. All claims involving inpatient admissions to general acute care hospitals orother facilities that are subject to a law or regulation mandating collectionof present on admission information. Present on admission is defined as present at the time the order forinpatient admission occurs -- conditions that develop during an outpatientencounter, including emergency department, observation, or outpatientsurgery, are considered as present on admission. POA indicator is assigned to principal and secondary diagnoses and theexternal cause of injury codes. 114. Present on Admission (POA)Reporting OptionsY - Yes present at the time of inpatient admissionN - No not present at the time of inpatient admissionU - Unknown documentation is insufficient to determine if condition is present on admissionW Clinically undetermined provider is unable to clinically determine whether condition was present on admission or notUnreported/Not used (or 1 for Medicare usage) (Exempt from POAreporting) General rules and examples available to understand to report theappropriate POA indicator for inpatient account settings in Appendix I of theICD-9-CM General Guidelines. 115. BASIC STEPS IN CODING Review the health record. Identify the diagnoses and procedures to be coded. Identify the principal diagnosis and the principalprocedure. Identify main term(s) in the Alphabetic Index. Review any subterms under the main term in the Index. Follow any cross-reference instructions, such as seealso Verify in the Tabular List the code(s) selected from theIndex. Refer to any instructional notation in the Tabular. Assign codes to the highest level of specificity. Assign codes to the diagnoses andprocedures, reporting all applicable codes andsequence in accordance with the guidelines. 116. Prakash.A.-CPCSenior Inpatient Medical CoderRevenueMed India Pvt Ltd