PART TWO. Introduction to ICD-9-CM. Chapter 2. ICD-9-CM Basics. Copyright 2009 by The McGraw-Hill Companies, Inc. All rights reserved.
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1 PART TWO Introduction to ICD-9-CM Chapter 2 ICD-9-CM Basics McGraw-Hill/Irwin Copyright 2009 by The McGraw-Hill Companies, Inc. All rights reserved.
2 After studying this chapter, you should be able to: 1. Briefly discuss the History and Background of ICD-9-CM. 2. Discuss the roles of the NCHS, CMS,AHIMA, and the AHA in maintaining and updating ICD-9-CM codes. 3. Explain how to locate the periodic updates to ICD- 9-CM codes using the internet. 4. Identify five uses of the ICD-9-CM. 5. Discuss the importance of the ICD-9-CM Official Guidelines for Coding and Reporting.
3 6. Describe the organization and content of Volumes 1, 2, and 3 of ICD-9-CM. 7. Interpret the formats, conventions, and symbols used in ICD-9-CM. 8. List the basic process of assigning ICD-9-CM codes. 9. Describe the meaning of coding to the highest level of specificity. 10.Identify common medical resources used to assist in the assignment of accurate ICD-9-CM codes. 2-3
4 Addenda AHA Coding Clinic for ICD-9-CM Alphabetic Index (Volume 2) Alphabetic Index to External Cause of Disease and Injury Alphabetic Index and Tabular List of Procedures (Volume 3) American Hospital Association (AHA) Braces Brackets Carryover lines Category Centers for Disease Control (CDC) KEY TERMS Colon Conventions Cooperating parties Cross-references E code Encoder Eponym Etiology Excludes ICD-9-CM Coordination and Maintenance Committee ICD-9-CM Official Guidelines for Coding and Reporting ICD-10-CM Chapter Code first underlying disease
5 Includes International Classification of Diseases Adapted for Indexing of Hospital Records and Operation Classification (ICDA) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Lozenge Main term Manifestation Omit code Parenthesis Section mark Subcategory Subclassification Subterm Supplemental classification system Table of Drugs and Chemicals Tabular List (Volume 1) Use additional code V code World Health Organization (WHO)
6 ICD = International Classification of Diseases 9 = 9th Revision CM = Clinical Modifications Represents how we have modified the ICD-9-DM for used in U.S. Represents a way to translate written diagnoses into numbers Describes: Diseases and injuries Signs and Symptoms Why a patient is seeking medical services 6
7 2-7 The classification system used to maintain all diagnoses for medical visits in the USA Maintained by NCHS (National Center for Health Statistics) and CMS (Centers for Medicare and Medicaid Services) CODE SET Three Volumes Volume 1 and 2 = used to classify diagnoses Volume 3 = used to classify inpatient procedures in hospitals (Billed by Hospitals)
8 U.S. Public Health Service Published ICDA (International Classification of Diseases, adapted for indexing of hospital records & Operation classification WHO (World Health Organization) published a ninth revision of ICD called ICD U.S. Public Health Service published its modified code set in order to meet statistical data need in the U.S. The expanded 3 volume is known as ICD-9-CM with over 13 thousand codes. Codes are classified for reporting: Morbidity (illnesses) Mortality (death)
9 2-9 ICD-9-CM is updated every year Maintained by: NCHS & CDC NCHS (National Center for Health Statistics) is part of the Centers for Disease Control(CDC) which maintains Volume 1 & Volume 2 CMS (Center for Medicare/Medicaid Services) maintains Volume 3. ICD-9-CM Coordination & Maintenance Committee: is a Federal Group that considers & adapts changes to the ICD-9-CM Code Set.
10 2-10 Addenda: Updating the ICD-9-CM* October 1 and April 1 of each year October 1 Major Updates April 1 includes codes that were not in October changes Codebooks published by U.S. Government Printing Office (GPO) on the Internet and in CD-ROM format each year *Medical coders must have the most updated version each year
11 2-11 The HIPPA (Health Insurance Portability and Accountability Act) RULE mandates the use of guidelines for coding and reporting when codes are selected. Guidelines Assist in: Standardizing the assignment of ICD-9-CM for all users by including rules for selecting the principal diagnosis when a patient has more than a single condition. Assist the coder in understanding the basic rules of code selection when using the ICD-9-CM Explain certain coding rules for specific medical conditions.
12 Table 2.1 Major Sections of the ICD-9-CM Official Guidelines for Coding and Reporting 2-12 Section I II III IV Appendix I Content Conventions, general coding guidelines, and chapterspecific guidelines Selection of Principal Diagnosis Reporting Additional Diagnoses Diagnostic and Reporting Guidelines for Outpatient Services Present on Admission Reporting Guidelines
13 2-13 Guidelines approved by cooperating parties: American Hospital Association (AHA) American Health Information Management Association (AHIMA) Center for Medical/Medicaid Services (CMS) National Center for Health Statistics (NCHS)
14 2-14 The ICD-9-CM is a statistical tool used for the purpose of converting medical diagnoses and inpatient hospital procedures into numbers. ICD-9-CM used to convert medical diagnoses & inpatient hospital procedures into numbers. The code set have 5 primary applications 1. Reporting and Research Provide a consistent defined way of reporting. ICD-9-CM can also important to the study of medication effects on patients with certain diseases.
15 Monitoring the Quality of Patient Care Ex: Hospital patients with hip replacements may be asked to complete questionnaires about their pain control after surgery Evaluating quality of care for patients with certain diagnoses or procedures allows health care providers to improve services. 3. Communications and Transactions Providers can communicate with payers about the reason for services(diagnoses) and treatment (procedure) provided using the ICD-9-CM.
16 4. Reimbursement Payment for services rendered to hospital inpatients is based on their disease & condition. Medicare patients - ICD-9-CM codes are used to calculate Medicare severity diagnosis-related group (MS-DRG) for payment 5. Administrative Uses ICD-9-CM data set can be used to study the types of patients seen and the services provided. Staffing decisions can be made based on the number of patients with a certain disease. 2-16
17 VOLUME 1 (Diseases and Injuries: Tabular List) 2. VOLUME 2 (Diseases and Injuries: Alphabetic Index) 3. VOLUME 3 (Procedures: Tabular List and Alphabetic Index)
18 Alphabetic Index Volume 2 The Alphabetic Index, is organized by medical terms/main terms. List words that describe diseases or injuries, such as pneumonia, bronchitis, infection, and fracture. Volume 2 (alpha index) codes are at the beginning of most ICD-9-CM code book, because they are used first. After codes have been located in volume 2 they are verified in volume 1 (tabular/numeric list)
19 Alphabetic Index Volume 2 Alphabetic Index Alphabetic-order Never used alone Section 1 Index to diseases and injuries Section 2 Table of drugs and chemicals Section 3 External causes of injuries and poisoning (E codes) Chapter 4 19
20 Table of Drugs and Chemicals Alphabetical listing of different drugs and chemicals such as: aspirin, and alcohol, gasoline and penicillin. Chapter 4 20
21 Index to External Causes of Injuries and Poisonings Research codes by the main term from the alphabetic index of E-Codes (section 3) Special Tables Neoplasms and Hypertension Chapter 4 21
22 2-22 Step I: Review complete medical documentation Step 2: Abstract the medical conditions and procedures that should be coded Step 3: Identify the main term for each condition and procedure Step 4: Locate the main terms in the Alphabetic Index Step 5: Verify the code in the Tabular List by reading all notes and applying appropriate conventions and guidelines
23 2-23 Main Terms (that represent diseases, injuries, problems, complaints, drugs, and external causes of diseases and conditions) Main terms are in Bold type Eponyms (names and phrases based on a person s name i.e., Gamstorp s disease) Subterms (words that are indented under a main term)
24 Indention Are 3 spaces under main terms Carry-over Lines Indented more than 2 spaces from level of preceding line. It is used when an entry will not fit on a single line. Modifiers In parentheses (can be present or absent) Chapter 4 24
25 Main terms Listed by condition Supplementary terms In parentheses () Don t affect the code selection Subterm Indented Listed by etiology Affect code selection Cross-reference Anatomical sites, or alternate main terms to help locate appropriate codes Hernia, hernial (acquired) (recurrent) with gangrene (obstructed) NEC obstruction NEC and gangrene abdomen (wall) - see Hernia, ventral abdominal, specified site NEC with gangrene (obstructed) obstruction and gangrene Chapter 4 25
26 2-26 Bronchitis (diffuse) (hypostatic) (infectious) (inflammatory) (simple) 490 with emphysema see Emphysema influenza, flu, or grippe obstruction airway, chronic with acute bronchitis exacerbation (acute)
27 Urinary tract infection Aspiration pneumonia Chapter 4 27
28 Fractured humerus Chronic obstructive pulmonary disease (COPD) 496 Chapter 4 28
29 Influenza with pneumonia Chronic respiratory failure Hypoglycemic coma Chapter 4 29
30 Organization & Format Volume 1 Diseases: Tabular List Numeric listing with 17 Chapters of disease & injuries Half devoted to conditions affecting a body system Remainder classify conditions according to etiology (the origin of the disease) Chapters are used to verify codes first looked-up in the Alphabetic. 2 Supplementary Classifacations V Codes Classification of factors influencing health status and contact with health services. E Codes Classify external causes of injury and poisonings Appendix A-E Chapter 4 30
31 2-31 V CODES (reports circumstances other than disease or injury) When V Codes are used for Primary Diagnosis it must be listed first followed by the condition that required medication or treatment A well-child visit; a visit for a routine chest x-ray Research Codes via Alpha Index, and verify in the Tabular List. Main Terms used to research V Codes are not the same as other medical terms.
32 2-32 E CODES (classify the causes of injury, poisoning, and adverse events and are used to gather statistics relating to these occurrences) They are never listed alone or first. The Condition is reported first, then the E Codes EXAMPLE: A patient encounter is for a sprained finger (diagnosis), after falling from a chair
33 E Codes are mandatory in death claims related to accidents, because they define: What happened and; When it happened. E Codes are also used to code the reason for an injury or poisoning. 33
34 V Codes Encounters for reasons other than illness or injury For example, routine physicals, flu shots, vaccinations Remember PreVentive medicine E Codes Indicate the external cause of injury or poisoning For example, fall from bicycle, car accident Remember External cause Chapter 4 34
35 Morphology of Neoplasms Glossary of Mental Disorders (officially removed October 1, 2004) Classification of Drugs by American Hospital Formulary Service List Number and ICD-9-CM Equivalents Classification of Industrial Accidents List of Three-Digit Categories Chapter 8 35
36 2-36 Chapter Section Category Subcategory Subclassification Range of codes Range of codes within a chapter Three-digit code Four-digit code Five-digit code
37 Volume 1 Numerical -order Never used alone Chapters (17) Index of type of diseases Sections Group of related conditions 37
38 Volume 1 - Tabular List Categories Major topics divided into three-digit code Subcategories Four-digit code numbers Fifth-digit Subclassifications Five-digit code numbers Chapter 4 38
39 The ICD-9-CM system Written as XXX.XX 3-digit categories for diseases, injuries, and symptoms 4-digit subcategories 5-digit subclassifications Goal is to report highest level of specificity E814 V39.20 Chapter 4 39
40 Digit Assignment Code to the Highest Level Available Use a 3-digit code only if there is no 4 Use a 4-digit code if there is no 5 Use a 5-digit code whenever possible For four & five digit codes: Add decimal point after 3rd digit E814 V39.20 Chapter 4 40
41 Coding Rule: Code a disease to the highest level of specificity. Diabetes Mellitus requires the use of five digits. Diagnostic Statement: Diabetes Mellitus with peripheral circulatory disorders (Category) (Sub-Cat.) Disease/Illness Complications (Sub-Class) Details the Type of Control Chapter 8 41
42 Family history of schizophrenia. V17.0 MMR vaccination (mumps, measles, & rubella) V06.4 Fall from balcony. E882 Circular saw accident E919.4 Chapter 4 42
43 Diverticulitis of the colon Osteoarthritis of the spine Heart palpitation Chapter 4 43
44 2-44 Used for documenting surgical procedures on inpatient hospital claims. Contains Numeric and Alpha List Used only by the facility (not used to classify procedures performed by physicians in any setting)
45 2-45 Formatted alphabetically by the type of procedure, eponym, or operation Procedure codes contain three or four digits, with two characters placed to the left of the decimal point EXAMPLES: 35.0 CLOSED HEART VALVOTOMY OPEN HEART VALVULOPLASTY WITHOUT REPLACEMENT, UNSPECIFIED VALVE
46 Repair of hammer toe Injection of chemotheraphy Suture of laceration of larynx Chapter 4 46
47 2-47 Special use of signs, abbreviations, format and Punctuation marks. Appear at the beginning of the ICD and throughout the ICD-9-CM Provide guidelines for using the ICD coding system. CARDINAL RULE: Codes are never selected from one volume alone Always start with the Alphabetic Index Finish by verifying the code in the Tabular List Specific details and examples of coding conventions in Tables 3.5 and 3.6 Page 72
48 2-48 Modifiers (also called parenthetical or nonessential modifiers) found in Alphabetic Index (Volumes 2 and 3) Abbreviations used in all three volumes EX: NEC Not Elsewhere Classified Notes used to define terms and give coding instruction. EX: Infarct, infarction.. myocardium, myocardial (acute or with a stated duration of 8 weeks or less) (with hypertension) Note Use the following fifth-digit subclassification with category 410: 0 episode unspecified 1 initial episode 2 subsequent episode without recurrence
49 NEC Not elsewhere classified condition doesn t have a specific code may have 4th digit of.8 NOS Not Otherwise Specified code is unspecified often coded with 4th digit of.9 continue looking for more specific code Chapter 4 49
50 2-50 Cross-References The terms see, see also, and see category indicate cross-references. This means that the coder must look elsewhere to code a particular condition. EXAMPLE: Parkinson s Disease, syndrome or tremor see Parkinson Paresthesia see also Disturbance, sensation Fever, brain, late effect, - see category 326
51 See, See Also, and See Category Cross-reference and directs the coder to look elsewhere for closely related terms, code categories and synonyms. See An explicit direction to look elsewhere See also Look under another main term See category Review entire category before assigning code 51
52 Instructional Notations 52
53 2-53 Punctuation ICD-9-CM uses various punctuation marks that direct the coders to following certain rules, provide additional meaning, or explain terms. EX: Brackets [ ] used to enclose synonyms, alternative words, and explanatory phrases in the Tabular List Pleuropneumonia-like organisms [PPLO] Slanted Brackets [ ] Some conditions may required two codes, one for the etiology (the cause or origin of the condition), and a second for the manifestation (a disease resulting from the underlying disease or disorder) Anthrax with pneumonia [484.5] Parentheses ( ) used in both the Alphabetic Index and the Tabular List to enclose terms that are supplementary. Also used for nonessential terms Can be present or absent without affecting code numbers
54 2-54 Punctuation (cont d) Colon : is used in the Tabular List after an incomplete term that needs one or more of the terms or modifiers that follow it. EX: Pharyngitis (acute): NOS Gangrenous Braces { } are occasionally used in the Tabular List to enclose a series of terms that, when combined with the statement to the right of the brace, results in that specific code assignment EX: INTERNAL INJURY OF THORAX, ABDOMEN, AND PELVIS ( ) Includes: {blast injuries, blunt trauma, bruise.}
55 2-55 Lozenge indicates that a code is unique to ICD-9-CM, the ICD-9-CM code does not appear in the ICD-9. The lozenge symbol is located in the ICD-9-CM Tabular List only and can be ignored by coders. EX: MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE Section Mark symbol precedes a code to indicate that there is a footnote with special instructions. This symbol is found in all three volumes. EX: 675 INFECTIONS OF THE BREAST AND NIPPLE ASSOCIATED WITH CHILDBIRTH
56 2-56 Typeface Bold Boldface print is used to identify main terms and titles in the Alphabetic Index. Bold type in the Tabular List depicts each code and code title. Italics In the Tabular List of Disease and Injuries, italics indicate that the code should not be reported alone or listed first. The code in italics typically represents a manifestation of disease the underlying cause should be reported first, before the code in italics. EX: PNEUMONIA IN OTHER INFECTIOUS DISEASE CLASSIFIED ELSEWHERE Code first underlying disease, as: Q fever (083.0) Typhoid fever (002.0)
57 The underlying disease is always the primary diagnosis. Directs the coder to another code to be used as the Primary Chapter 4 57
58 2-58 Includes refers to a code to give an example or define the contents of the code or code series Ex: TUBERCULOSIS ( ) Includes: Embolism, of basilar Excludes instructs the coder about words or conditions that should be coded elsewhere. In other words, these conditions are not included in the code Ex: HEMMORRHOIDS Includes: Hemorrhoids Excludes: that complicating pregnancy, childbirth, or the puerperium (671.8)
59 Inclusion defines What it is Exclusion defines What it is not. An Exclusion Box may indicate: 1) The condition may have to be coded elsewhere 2) The code cannot be assigned if the associated condition is present, or 3) Additional codes may be required to fully explain the condition. Chapter 4 59
60 60
61 2-61 Use Additional Code tells the coder to also code further information if it is documented. Ex: URINARY TRACT INFECTION, SITE NOT SPECIFIED Use additional code to identify organism, such as Escherichia coli [E. coli] (041.4)
62 Provides the coder with suggestions for the use of additional codes that may give a more complete picture of the diagnosis. Chapter 4 62
63 2-63 Code First Underlying Disease is located only in the Tabular List with codes that are not intended to be selected as primary disease because they are manifestations of other underlying diseases Ex: 517 LUNG INVOLVEMENT IN CONDITIONS CLASSIFIED ELSEWHERE Excludes: Rheumatic lung ((714.81) RHEUMATIC PNEUMONIA Code first underlying disease (390)
64 Instructional Notations The underlying disease is always the primary diagnosis. Directs the coder to another code to be used as the Primary Chapter 4 64
65 2-65 Omit Code is found only in the Alphabetic Index to Procedures in Volume 3. It is seen next to a term listing an incision, such a laparatomy. Omit Code means when an incision was made for the purpose of performing further surgery, the code for the incision should be omitted, or not coded. Ex: Arthrotomy As operative approach omit code
66 2-66 Three Tables in ICD-9-CM are used to provide an organized structure for the coding of certain diseases and drugs. The format of each table is based on the need to classify different types of disease, sites of disease, or circumstances of disease. The Tables are: 1. HYPERTENSION TABLE 2. NEOPLASM TABLE 3. TABLE OF DRUGS AND CHEMICALS
67 2-67 HYPERTENSION TABLE located at the main term hypertension in the Alphabetic Index. It contains a complete listing of conditions associate with hypertension (subterms), and requires classification of the hypertension conditions as malignant, benign, or unspecified Example: Benign cardiorenal hypertension is classified as code The main term is hypertension; the subterm is cardiorenal, and the second column lists benign.
68 Malignant - presenting a high risk, considered severe or life-threatening; out of control. Benign - presenting a low risk; considered mild or non life-threatening; under control. Unspecified - indicating the status of malignant or benign is not documented in the diagnostic statement or medical record. Chapter 4 68
69 Benign hypertension Benign hypertension complicating pregnancy with chronic preeclampsia Hypertension with heart failure Chapter 4 69
70 NEOPLASM TABLE the table is organized alphabetically by body or anatomical site. The first column list anatomical location, the next six columns relate to the behavior of the neoplasm. 2-70
71 Neoplasm Table Primary (Malignancy) Original site of tumor Secondary (site of metastasis) Another site where tumor has spread Carcinoma in Situ Localized malignancy that has not spread Benign Nonmalignant, noninvasive tumor Uncertain Behavior Neither benign nor malignant Unspecified Nature of the tumor not indicated in diagnostic statement Chapter 4 71
72 Malignant neoplasm of the urinary bladder; anterior wall Primary liver cancer Primary malignant neoplasm of ovary Chapter 4 72
73 2-73 TABLE OF DRUGS AND CHEMICALS is used to classify poisoning or adverse effects, which are conditions The table is organized alphabetically by the drug or chemical name.
74 Poisoning - indicates a condition resulting from an intentional overdose of drugs or chemical substances or from the wrong drug or agent given or taken in error. Chapter 4 74
75 Accident (External Cause) - indicates accidental overdose, wrong substance given or taken, and to show external causes of poisonings. Therapeutic Use (External Cause) - indicates the correct substance given or taken that caused an adverse effect. 75
76 Suicide Attempt (External Cause) - indicates a self-inflicted poisoning. Assault (External Cause) - indicates a poisoning that has been inflicted by another person intending to harm or kill. Undetermined (External Cause) - indicates that the medical record does not state whether the poisoning was accidental or intentional. Chapter 4 76
77 Baby Kathy got into the kitchen cabin and ingested liquid household ammonia & E861.4 Accidental overdose of Valium & E853.2 Chapter 4 77
78 2-78 The best way to keep up-to-date on ICD-9-CM changes is to use the Internet For all health care providers to use ICD-9-CM accurately and consistently, the Official Guidelines for Coding and Reporting for its use must be followed. Having the resources to assign ICD-9-CM codes accurately is essential.
79 Access to national coding guidelines Medical dictionaries Medical Internet sites Published coding advice Continuing education 2-79
80 2-80 Official Guidelines for Coding and Reporting -- ICD-9-CM Coordination and Maintenance Committee ICD-9-CM Code Updates See also: The American Hospital Association Coding Clinic for ICD-9-CM NCHS Website (National Center for Health Statistics)
81 Pericarditis; Chronic Stevens-Johnson Syndrome Child abused by Stepfather E967.0 Chapter 4 81
82 Metacarpus Gastrointestinal Disorder History (of)/person history of/polps Colonic. V12.72 History (of)/family history of/polps Colonic. V18.51 Chapter 4 82
83 Family history of schizophrenia. V17.0 MMR vaccination (mumps, measles, & rubella) V06.4 Fall from balcony. E882 Chapter 4 83
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