ICD-9 Coding. About the Presenter. Today s Course. An Introduction To Using The Diagnosis Coding System

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1 ICD-9 Coding An Introduction To Using The Diagnosis Coding System Presented By Economedix Your Partner In Building High Performance Practices About the Presenter R. Thomas (Tom) Loughrey Chairman & CEO Former President of Conomikes Associates, Inc. Former Hospital Administrator & founder of a medical billing firm BS Degree - Penn State University MBA in Health & Hospital Administration from Univ. of Florida Professional Memberships MGMA, HCFMA & American College of Health Care Administrators Created and Presented Thousands of Seminars & Workshops on all aspects of Practice Management Today s Course Organization of ICD-9 Common Conventions Volume II The Index Volume I The Tabular Listings Tables and Special Sections 1

2 Organization of ICD-9 Two Volumes Volume I A tabular listing of terms, descriptions, codes and notes Volume II An alphabetic listing of diseases, illnesses, injuries, conditions, signs and symptoms V codes and E codes Tables Drugs and chemicals (poisons) Neoplasms and Hypertension Index to External Causes of Injury and Poisoning ICD-9-CM Although usually referred to as simply, ICD-9, the formal name is International Classification of Diseases, 9 th Revision, Clinical Modification. ICD-9-CM is the version of ICD-9 most commonly used in the United States. It should not be confused with other texts called, ICD-9 that are used internationally. Background to ICD-9 17 th Century England London Bills of Mortality 1937 International Causes of Death 1948 World Health Organization publishes International Classification of Diseases (ICD) th Revision published by WHO 1977 US Center for Health Statistics modifies ICD-9 statistical information with clinical information ICD-9-CM 1988 Medicare requires use of ICD-9 codes for all claims 2

3 Guidelines for Selecting Codes Identify each service, procedure or supply with an ICD-9 code that explains the need for the item. CPT and HCPCS codes generally describe what was provided ICD-9 codes explain why it was done Guidelines for Selecting Codes Identify the services for circumstances other than disease and injuries, with V-codes Sometimes called, the walking-well codes, these are provided to describe reasons why otherwise healthy people might have an encounter for health services Guidelines for Selecting Codes Code the primary diagnosis first Code secondary diagnoses next Code any co-existing diagnoses that affect the care and treatment Do not code diagnoses that are not applicable to the patient for any care or treatment 3

4 Guidelines for Selecting Codes Code to the highest level of specificity ICD-9 codes have from three to five digits 460 Acute nasopharyngitis (common cold) Acute sinusitis Frontal Acute bronchiolitis due to respiratory synctial virus Guidelines for Selecting Codes Code a chronic diagnosis as long as it is applicable to the treatment Example It is appropriate to code for diabetes for a patient receiving an eye exam It is inappropriate to code for diabetes for a patient receiving an x-ray for a fracture (unless caused by the diabetes) Guidelines for Selecting Codes When only ancillary services are provided (tests, x-rays, etc) the appropriate V-code should be coded first and the problem second. Patient receiving physical therapy for a ruptured disk: V57.1 other physical therapy, except breathing Lumbar intervertebral disc without myelopathy 4

5 Guidelines for Selecting Codes Look up codes in Volume II, the Index by name of condition, injury, circumstance, illness Assign a tentative code Look up code by number in Volume I, the tabular list Check notes and assign final code using complete code Example of Assigning Code 1. Patient is being treated for cardiac arrhythmia (atrial fibrillation) 2. Find by looking up fibrillation and locate atrial Find by looking up arrhythmia and locate cardiac Look up 427 in Volume I Cardiac Dysrhytmias Most specific is Note separate code for atrial flutter Common Coding Conventions Notes: provide additional instruction and explanation. One of the most common notes concerns coding underlying diseases as primary Myopathy in endocrine diseases classified elsewhere Code first the underlying disease, as: Addison s Disease (255.4) Cushing s Syndrome ) Hypopituitarism (253.2) Myxedema ( ) Thyrotoxicosis ( ) Italicized text always refers to secondary diagnoses. List the underlying disease first Notes 5

6 Common Coding Conventions Includes and Excludes notes [ ] - brackets enclose synonyms, alternate words or explanatory phrases infectious organism [e.g., Staphylococcus 041.1] ( ) Parentheses enclose supplementary words that may be absent in the statement. streptococcal (391.2) Common Coding Conventions NOS Not otherwise specified. Indicates a nonspecific code. Coder should look for more information for more definitive code NEC Not elsewhere classifiable. To be used only when coder lacks additional information to code more specifically See usually directs coder to more specific terminology Common Coding Conventions See also indicates additional information available Essential Modifiers subterms which are listed below the main term in alphabetic order. An essential modifier that clarifies a previous is indented two spaces. Cystic see also condition breast, chronic corpora lutea degeneration, congenital brain kidney

7 Medical Necessity Coding Basics Usually the first requirement of third party payers One diagnosis may be insufficient to document necessity of services Rationale for selected codes should be available in the medical record Coding Basics Primary Diagnosis The first diagnosis on the HCFA-1500 claim form The primary reason the patient is being seen/treated The most specific primary diagnosis may be unavailable until test results are back Additional diagnoses may be used if the affect the treatment Look It Up! 1. Chronic Tonsillitis a) b) 474 c) d) Supervision of normal first pregnancy a) V22 b) 220 c) V22.0 7

8 Common Coding Problems Symptoms Hypertension Neoplasms Obstetrics Cardiac problems Injuries Common Coding Problems Complications Italicized codes Burns Accidents Poisonings Adverse Effects Late Effects Symptoms Code only what you know. This means that sometimes the only thing known are signs and symptoms Can be found in categories 780 to 789 Used as provisional diagnoses until more definitive diagnosis is known. Pay particular attention to the excludes notes 8

9 Hypertension The general coding rule is to identify a code in the index and then look it up in the tabular list. This is an exception to the rule Check the hypertension table in the index. Table lists complete codes. Hypertension is subclassified as Benign, Malignant or Unspecified Benign no failure of an affected organ system Malignant involves failure of an organ system Unspecified status of organ system is not specified Most often coded as 401.9(very non-specific) or in place of high blood pressure reading (796.2) Neoplasms Another exception to the rule. Neoplasm table is found in the index and all codes are complete. Four categories of Neoplasms Malignant Benign Uncertain behavior Unspecified Malignant Neoplasms Three categories of malignant neoplasms Primary Secondary (metasticized) Ca in situ Could be a tragic mistake to list a benign neoplasm as malignant prematurely 9

10 Neoplasm Table Neoplasms are listed by anatomic site alphabetically Abdomen to Zuckerkandl s organ (an organ in the solar plexus at the aortic bifurcation) Connective tissue is further classified by anatomic site Some neoplasms may only be primary malignancies by definition or are never found in situ Neoplasm Table If the descriptive language does not specify the sub-category, then the term will have to be looked up in the index. Adenoma see also Neoplasm, benign Squamous cell carcinomas and epidermoid carcinomas are skin cancers and classified to skin of the site (arm, trunk, face, etc) Papillomas are skin neoplasms categorized to the benign categories of skin sites Past Neoplasms Patient returns for a follow-up visit several years after successful treatment for malignant neoplasm of breast. Patient had radical mastectomy. V10.3 Personal history of malignant neoplasm of breast V45.71 Acquired absence of breast 10

11 Dealing With V Codes Difficult to look up in the index Relatively short section Persons with health hazards related to communicable diseases Persons with need for isolation Persons with potential health hazards related to personal & family history Related to reproduction & development Other circumstances Examinations and screenings no Dx Obstetrics Some codes may change when condition is present in pregnant female Hypertension unspecified Transient hypertension pregnancy Many codes related to problems of delivery require a fifth digit to designate the delivered state with the antepartum condition Many instructional notes and fourth and fifth digit codes Cardiac Problems Problem is with myocardial infarctions Original diagnosis of acute MI acute MI, anterolateral wall, initial episode Subsequent visits up to 8 weeks acute MI, anterolateral wall, subsequent episode Six month follow-up, no symptoms 412 Old MI, healed 11

12 Injuries Fractures extensive fifth digits for bones and parts of the bones Internal injuries virtually all injuries to internal organs no open woundsextensive fifth digits for injury sites Open wounds head, neck, trunk separate from limbs Complications Complications of surgical and medical care If complication occurs with primary diagnosis, code complication secondary If complication follows primary problem, code the complication first during cholecystectomy patient has cardiac arrest acute cholecystitis cardiac complications Italicized Codes Always secondary even if being treated primary Chronic mycotic otitis externa Code first underlying disease aspergillosis (117.3) otomycosis NOS (111.9) 12

13 Burns Burn coding is dependent on four factors: 1) Location of the burn site 2) Severity of the burn 3) Percentage of total body surface burned 4) Percentage of total body surface with third degree burns identify burn site 948 identifies total percent burned 949 identifies total percent with 3 rd degree burns Rule of Nines for Burns Head = 9% Each arm = 9% (18%) Each side = 18% (36%) Each leg = 18% (36%) Perineum = 1% Total = 100% Full-thickness skin loss, multiple sites lower limb % of body surface, 0-10% 3 rd degree burns Type of Injury Accidents Location of the injury Cause of Injury Open wound of fingers with tendon involvement E849.0 Place of occurrence, home E900.2 Accident caused by garbage disposal 13

14 Adverse Effects An adverse effect of some treatment Patient experiencing severe nausea and vomiting. Prescription for tranquilizer. Returns with vertigo and headache Vertigo Headache E939.1 Adverse effects in therapeutic use, phenothiazine based tranquilizers Poisonings What was the poison and what caused it? Use Table of Drugs and Chemicals Child injests aspirin and is brought to ER unconscious Poisoning by salicylates other alteration of consciousness E850.3 Accidental poisoning by salicylates E Codes Best found in the Table of Drugs and Chemicals for poisonings and, In the Index to External Causes Alphabetic listing by cause E827 Collision with an animal drawn vehicle E884.6 Fall off toilet E909.4 Tsunami Always secondary diagnoses 14

15 Late Effects A long-term effect or residual problem after the acute phase of an illness or injury Generally occur after one year Code the problem and the cause Malunion of fracture Late effect of fracture of lower extremities Resource for ICD-9 Books Medicode 5225 Wiley Post Way Suite 500 Salt Lake City, UT Fax Thank you for participating in this seminar presentation from Economedix! Please go to To complete the Evaluation then you can proceed to the Quiz to Complete the CME / CEU Process 15