ICD-9-CM AND ICD-10-CM

Transcription

1 P A R T I ICD-9-CM AND ICD-10-CM 2 Introduction to ICD-9-CM 4 ICD-9-CM Chapter-Specific Guidelines, Part II: Chapters ICD-9-CM Chapter-Specific Guidelines, Part I: Chapters Introduction to ICD-10-CM

2 2 INTRODUCTION TO ICD-9-CM Key Learning TermsOutcomes After completing this chapter, students should be able to: 2.1 Explain the structure of the ICD-9-CM manual. 2.2 Describe how to use Volumes 1 and 2 to determine diagnosis codes. 2.3 Define the conventions used in Volumes 1 and 2 that help coders identify correct diagnosis codes. 2.4 Discuss general outpatient coding principles to select appropriate diagnosis codes. Key Terms Alphabetic Index of Diseases (Volume 2) Encounter First-listed diagnosis Hypertension Table NEC (not elsewhere classifiable) Neoplasm Table NOS (not otherwise specified) Principal diagnosis Secondary diagnosis Sign Supplemental classification Symptom Table of Drugs and Chemicals Tabular List of Diseases (Volume 1) Visit

3 Introduction Describing medical services completely requires the use of at least two out of three separate coding systems. Two coding systems Current Procedural Terminology (CPT) and Healthcare Common Procedural Coding System (HCPCS) describe the actual services provided and are discussed in later chapters of this book. A third system, the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM or ICD-9), describes the reasons those services were provided. These three coding systems can be thought of as the what and the why regarding the services provided. The ICD-9-CM coding system is based on the official version of the World Health Organization s (WHO) ninth revision of the International Classification of Diseases (ICD-9). The World Health Organization no longer maintains ICD-9, publishing instead the ICD-10. Two federal agencies the National Center for Health Statistics and the Cen ters for Medicare and Medicaid Services maintain ICD-9-CM through the ICD-9-CM Coordination and Maintenance Committee, which publishes annual updates of the ICD-9-CM manual in October of each year. These two entities are responsible for converting the ICD-9-CM coding system to two new systems, ICD-10-CM (Diagnoses) and ICD-10-PCS (Procedures), scheduled to begin on October 1, Correct diagnosis coding facilitates payment for services, tracks disease and associated healthcare usage, advances research, and aids patient care. Diagnosis codes should be reported to the highest level of specificity known and accurately represent information in the medical record. It is important to review the medical record sufficiently to ascertain all the conditions treated. The ICD-9-CM diagnosis codes support the medical necessity of the treatments provided to the patient. Reporting diagnosis codes will change significantly in 2013 when the ICD-10-CM code set replaces the ICD-9-CM codes. ICD-10-CM will be discussed in detail in Chapter 5. Some instructors may choose to teach ICD-9-CM and ICD-10-CM together, whereas others may separate the two. To accommodate multiple approaches to learning the current coding system as well as the future codes, exercises in Chapters 3 and 4 will include answers for both. CODER S TIP Many payers have claim edits in their adjudication (claims processing) systems that establish diagnosis to procedure code relationships to justify payments for the claimed procedure. Coders should be familiar with the specific requirements for each payer. When preparing a claim, review all diagnosis codes associated with the patient and visit to make sure that important information for reporting the particular service is not overlooked. 2.1 The Structure of the ICD-9-CM Manual The ICD-9-CM code manual consists of three volumes. Volume 1 (Tabular List of Diseases) and Volume 2 (Alphabetic Index of Diseases) are used together to determine appropriate diagnosis codes. These codes are used to report diagnoses in all settings. Volume 3, which contains both a tabular and alphabetical list of procedure codes, is used by hospitals to identify procedures performed on patients in their facilities. Physicians and other professionals do not use Volume 3 to report procedures. Each volume is divided into chapters, tables, or appendices. The chapters in Volume 1 cover codes describing specific diseases and conditions. Volume 2 includes several CHAPTER 2 INTRODUCTION TO ICD-9-CM 37

4 tables with information necessary to identify codes describing particular conditions. Chapters in Volume 3 describe procedures on specific body systems. Each of these is discussed in more detail below. CODER S TIP Coders must understand the basic structure of the ICD-9-CM manual and the information included in each volume. It is also important to understand which volumes are used to report diagnosis and procedure codes in each healthcare setting. EXERCISE 2.1 Also available in Use the ICD-9-CM manual to answer the following questions. 1. How many volumes are included in the ICD-9-CM manual? 2. Identify the volumes by name and number. 3. Which healthcare entities use the codes in Volume 3? Tabular List of Diseases (Volume 1) Volume 1 of the ICD-9-CM manual, which covers codes describing specific diseases and conditions. Alphabetic Index of Diseases (Volume 2) Volume 2 of the ICD-9-CM manual, which includes several tables with information necessary to identify codes describing particular conditions. When assigning codes for neoplasms, begin with the Neoplasm Table that appears in Volume 2 of the ICD-9-CM manual. 2.2 Using Volumes 1 and 2 to Determine Diagnosis Codes Volume 1 is the Tabular List of Diseases. Volume 2 is the Alphabetic Index of Diseases. Coders use both volumes in tandem to determine correct diagnosis codes. When selecting a code to describe a diagnosis, coders actually use the Alphabetic Index in Volume 2 first to identify possible diagnosis codes, and then use the list of individual codes and their descriptors in Volume 1 to select the most appropriate code from among them. Because coders should always use the volumes in this order, Volume 2 is presented first, then Volume 1. Volume 2: Alphabetic Index of Diseases The Alphabetic Index of Diseases lists diseases, conditions, and injuries along with their accompanying codes. It is used as a guide in finding the correct codes. In most manuals, Volume 2 actually precedes Volume 1, and the two volumes are always used together to validate or refine the code selection. Volume 2 has three discrete sections: Section 1: Alphabetic Index to diseases, conditions and injuries. This section includes the Hypertension Table and Neoplasm Table, which coders use to select the correct codes to describe related conditions. Figure 2.1 shows an example of entries in the Alphabetic Index. Section 2: Table of Drugs and Chemicals, which includes an extensive list of drugs, industrial solvents, corrosive gases, noxious plants, pesticides, and other toxic agents. Coders use this table to identify poisonings and external causes of adverse affects. Section 3: Alphabetic Index to External Causes of Injury and Poisoning (E-codes), a list of codes and terms that describe environmental circumstances, such as accidents or acts of violence, and other conditions that may be the cause of injury or other adverse effects. 38 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

5 FIGURE 2.1 Example of Alphabetic Index Entries C Cacergasia Cachexia cancerous - see also Neoplasm, by site, malignant cardiac - see Disease, heart dehydration with hypernatremia hyponatremia due to malnutrition exophthalmic th heart - see Disease, heart hypophyseal hypopituitary lead specified type of lead - see Table of Drugs and Chemicals malaria malignant see also Neoplasm, by site, malignant marsh nervous old age 797 pachydermic - see Hypothyroidism paludal pituitary (postpartum) Diagnosis codes that identify the main reason for the encounter should be listed first. When coding for professional medical services such as ophthalmology (rather than physician visits), usually referred to as outpatient coding, the major diagnosis is usually referred to as the first-listed diagnosis. For hospital coding, the major diagnosis is often referred to as the principal diagnosis. Because this text primarily addresses outpatient coding, the main diagnosis will be referred to as the first-listed diagnosis. Additional or secondary diagnosis codes may be listed to identify other conditions that are present. CODER S TIP renal (see also Disease, renal) saturnine specified type of lead - see Table of Drugs and Chemicals senile 797 Simmonds (pituitary cachexia) splenica strumipriva (see also Hypothyroidism) tuberculous NEC (see also Tuberculosis) th Café au lait spots Caffey s disease or syndrome (infantile cortical hyperostosis) Caisson disease Caked breast (puerperal, postpartum) th Cake kidney Calabar swelling Calcaneal spur Calcaneoapophysitis Calcaneonavicular bar Calcareous - see condition Calcicosis (occupational) 502 Calciferol (vitamin D) deficiency with osteomalacia rickets (see also Rickets) It is imperative to use both Volumes 1 and 2 to determine the correct ICD-9-CM code. Always start with Volume 2. After finding codes in Volume 2 that may describe the condition, refer to those code sections in Volume 1 for critical guidance regarding the use of additional digits, alternative codes, or additional codes. CODING EXAMPLE A patient presents with a migraine headache. Turning to Volume 2, coders can look under migraine to find a list of four-digit codes ranging from to that describe different conditions associated with migraines. Each of these codes includes a symbol indicating that a fifth digit is necessary. Volume 1 includes additional information regarding codes , including lists of conditions included under each code and specific excluded conditions. It is not possible to determine the correct code without reviewing these inclusions and exclusions, as well as the fifth digits necessary to completely describe the patient s condition. hypertension table A table containing a complete list of all conditions that are either due to or associated with hypertension. neoplasm table A table used to select correct codes for neoplasms. table of drugs and chemicals A table that includes an extensive list of drugs, industrial solvents, corrosive gases, noxious plants, pesticides, and other toxic agents to identify poisonings and external causes of adverse affects. first-listed diagnosis The major diagnosis used to identify the main reason for outpatient or professional services. principal diagnosis The major diagnosis used to identify the main reason for the service when coding for the hospital. secondary diagnosis Additional diagnoses used to identify conditions that are present in addition to the major diagnosis. CHAPTER 2 INTRODUCTION TO ICD-9-CM 39

6 etiology The origins and causes for the development of a disease. supplemental classification Additional information beyond the diagnosis codes used to fully describe the reason a patient encountered the healthcare system. Volume 1: Tabular List of Diseases The Tabular List of Diseases (Volume 1) consists of three parts: Disease classification by etiology (cause) or anatomical (body) site Supplementary classification (V- and E-codes) Appendices Diseases are primarily classified by their causes or the anatomical sites affected by those diseases. This section of Volume 1 is divided into 17 individual chapters containing categories and subcategories of codes that describe diseases (see Table 2.1). Each category is designated by three-digit codes. In most cases, this is not sufficient to accurately report the diagnosis or condition. Subcategories include codes with either a fourth character or fourth and fifth characters to identify the diagnosis in sufficient detail for reporting purposes. Figure 2.2 provides an example of entries in the Tabular List. The second part of Volume 1 is comprised of Chapters 18 and 19. Codes in these chapters describe supplemental classifications, which provide additional information beyond the diagnosis codes, including: 18. Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01 V91) 19. Supplementary Classification of External Causes of Injury and Poisoning (E800 E999) The use of V- and E-codes will be discussed in greater detail below. TABLE 2.1 Tabular List Organization Chapter Descriptive Title Categories 1. Infectious and Parasitic Diseases Neoplasms Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders Diseases of the Blood and Blood-Forming Organs Mental Disorders Diseases of the Nervous System and Sense Organs Diseases of the Circulatory System Diseases of the Respiratory System Diseases of the Digestive System Diseases of the Genitourinary System Complications of Pregnancy, Childbirth, and the Puerperium Diseases of the Skin and Subcutaneous Tissue Diseases of the Musculoskeletal System and Connective Tissue Congenital Anomalies Certain Conditions Originating in the Perinatal Period Symptoms, Signs, and Ill-Defined Conditions Injury and Poisoning PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

7 FIGURE 2.2 Example of Tabular List Entries 4 th 585 Chronic kidney disease (CKD) Includes Chronic uremia Code first hypertensive chronic kidney disease, if applicable, ( , ) Use additional code to identify: kidney transplant status, if applicable (V42.0) manifestation as: uremic: neuropathy (357.4) pericarditis (420.0) Chronic kidney disease, Stage I Chronic kidney disease, Stage II (mild) Chronic kidney disease, Stage III (moderate) Chronic kidney disease, Stage IV (severe) Chronic kidney disease, Stage V% Excludes chronic kidney disease, stage V requiring chronic dialysis (585.6) End stage renal disease, Chronic kidney disease, stage V requiring chronic dialysis Chronic kidney disease, unspecified Chronic renal disease Chronic renal failure NOS Chronic renal insufficiency The third part of Volume 1 includes four separate appendices: Appendix A: Morphology of Neoplasms Appendix C: Classification of Drugs by American Hospital Formulary Services List Number and Their ICD-9-CM Equivalents Appendix D: Classification of Industrial Accidents According to Agency Appendix E: List of Three-Digit Categories Note that there is no Appendix B. CODER S TIP Appendix B (The Glossary of Mental Disorders) was officially deleted on October 1, 2004, and is no longer included in the ICD-9-CM manual. Volume 3: Tabular List and Alphabetic List for Procedure Codes As mentioned earlier in this chapter, Volume 3 of the ICD-9-CM manual is used only in hospital settings. CPT codes are used to describe procedures reported by professionals. These will be discussed in great detail later in this book. The approximately 4,000 codes in Volume 3 are divided into 17 chapters designated as 0 through 16. Each chapter contains one or more two-digit sections describing particular types of procedures. Specific procedure codes include either a third digit or third and fourth digits for specificity. In each Volume 3 code, there is a decimal after the second digit, and coders must code to the greatest level of specificity if more CHAPTER 2 INTRODUCTION TO ICD-9-CM 41

8 detailed information is available. The 17 chapters of Volume 3 include broad categories of procedures designated by one or more two-digit sections: 00 Procedures and Interventions, Not Elsewhere Classified Operations on the Nervous System Operations on the Endocrine System Operations on the Eye Operations on the Ear Operations on the Nose, Mouth, and Pharynx Operations on the Respiratory System Operations on the Cardiovascular System Operations on the Hemic and Lymphatic System Operations on the Digestive System Operations on the Urinary System Operations on the Male Genital Organs Operations on the Female Genital Organs Obstetrical Procedures Operations on the Musculoskeletal System Operations on the Integumentary System Miscellaneous Diagnostic and Therapeutic Procedures Exercise 2.2 Also available in 1. List the contents of Volume 2 of the ICD-9-CM manual. 2. Describe the structure of Volume 1 of the ICD-9-CM manual. 3. In general terms, describe the process that coders use to select the correct diagnosis code to describe the condition for which the patient encountered the healthcare system. Some diagnosis or procedure codes are only appropriate for patients of a particular age or gender. When looking up the code for a condition, pay attention to the instructions listed for that code. 2.3 ICD-9-CM Conventions The ICD-9-CM manual is constructed with conventions intended to guide coders when identifying diagnosis or procedure codes. Most editions of the manual include a guide to these conventions at the beginning. The most common conventions span a wide range: Abbreviations Punctuation Instructional notations Use additional code instruction Code first underlying disease instruction Update notations Additional digit specificity indicator Diagnosis code-specific color highlights Age conflict edits Sex conflict edits Hospital-acquired condition (HAC) indicators These and other commonly encountered conventions are discussed on the following pages, including when coders are likely to encounter the use of these conventions in the ICD-9-CM manual. 42 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

9 Abbreviations NEC (not elsewhere classifiable) identifies codes that are used when the available information indicates a specific diagnosis but the listed codes do not identify the specific condition present in that patient. NOS (not otherwise specified) indicates codes that are used when there is not enough information to allow a specific diagnosis. Punctuation [ ] Brackets enclose synonyms, alternative wording, or explanatory phrases that may be useful in identifying the correct diagnosis codes associated with a condition. Note: Red brackets [ ] appear in some codes in the Tabular List of Diseases. As explained below, these have a different use than black brackets, and the two should not be confused. [ ] Italic brackets indicate that a separate code included within the italicized brackets must be listed with the diagnosis code to indicate an associated manifestation. ( ) Parentheses indicate that the enclosed words may be either present or absent in the description of a condition without affecting the code used to designate that diagnosis. : Colons are used after an incomplete term in the Tabular List of Diseases to indicate that one or more of the modifiers following the colon is necessary to assign that code. NEC (not elsewhere classifiable) Identifies codes that are used when the available information indicates a specific diagnosis, but the listed codes do not identify the specific condition present in that patient. NOS (not otherwise specified) Indicates codes that are used when there is not enough information to allow a specific diagnosis. Instructional Notations Includes Conditions following this notation are included in that category. Excludes Conditions following this notation are NOT described by that code, and other codes must be used to designate those conditions. Use Additional Code Instruction This instruction is included in the Tabular List when the code is insufficient on its own to describe the diagnosis and additional code(s) must be listed. When this instruction appears, the choices of the required additional codes appear in parentheses following the instruction. Code First Underlying Disease Instruction This instruction indicates that the code describes a manifestation that cannot be used as the first-listed diagnosis. The code cannot be sequenced before the underlying disease. This instruction only appears in the Tabular List and requires that the etiology or underlying disease must be listed first and the manifestation to which the instruction is attached listed secondarily. CODER S TIP It is important that coders understand the difference between the use additional code and the code first underlying disease instructions. The use additional code instruction indicates that the selected code is not sufficient on its own to describe the first-listed diagnosis and other codes must be listed. Choices of additional codes are listed in parentheses following the instruction. However, the code first underlying disease instruction indicates that the code does not indicate a diagnosis. These codes cannot be the first-listed diagnosis. Instead these codes are listed as secondary diagnoses after the first-listed diagnosis. CHAPTER 2 INTRODUCTION TO ICD-9-CM 43

10 Update Notations A bullet in the Tabular List indicates a new category, subcategory, or code. Δ A triangle symbol in the Tabular List indicates that the category, subcategory, or code has been revised. Text Newly added text is indicated with underlining. Text Newly deleted text is indicated with strikethrough. Additional Digit Specificity Indicator When a 4 th or 5 th symbol appears with three-digit or four-digit codes, an additional digit is necessary to designate a more specific code. In most cases, the specific codes with the additional necessary digits follow the code with the indicator. In general, three-digit numbers identify categories of codes. In most cases, the three-digit number is not a specific diagnosis code. Most category numbers have an associated symbol indicating that a fourth digit is required to code correctly (see below for a complete discussion of required digits indicators). A few three-digit codes are sufficient to identify a specific disease and no 4th digit required symbol is present. Four-digit numbers may identify a specific disease code or identify a subcategory of codes, each of which is identified with a five-digit code number. When a fifth digit is required, a 5th digit required symbol is added to the four-digit subcategory number. In some cases, multiple codes have common fourth or fifth digits to indicate the specificity required for correct code selection. In these instances, the common code designations are listed once in red at the beginning of the code section. Not all of the common code designations necessarily apply to every code in that section. When only some of the common code designations listed at the beginning of the code section are applicable, those that apply are listed in red parentheses (#) as a range or list of designations following the code. Diagnosis Code Specific Color Highlights In some editions of the ICD-9-CM manual, certain diagnosis codes may include a color designation to indicate that the code cannot be used as the first-listed diagnosis. A code with a blue background describes a manifestation of an underlying disease, not the disease itself. A code with a red background describes circumstances that influence an individual s health but are not a current illness or injury. Codes with these backgrounds are not acceptable as the first-listed diagnosis. Age Conflict Edits Some diagnosis codes are only indicated for certain age ranges. In these cases, an age indicator is included with the code to specify the appropriate ages for that diagnosis. The age indicators include: N (Newborn): 0 years of age, newborns and neonates only P (Pediatric): 0 17 years of age M (Maternity): years of age A (Adult): 15 years of age and older Sex Conflict Edits Some diagnosis or procedure codes are only indicated for one gender, either male or female. When this is the case, a gender symbol (male:, female: ) is included with the code descriptor to indicate the appropriate gender. Hospital-Acquired Condition (HAC) Indicator Medicare and Medicaid are prohibited from paying for care provided to treat or correct some conditions that were not present on admission to the hospital. Diagnoses with the 44 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

11 HAC indicator (an H printed on a light-blue background in most ICD-9-CM manuals) are not considered secondary diagnoses for purposes of hospital payments unless that condition is coded as having been present when the patient was admitted to the hospital. Other and Unspecified Codes Other or other specified diagnosis codes are often indicated with an 8 as the fourth digit or 9 as the fifth digit. These are used when the information in the record provides enough information to indicate what the specific diagnosis is, but a separate code describing that diagnosis does not exist. The use of NEC in the index indicates that the condition should be designated with an other code. Unspecified diagnosis codes are usually indicated with a 9 as the fourth digit or 0 as the fifth digit. These codes are used when the information available is insufficient to determine the exact diagnosis. See and See Also Instructions The see instruction indicates that another term should be utilized to identify the correct diagnosis code. Coders should refer to the term identified in the see instruction before choosing a diagnosis code to describe the condition. The see also instruction indicates that another term may be referenced for additional information, but it is not necessary to do so. This means that the term that includes the see also instruction may be used as the correct diagnosis. Signs and Symptoms ICD-9-CM diagnosis codes that describe signs and symptoms, rather than specific diseases, may be used as the first-listed diagnosis when a specific diagnosis has not been established for the patient. Many of the codes in Chapter 16 of ICD-9-CM Volume 1 ( ) describe symptoms. Signs and symptoms commonly associated with a specific reported diagnosis should not be listed as additional diagnosis codes. However, signs and symptoms not usually associated with a specific diagnosis may be listed if present. Combination Codes A combination code is a single code that designates two diagnoses, a single diagnosis combined with one or more manifestations, or a single diagnosis with an associated complication. Individual codes should not be used when a combination code exists that accurately describes the patient s condition. Combination codes can be identified by the entries in the Alphabetic Index, or by referring to the inclusion and exclusion notes in the Tabular List. Each of the 17 etiology and anatomical disease-specific chapters and the two supplemental classification chapters have specific guidance or instructions associated with them. These specific instructions will be covered in subsequent chapters of this book. If clinical documentation indicates a specific diagnosis, do not report codes for associated signs or symptoms. However, signs or symptoms can be assigned codes if there is no specific diagnosis, or if they are not associated with the diagnosis. sign Objective evidence of disease. symptom Subjective manifestation of disease. From the perspective of the... CODER To code accurately, it is important to understand the symbols and instructional notes located in the Tabular List found in Volume 1. EXERCISE 2.3 Also available in 1. Define the meaning or use of the following common ICD-9-CM conventions: a. Includes b. Excludes c. [ ] d. ( ) (Continued) CHAPTER 2 INTRODUCTION TO ICD-9-CM 45

12 2. Distinguish between the see instruction and the see also instruction. 3. Distinguish between the code definition of other and the meaning of unspecified. 4. When is it appropriate to assign a code that describes signs and symptoms? 5. What does it mean when the instructional notes state, Code first underlying disease? Where in the ICD-9-CM manual is this instruction found? 6. Describe the meaning of a combination code. 7. What do the symbols 4 th and 5 th indicate? encounter A patient s interaction with the healthcare system for a service or procedure. visit Term often used interchangeably with encounter to describe an interaction with the healthcare system for a service or procedure. 2.4 Outpatient Coding Principles Outpatient coding includes reporting professional services provided in offices, outpatient hospital settings, and inpatient hospital settings. Outpatient coding is also used to report hospital services provided in the outpatient setting. Outpatient coding is not used to report hospital services provided in the inpatient setting. The major reason for a health system encounter or visit is reported as the first-listed condition. The terms encounter and visit generally mean the same thing and will be used interchangeably in this text. The first-listed condition is selected to the greatest degree of specificity that can be ascertained from the medical record. A specific diagnosis may not be available after the first visit, but may be determined at a later date. When no specific diagnosis is documented in the medical record, codes describing signs and/or symptoms may be the first-listed condition. Many ICD-9-CM codes describing signs/symptoms are listed in Chapter 16 (Symptoms, Signs, and Ill-Defined Conditions). These will be discussed in greater detail in subsequent chapters. For example, a patient may present with nonspecific signs or symptoms that do not allow a definitive diagnosis, even after a physical exam. In those cases, the manifestations of the disease (signs/symptoms) may be reported as the first-listed condition for that visit. If a more definitive diagnosis can be made after the results of lab tests are obtained, the more definitive diagnosis is reported as the first-listed condition on subsequent visits. CODER S TIP From the perspective of the... CODER To correctly report surgical procedures, it is necessary to know the reason (diagnosis) the surgeon performed the procedure. At times it is not possible to determine a specific diagnosis from the medical records. For example, a patient may present with ecchymoses on his arms and legs. No specific cause could be determined and none is documented in the medical record. The firstlisted condition is identified by the presenting signs/symptoms and is reported as (spontaneous ecchymoses, petechiae). Lab work is ordered and the results come back several days later revealing a low platelet count. When the patient returns for a follow-up visit, the first-listed condition is reported as (thrombocytopenia, unspecified). If a patient undergoes outpatient surgery, the reason for the surgery is reported as the first-listed condition. This code is reported even if the surgery is subsequently canceled because of another condition or contraindication. The other condition may be reported as an additional diagnosis. 46 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

13 If a patient is admitted for observation of a medical condition, the medical condition for which the observation is occurring should be coded as the first-listed condition. When a patient undergoing outpatient surgery develops a complication that requires observation, the reason for the surgery should be reported as the first-listed condition, followed by codes for the complication necessitating the observation. Diagnosis codes may have three, four, or five digits. Diagnosis codes must be reported to the greatest level of specificity that may be determined from the medical records. When fourth or fifth digits are necessary to accurately report a diagnosis, indicators are included to alert coders to this. Three-digit diagnosis codes cannot be reported as definitive diagnosis codes unless the three-digit code is not further subdivided. If fourth- and fifth-digit codes are available, they must be reported. Some encounters occur for circumstances other than for the diagnosis and treatment of diseases or injuries. Those encounters are usually reported with codes from the Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01 V91). These codes will be discussed in detail in Chapter 4. Specific Guidelines for Coding Outpatient Encounters If a patient receives only diagnostic services during an encounter or visit, the firstlisted condition should be the medical diagnosis or condition for which the diagnostic services are performed. Other conditions may be reported with additional codes. V-codes may be used to report lab tests and/or radiological studies in the absence of specific diagnoses, signs, or symptoms. If the results of lab tests or radiological studies are known at the time of the encounter and the report of those results is available, codes identifying confirmed diagnoses should be reported. Codes describing signs and symptoms are not reported in addition to the definitive diagnosis codes. If a patient receives only therapeutic services during an encounter, the code describing the diagnosis or condition for which the treatment is provided should be the first-listed condition. Codes identifying other conditions may be listed as additional diagnoses. The only exception to this instruction is when the primary reason for the visit is chemotherapy, radiation therapy, or rehabilitation, in which case the appropriate V-code is the first-listed diagnosis followed by the code identifying the underlying reasons for those treatments. Codes listed in Volumes 1 and 2 of the ICD-9-CM manual are used to report the diagnoses associated with professional services provided in offices, outpatient hospital settings, inpatient hospital settings, and other health care settings. EXERCISE 2.4 Also available in 1. What is the major factor that determines which code should be identified as the first-listed condition? 2. What criteria are used to determine the first-listed condition if the medical record does not include a diagnosis for the visit? 3. If the patient currently has a condition that is not the reason for the visit or that is not causing the patient any difficulties at the time of the visit, are those conditions reported? If so, what codes are generally used to report those conditions? 4. If a patient is admitted for observation of a medical condition, what would be the first-listed diagnosis? 5. What would be the first-listed diagnosis code if a patient receives only diagnostic services during an encounter or visit? 6. Diagnosis codes must be reported to the that can be determined from the medical records 7. The major reason for a health system encounter or visit is reported as the. CHAPTER 2 INTRODUCTION TO ICD-9-CM 47

14 CHAPTER 2 REVIEW Summary Learning Outcome 2.1 Explain the structure of the ICD-9-CM manual. Pages 2.2 Describe how to use Volumes 1 and 2 to determine diagnosis codes. Pages 2.3 Define the conventions utilized in Volumes 1 and 2 that help coders identify correct diagnosis codes. Pages 2.4 Discuss general outpatient coding principles to select appropriate diagnosis codes. Pages Key Concepts/Examples The ICD-9-CM manual is divided into three volumes. Volume 1 is the Tabular List of Diseases. Volume 2 is the Alphabetic Index of Diseases. Volume 3 lists procedures reported by hospitals. The codes in Volume 3 are not used to report procedures on physician or outpatient claims. Volumes 1 and 2 are used together to determine the correct diagnosis code(s) to describe any medical condition. Coders begin with Volume 2 to locate possible diagnosis codes in the Alphabetic Index. Volume 1 is then used to determine which of these codes is most appropriate to report the diagnosis. These codes are used to report the diagnoses of patients in any healthcare setting. Several conventions and notations are used in Volumes 1 and 2 to help coders determine the correct diagnosis codes, including abbreviations, punctuation, notations, and specific instructions regarding how a particular code may be used. Specific instructions list conditions that are included or excluded under a particular code. Indicators specify age limits, sex limits, and whether a third, fourth, or fifth digit is necessary to accurately report that condition. General guidelines are outlined to select diagnosis codes for reporting conditions in the outpatient setting, including professional services. The first-listed condition should identify the main reason the patient was seen. In most cases, this will identify a specific diagnosis. In some cases, a specific diagnosis is not known at the time the patient is seen, particularly on a first visit. In that case, codes identifying signs and/or symptoms may be reported as the first-listed condition. When the actual diagnosis is known, that is reported instead of codes describing signs or symptoms. When a patient undergoes outpatient surgery, the reason for the surgery is the first-listed condition, not the surgery itself. Sometimes patients encounter the healthcare system for reasons other than to diagnose or treat an underlying condition. These encounters are reported using codes in categories V01 V91. Using Terminology Match the key terms with their definitions: 1. LO2.1 Tabular List of Diseases (Volume 1) 2. LO2.1 Alphabetic Index of Diseases (Volume 2) 3. LO2.1 Hypertension Table 4. LO2.1 Neoplasm Table 5. LO2.1 Table of Drugs and Chemicals 6. LO2.1 First-listed diagnosis A. Codes that provide additional information beyond diagnosis codes (e.g., V- and E-codes) B. Not elsewhere classifiable C. ICD-9 volume used to validate selection of diagnosis codes D. List used to identify poisoning and external causes of adverse effects E. Not otherwise specified F. Outpatient/professional coding, major or primary diagnosis G. Codes used to identify other conditions present 48 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

15 7. LO2.1 Principle diagnosis 8. LO2.1 Additional diagnosis 9. LO2.1 Supplemental classification 10. LO2.2 NEC 11. LO2.2 NOS 12. LO2.3 Sign 13. LO2.3 Symptom 14. LO2.3 Encounter H. ICD-9 volume that lists diseases, conditions, etc., and acts as a guide to identifying a diagnosis code I. Hospital coding, major or primary diagnosis J. Term used to describe an outpatient service K. Objective evidence of disease L. Subjective manifestation of disease M. Table used to identify diagnosis for a tumor N. Table used to identify diagnosis for hypertensive renal disease Checking Your Understanding Select the answer that best completes the statement or answers the question. 1. LO2.1 Which volume of ICD-9 would be used first to identify the code for a patient with congestive heart failure? a. Volume 1 b. Volume 2 c. Volume 3 d. CPT 2. LO2.2 Which instruction indicates that another term should be utilized to identify the correct diagnosis? a. See b. See also c. NEC d. Includes 3. LO2.1 Where is the Neoplasm Table located within the ICD-9 manual? a. Appendices b. Volume 3 c. Volume 1 d. Volume 2 4. LO2.3 Which of the following should a coder use to assign a code when the outpatient medical record does not state a definitive diagnosis? a. Signs and symptoms b. Probable diagnosis c. Rule out diagnosis d. Suspected liver failure 5. LO2.3 In which of the following settings would you use outpatient coding principles? a. Physician office b. Inpatient services c. Hospital services d. Skilled nursing facility Enhance your learning by completing these exercises and more at mcgrawhillconnect.com! CHAPTER 2 INTRODUCTION TO ICD-9-CM 49

16 6. LO2.3 A patient presented to the outpatient clinic with cough, chest congestion, and a fever. A chest x-ray was performed and a diagnosis of bronchitis was made. The first-listed diagnosis in this scenario would be which of the following? a. Cough b. Chest congestion c. Bronchitis d. Fever 7. LO2.2 When looking up a code for abdominal pain in the Alphabetic Index of the ICD-9 manual, the 5 th symbol appears next to the code for What does this symbol indicate? a. The code has been deleted. b. The code is new. c. The code requires additional digit(s). d. The patient required moderate conscious sedation. 8. LO2.2 Which convention means that the physician s documentation was not specific enough to give the diagnosis a more detailed code? a. NEC b. NOS c. Includes d. Excludes 9. LO2.2 Which convention provides additional descriptions, terms, or phrases that are included in the description of the code? a. Brackets b. Parentheses c. Braces d. Colons 10. LO2.1 ICD-9-CM codes identify: a. The why of a healthcare encounter. b. The who of a healthcare encounter. c. The where of a healthcare encounter. d. The when of a healthcare encounter. 11. Which of the following qualifies as medical necessity? a. The procedure does not meet insurance payer criteria for coverage based upon the correct diagnostic code linkage. b. A preexisting condition was treated under HIPAA Administrative Simplification I. c. The provider was qualified to provide the service or treatment. d. The medical service can be substantiated based upon correct code linkage between procedure and diagnosis. 12. LO2.3 Which of the following information is used to code from a physician s report? a. A definitive diagnosis b. Subjective reasons for the visit (symptoms) c. Objective reasons for the visit (signs) d. All of these 50 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

17 13. LO2.1 Which of the following is another way to describe V-codes? a. Poisoning codes b. Adverse effect codes c. Supplemental classification codes d. Morphology codes 14. LO2.2 Coding to the highest level of specificity for a disease means coding to which digit? a. Third digit b. Fourth digit c. Third, fourth, or fifth digit d. Always the fifth digit 15. LO2.2 Where would the code describing a benign skin lesion on the back be found? a. Neoplasm Table b. Volume 1 (Tabular List) c. Volume 3 d. HCPCS manual 16. LO2.2 Which of the following statements is true? a. A coder may use the Alphabetic Index to assign a code. b. A coder should use the Tabular List first when searching for code assignment. c. A coder may only use the Alphabetic Index to Disease and Injuries when assigning a code. d. A coder must reference the Alphabetic Index and then assign a code from the Tabular List. 17. LO2.2 Which fifth-digit subclassification is for use with code 550.1, bilateral inguinal hernia with obstruction, without mention of gangrene or recurrence? a. 0 b. 1 c. 2 d LO2.3 Which of the following would be the main term to look for in the Alphabetic Index (Volume 2) of the ICD-9-CM manual when the diagnosis is congestive heart failure? a. Congestive b. Heart c. Failure d. Disease 19. LO2.1 Where in the ICD-9-CM manual can you find an extensive list of drugs, gases, pesticides, and other toxic agents used to identify poisonings and external causes of adverse effects? a. Alphabetic Index to External Causes of Injury and Poisoning b. Table of Drugs and Chemicals c. Volume 3 d. Appendices Enhance your learning by completing these exercises and more at mcgrawhillconnect.com! CHAPTER 2 INTRODUCTION TO ICD-9-CM 51

18 20. LO2.1 Where in the ICD-9-CM manual would codes be found to describe environmental circumstances and conditions contributing to injury or other adverse effects? a. Index to External Causes of Injury and Poisoning (E-codes) b. Table of Drugs and Chemicals c. Volume 3 d. Appendices Applying Your Skills Fill in the blank with the word(s) to complete each sentence. 1. LO2.1 ICD-9-CM Volume 1 is also known as the. 2. LO2.1 ICD-9-CM Volume 2 is also known as the. 3. LO2.1 ICD-9-CM Volume 3 is also identified as the. 4. LO2.1 Third-party payers look for diagnostic codes that are appropriately linked with their corresponding procedures in order to meet criteria for reimbursement. 5. LO2.1 Agencies that make up the ICD-9-CM Coordination and Maintenance Committee are the and. 6. LO2.2 A coder would look up as the main term in Volume 2 (Alphabetic Index) when a patient is seen in the office for migraine headaches. 7. LO2.1 The three sections of Volume 2 are,, and. 8. LO2.1 The three sections of Volume 1 are,, and 9. LO2.1 The code range used for diseases of the digestive system is. 10. LO2.1 To report a congenital anomaly, the coder would use code range. 11. LO2.2 In Volume 3, the decimal occurs after the digit. 12. LO2.2 A bullet next to a code in the Tabular Index indicates. 13. LO2.2 An italic bracket next to a code indicates that a must also be coded. 14. LO2.2 The abbreviation for a hospital-acquired condition is. 15. LO2.2 The age range included in the age indicator for maternity (M) is. 16. LO2.2 The age range included in the age indicator for a newborn (N) is. 17. LO2.3 If a patient undergoes outpatient surgery, the is reported as the first-listed diagnosis. 18. LO2.3 The instruction indicates that another term may be referenced for additional information. 19. LO2.3 A patient s appointment for a service or procedure is referred to as an or visit. 20. LO2.3 When a patient s medical record states that the patient has a diagnosis of rapid heart rate, the main term the coder would look for in Volume 2 (Alphabetic Index to Diseases) is. 21. LO2.3 If you do not know the definitive diagnosis at the time of the encounter or visit, it is permissible to code. 52 PART I ICD-9-CM AND ICD-10-CM CPT only 2010 American Medical Association. All rights reserved.

19 22. LO2.3 When a surgery is cancelled because of another condition or complication, the first-listed diagnosis is the. 23. LO2.3 If a patient undergoes surgery and develops a complication that requires observation, the first-listed diagnosis would be the and the second code would be for the. 24. LO2.3 During an encounter, a patient receives diagnostic services only. The first-listed diagnosis should be for the. 25. LO2.3 When reporting lab tests and radiological studies in the absence of a specific diagnosis or signs and symptoms, the coder may report a. 26. LO2.3 When a patient receives only therapeutic services during an encounter, the code describing the diagnosis or condition for which the treatment is provided is the. 27. LO2.1 The diagnosis is defined as the reason the encounter occurred. 28. LO2.2 The symbol that indicates that one or more modifiers of a diagnosis code follow is a. 29. LO2.2 Conditions following the notation are among the specific conditions described by that diagnosis code. 30. LO2.2 Conditions following the notation are among the specific conditions that are not described by that diagnosis code. Thinking It Through Use your critical-thinking skills to answer the questions below. 1. LO2.1 How does a coder know that a code from Volume 1 or 2 requires a fourth or fifth digit? 2. LO2.1, LO2.2 Why are codes carried out to specific digits in certain cases? 3. LO2.2 Explain the necessity for the designation of a hospital-acquired condition (HAC). 4. LO2.2 Using Volume 2 of your ICD-9 manual, find and list an example of each of the following conventions: NEC, NOS, and Excludes. 5. LO2.2 Using your ICD-9 manual, identify symbols for the following revised code, new code, and deleted code. Enhance your learning by completing these exercises and more at mcgrawhillconnect.com! CHAPTER 2 INTRODUCTION TO ICD-9-CM 53