Answer Key. ICD-9-CM Coding Concepts Version

Transcription

1 Answer Key ICD-9-CM Coding Concepts 2012 Version

2 Table of Contents CHAPTER 1-INTRODUCTION TO ICD-9-CM CONCEPTS... 3 C1-INFECTIOUS AND PARASITIC DISEASE... 6 ( )... 6 C2-NEOPLASMS ( ) C3-ENDOCRINE, NUTRITIONAL, & METABOLIC DISEASE & IMMUNITY DISORDER ( ) C4-DISEASES OF BLOOD AND BLOOD FORMING ORGANS ( ) C6-DISEASES OF NERVOUS SYSTEM AND SENSE ORGAN ( ) C7-DISEASE OF THE CIRCULATORY SYSTEM ( ) C8-DISEASES OF RESPIRATORY SYSTEM ( ) C10-DISEASES OF GENITOURINARY SYSTEM ( ) C11-COMPLICATIONS OF PREGNANCY, CHILDBIRTH AND PUERPERIUM ( ) C12-DISEASES OF SKIN AND SUBCUTANEOUS TISSUE ( ) C13-DISEASES OF MUSCULOSKELETAL AND CONNECTIVE TISSUE ( ) C14-CONGENITAL ANOMALIES ( ) C15-NEWBORN (PERINATAL) GUIDELINES ( ) C17-INJURY AND POISONING ( ) C18-CLASSIFICATION OF FACTORS INFLUENCING HEALTH STATUS & CONTACT WITH HEALTH SERVICES (V01-V90) C19-SUPPLEMENTAL CLASSIFICATION OF EXTERNAL CAUSES OF INJURY & POISONING (E000-E999) CHAPTER 2 SELECTION OF PRINCIPAL AND SECONDARY DIAGNOSES CHAPTER 3- GUIDELINES FOR OUTPATIENT SERVICES Lisa L. Campbell 2

3 Chapter 1-Introduction to ICD-9-CM Concepts Question Answer Guidelines 1 a. AHIMA 1 b. AHA c. NCHS d. CMS 2 Health Insurance Portability and Accountability Act (HIPAA) 1 3 Complete and accurate documentation code assignment, 1 and reporting of diagnoses and procedure 4 Including hospital admissions 1 5 Diagnosis 1 6 a. Conventions general coding guideline and chapter specific guidelines 1 b. Selection of principal diagnosis c. Reporting additional diagnoses d. Diagnostic coding and reporting guidelines for outpatient services Conventions for ICD-9-CM Question Answer Guidelines 1 a. True 6 2 An indented format for ease in reference 6 3 Not elsewhere classifiable 6 4 Not elsewhere classifiable 6 5 Not otherwise specified 6 6 a. Used to enclose synonyms, alternative wording or explanatory phrases 6-7 b. Enclosed supplementary words that may or may not c. Used after an incomplete term that needs one or more of the modifiers 7 Further defines or gives an example of the contents of the category 8 Indicates you must look to a different code series or coded elsewhere Lisa L. Campbell 3

4 9 List of terms that are included under certain four and five 7 digit codes 10 Are for use when the information in the medical record 7 provides detail for which a specific code does not exist 11 Are for use when the information in the medical record is 7 insufficient to assign a more specific code 12 This instructional note indicates the proper sequencing 8 order of the codes, etiology followed by manifestation 13 This instructional note indicates the proper sequencing 8 order of the codes, etiology followed by manifestation 14 These are manifestation codes, where the use additional 8 code note will still be present and the rules for sequencing apply 15 Diabetes Mellitus, category Mean either and or or when it appears in a title 8 17 It is sequenced immediately following the main term not in 9 alphabetical order 18 Indicates that another term should be referenced 9 19 Instructs the user that there is another main term that may also be referenced that may provide additional index entries that may be useful 9 General Coding Guidelines Question Answer Guidelines 1 Reliance on only the Alphabetical Index or the Tabular list 9 leads to errors in code assignments and less specificity in code selection 2 To code to the highest specificity. The coder should be lead 9 and guided by the instructional notes 3 Diagnosis and procedure codes are to be used at their 9 highest number of digits available 4 Codes from through V ICD-9-CM for the classification of diseases and injuries 10 6 b. False 10 7 Signs and symptoms that are routinely associated with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification Lisa L. Campbell 4

5 8 Additional signs and symptoms that may not be routinely 10 associated with a disease process should be coded when present 9 To fully describe a single condition that affects multiple 10 body systems 10 Code both and sequence the acute code first Is a single code used to classify two diagnoses or a 11 diagnosis with an associated secondary process (manifestation) 12 Is the residual effect after the acute phase of an illness or 11 injury has terminated. 13 No, it may occur months or years later The condition or nature of the late effect is sequenced first. The late effect code is sequenced second a. True If it did occur, code as confirmed diagnosis. If it did not 12 occur, reference the Alphabetic Index to determine if the condition has a subentry term for impending or threatened and also reference main term entries for Impending and for Threatened. If the sub-terms are listed, assign the given code. If the sub-terms are not listed, code the existing underlying condition(s) and not the condition described as impending or threatened. 17 Each unique ICD-9-CM diagnosis code may be reported 12 only once for an encounter 18 The appropriate V code from category V57, Care involving 12 use of rehabilitation procedures, as the principal/first-listed diagnosis. The code for the condition for which the service is being performed should be reported as an additional diagnosis. 19 May be based on medical record documentation from 12 clinicians who are not the patient s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient s diagnosis), since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents the pressure ulcer stages). 20 Secondary diagnoses Lisa L. Campbell 5

6 C1-Infectious and Parasitic Disease ( ) Human Immunodeficiency Virus 1 You should only code confirmed cases of HIV 13 infection/illness 2 Principal diagnosis should be 042, followed by an additional 13 diagnosis codes for all reported HIV related condition 3 The code for the unrelated condition should be the principal diagnosis. Other diagnoses would be 042 followed by additional diagnoses codes for all reported HIV related conditions b. No 14 5 Is to be applied when the patient without any 14 documentation of symptoms is listed as being HIV positive, known HIV, HIV test positive 6 Patients with inconclusive HIV serology but no definitive diagnosis or manifestations of the illness may be assigned code b. No X followed by V V V Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis, and Septic Shock 1 They are not considered synonymous terms 15 2 a. Generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi or other organisms Lisa L. Campbell 6

7 b. Generally refers to the systemic response to infection, trauma/burns or other insult with symptoms including fever, tachycardia, tachypnea and leukocytosis c. Generally refers to SIRS due to infection d. Generally refers to sepsis with associated acute organ dysfunction 3 a. True 16 4 Before the code from subcategory systemic 16 inflammatory response syndrome (SIRS) 5 Systemic infection; , Sepsis; , severe sepsis 16 6 The associated acute organ dysfunction 16 7 The instruction for coding severe sepsis 16 8 Subcategory May require querying the provider prior to assignment of the code 17 Sequencing Sepsis and Severe Sepsis 1 Code sepsis or , sever sepsis as required by the sequencing rules in the Tabular List 17 2 b. False 17 3 Secondary diagnoses, code or May not be confirmed until sometime after admission 17 5 Should be queried 17 Sepsis/SIRS with Localized Infection 1 Systemic infection, or , Localized infection Bacterial Sepsis and Septicemia ; Lisa L. Campbell 7

8 ; the provider should be queried as to whether the 18 patient has sepsis, an infection with SIRS 3 Not assigned code Septic Shock 1 Represents a type of acute organ dysfunction 18 2 Systemic Infection; and The severe sepsis is not documented 19 Sepsis and Septic Shock Complicating Abortion and Pregnancy 1 Category codes in Chapter 11 ( ) 19 Negative or Inconclusive Blood Cultures 1 b. No 19 Newborn Sepsis 1 I.C.15.j. 19 Sepsis Due to a Postprocedural Infection 1 Documentation of the relationship between the infection 19 and the procedure 2 The appropriate sepsis codes Lisa L. Campbell 8

9 External Cause of Injury Codes with SIRS 1 Section I.C.19.a.7 20 Sepsis and Severe Sepsis Associated with Non-Infectious Process 1 Noninfectious condition should be sequenced first followed 20 by the code for the systemic infection and either code Sepsis or severe sepsis 2 Non-Infectious Condition 20 3 May be assigned as principal diagnosis 20 4 One 20 5 Code or Do not additionally assign code , Systemic inflammatory response syndrome due to non-infectious process without acute organ dysfunction, or , Systemic inflammatory response syndrome with acute organ dysfunction. 20 Methicillin Resistant Staphylococcus Aureus (MRSA) 1 For the condition (e.g., code , Methicillin resistant 21 Staphylococcus Aureus septicemia or code , Methicillin resistant pneumonia due to Staphylococcus Aureus). Do not assign code , Methicillin resistant Staphylococcus Aureus, as an additional code because the code includes the type of infection and the MRSA organism. Do not assign a code from subcategory V09.0, Infection with microorganisms resistant to penicillin, as an additional diagnosis , Methicillin resistant Staphylococcus Aureus, for the MRSA infection. Do not assign a code from subcategory V09.0, Infection with microorganisms resistant to penicillin Lisa L. Campbell 9

10 3 Colonized or being a carrier. Colonization means that MSSA 21 or MSRA is present on or in the body without necessarily causing illness. A positive MRSA colonization test might be documented by the provider as MRSA screen positive or MRSA nasal swab positive. 4 b. False 22 5 b. False 22 6 b. False 22 7 V C2-Neoplasms ( ) 1 a. True 22 2 The malignancy 23 3 The secondary neoplasm is designated as the principal 23 diagnosis even though the primary malignancy is still present 4 The appropriate anemia code is designated as the principal 23 diagnosis and is followed by appropriate code(s) for the malignancy 5 The anemia is sequenced first. The appropriate neoplasm code should be assigned as an additional code. 6 The dehydration is sequenced first followed by the code for 24 the malignancy 7 Designate the complication as the principal or first-listed 24 diagnosis if treatment is directed at resolving the complication 8 When a primary malignancy has been previously excised or 24 eradicated from its site, there is no further treatment directed to that site, there is no evidence of any existing primary malignancy 9 The neoplasm code should be assigned as principal or first 24 listed diagnosis, using codes in the series or where appropriate in the series 10 V V Lisa L. Campbell 10

11 12 The primary malignancy or appropriate metastatic site is 25 designated as the principal or first listed diagnosis even though chemotherapy or radiotherapy is administered 13 Symptoms, signs, and ill-defined conditions listed in 25 Chapter 16 characteristic of or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first- listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm. 14 Transplant Complication 25 C3-Endocrine, Nutritional, & Metabolic Disease & Immunity Disorder ( ) 1 A fifth digits is required for all category 250 codes to identify 26 the type of diabetes mellitus and whether the diabetes is controlled or uncontrolled 2 No 26 3 Type II 26 4 V The codes from category 250 must be sequenced before the 27 code for the associated conditions 6 Section I.C.11.f 27 7 Section I.C.11.g Mechanical complication due to insulin pump, as the 27 principal or first listed code followed by the appropriate diabetes mellitus code based on documentation Mechanical complication due to insulin pump 27 followed by code 962.3, poisoning by insulin and antidiabetic agents 10 Associated with secondary diabetes mellitus b. False a. True Sequenced before the codes for the associated conditions The reason for the encounter, applicable ICD-9-CM 28 sequencing conventions, and chapter specific guidelines 15 Assign code 251.3, Post surgical hypoinsulinemia Lisa L. Campbell 11

12 16 a. True 29 C4-Diseases of Blood and Blood Forming Organs ( ) 1 If the reason for the encounter is to treat the anemia 29 2 The stage of chronic kidney disease 30 3 Malignancy; antineoplastic chemotherapy drugs, which is an adverse effect 30 C6-Diseases of Nervous System and Sense Organ ( ) 1 Provide more detail about acute or chronic pain and 30 neoplasm related pain unless otherwise indicated 2 Assign codes from category 338, except for post 30 thoracotomy pain, postoperative pain, neoplasm related pain or central pain syndrome 3 Underlying (definitive) diagnosis is known unless the reason 30 for the encounter is pain control/management and not management of the underlying condition 4 a. When pain control or pain management is the reason for the admission/encounter (e.g., a patient with displaced intervertebral disc, nerve impingement and severe back pain presents for injection of steroid into the spinal canal). The underlying cause of the pain should be reported as an additional diagnosis, if known. b. When an admission or encounter is for a procedure aimed at treating the underlying condition (e.g., spinal fusion, kyphoplasty), a code for the underlying condition (e.g., vertebral fracture, spinal stenosis) should be assigned as the principal diagnosis. No code from category 338 should be assigned Lisa L. Campbell 12

13 c. When a patient is admitted for the insertion of a neurostimulator for pain control, assign the appropriate pain code as the principal or first listed diagnosis. When an admission or encounter is for a procedure aimed at treating the underlying condition and a neurostimulator is inserted for pain control during the same admission/encounter, a code for the underlying condition should be assigned as the principal diagnosis and the appropriate pain code should be assigned as a secondary diagnosis. 5 If the category 338 code provides additional information 31 6 The code from category 338 followed by the code 32 identifying the specific site of pain 7 The code for the specific site of pain first, followed by the 32 appropriate code from category The appropriate code(s) found in Chapter 17 injury and 32 poisoning 9 Whether the pain is acute or chronic Postoperative pain code in category The appropriate code(s) found in Chapter 17, injury and 33 poisoning 12 Category Documented as postoperative pain control/management Presents for outpatient surgery and develops and unusual or 33 inordinate amount of postoperative pain 15 a. True Section III. Reporting Additional Diagnoses and Section IV. 33 Diagnostic Coding & Reporting in the Outpatient Setting 17 b. False a. True b. False 34 C7-Disease of the Circulatory System ( ) 1 a. Malignant b. Benign c. Unspecified Lisa L. Campbell 13

14 2 When the medical record documentation supports such a 34 designation 3 When a casual relationship is stated or implied 34 4 Use an additional code from category 428 to identify the type of heart failure in those patients with heart failure 5 Chronic kidney disease (CKD) with hypertension as hypertensive chronic kidney disease 35 6 (0) CKD stage 1 through 4, or unspecified 35 (1) CKD stage 5 or end stage renal disease 7 When both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis 35 8 a. (0) Without heart failure and with chronic kidney disease (CKD) stage 1 through 4 or unspecified b. (1) With heart failure and with CKD stage 1 through state 4 or unspecified c. (2) Without heart failure and with CKD stage 5 or end stage renal disease d. (3) With heart failure and with CKD stage 5 or end stage renal disease 9 First assign codes from , cerebrovascular disease 36 then the appropriate hypertension code from categories First assign the code from subcategory , Hypertensive 36 retinopathy, then the appropriate codes from categories to indicate the type of hypertension 11 Two codes are required: one to identify the underlying 36 etiology and one from category 405 to indentify the hypertension; sequencing is determined by the reason for admission/encounter 12 Controlled usually refers to an existing state of hypertension 36 under control by therapy; Uncontrolled untreated hypertension not responding to current therapeutic regimen 13 Without diagnosis of hypertension rather than a code from 37 category Cerebral Infarction Clearly specify the cause and effect relationship between the 37 medical intervention and the cerebrovascular accident in order to assign the code 16 To indicate conditions classifiable to categories as 37 the causes of late effects themselves classified elsewhere 17 If the patient has a current cerebrovascular accident (CVA) and deficits from and old CVA Lisa L. Campbell 14

15 18 When no neurologic deficits are present and and Query the provider as to the site or assign a code from 38 subcategory Subendocardial AMI STEMI; as STEMI 38 C8-Diseases of Respiratory System ( ) 1 Obstructive chronic bronchitis subcategory and 39 emphysema category A worsening or a decompensation of a chronic condition 39 3 Many variations in the way these conditions are documented 39 4 A patient failure to respond to therapy administered during 39 an asthmatic episode and is a life threatening complication that requires emergency care 5 b. No 40 6 a. True 40 7 It is the condition established after study to be chiefly 40 responsible for occasioning the admission to the hospital and the selection is supported by the Alphabetic Index and Tabular List 8 It occurs after admission or if it is present on admission but 40 does not meet the definition of principal diagnosis 9 Will not be the same in every situation Query the provider for clarification a. True b. False Category 487 should be assigned Lisa L. Campbell 15

16 C10-Diseases of Genitourinary System ( ) 1 I to V 41 2 The provider has documented end-stage-renal disease 41 (ESRD) The kidney transplant may not fully restore kidney function 42 5 V Query the provider 42 7 The conventions in the Tabular List 42 C11-Complications of Pregnancy, Childbirth and Puerperium ( ) General Rules for Obstetric Cases 1 a. True 42 2 b. False 42 3 Antepartum, postpartum and whether a delivery has also 43 occurred 4 The fifth-digits, which are appropriate for each code number, are listed in brackets under each code. The fifthdigits on each code should all be consistent with each other. 43 Selection of OB Principal or First listed Diagnosis 1 V a. True 43 3 The principal complication of the pregnancy which 43 necessitated the encounter 4 The main circumstances or complication of the delivery Lisa L. Campbell 16

17 5 An outcome of delivery code should be included on every maternal record when a delivery has occurred 44 Fetal Conditions Affecting the Management of the Mother 1 b. False 44 2 Category HIV Infection in Pregnancy, Childbirth and the Puerperium X 44 Current Conditions 1 Subcategory 648X 45 Diabetes Mellitus in Pregnancy X 45 2 V Gestational Diabetes X Lisa L. Campbell 17

18 Normal Delivery, In cases when a woman is admitted for a full-term normal 45 delivery, healthy infant without any complications antepartum complication, during the delivery, or postpartum during the delivery episode 2 b. False 45 3 Had a complication at some point during her pregnancy but 46 the complication is not present at the time of the admission for delivery 4 V The Postpartum Period 1 Immediately after delivery and continues for six weeks 46 following delivery 2 Is any complication occurring within the six week period 46 3 a. Yes 46 4 Postpartum complications that occur during the same 46 admission as the delivery are identified with a fifth digit of 2. Subsequent admissions/encounters for postpartum complications should be identified with a fifth digit of 4. 5 V24.0 Postpartum care and examination immediately after 46 delivery should be assigned as the principal diagnosis 6 a. True 47 7 A secondary code to identify the causal organism 47 8 A code from category 038, Septicemia should not be used for puerperal sepsis. 47 Code 677, Late Effect of Complication of Pregnancy, Childbirth, and the Puerperium 1 Initial complication of a pregnancy develops a sequelae requiring care or treatment at a future date Lisa L. Campbell 18

19 2 Anytime after the initial postpartum period 47 3 This code like all late effect codes is to be sequenced 47 following the code describing the sequel of the complication Abortions 1 Fifth digits are required for abortion categories Fifth digit assignment is based on the status of the patient at the beginning (or start) of the encounter. Fifth digit (1) incomplete, indicates that all of the products conception have not been expelled from the uterus. Fifth digit (2) complete indicates that all products of conception have been expelled from the uterus prior to the episode of care. 2 Code from categories and may be used as 48 additional codes with an abortion code to indicate the complication leading to the abortion; fifth digit , Early onset of delivery with an appropriate code 48 from category V27, outcome of delivery 5 Category 634, spontaneous abortions or 635 legally induced abortion with a fifth digit of 1 (incomplete) 48 C12-Diseases of Skin and Subcutaneous Tissue ( ) 1 A code from subcategory 707.0, Pressure ulcer, to identify 48 the site of the pressure ulcer and a code from subcategory 707.2, Pressure ulcer stages. 2 As an additional diagnosis with a code(s) from subcategory , Pressure Ulcer. Codes from 707.2, Pressure ulcer stages, may not be assigned as a principal or first-listed diagnosis. The pressure ulcer stage codes should only be used with pressure ulcers and not with other types of ulcers (e.g., stasis ulcer). 3 Which is designated by stages I-IV and unstageable Lisa L. Campbell 19

20 4 Pressure ulcers whose stage cannot be clinically determined 49 (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma 5 Of the stage or documentation of the terms found in the 49 index 6 The site and one code for the stage should be reported 49 7 Assign one code for the site and the appropriate codes for 49 the pressure ulcer stage 8 Assign the appropriate codes for each different site and a 50 code for each different pressure ulcer stage 9 a. True Pressure ulcer stage code based on the documentation in 50 the medical record 11 b. False Query the provider Highest stage reported for that site 50 C13-Diseases of Musculoskeletal and Connective Tissue ( ) ; Newly Diagnosed 50 2 Receiving active treatment for the fracture 50 3 Completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase 51 C14-Congenital Anomalies ( ) 1 An anomaly is documented 51 2 Assign additional codes for any manifestations that may be present Lisa L. Campbell 20

21 3 Not be coded separately 51 4 The life of the patient 51 5 Personal history code should be used to identify the history 51 of the anomaly 6 Later in life 51 7 Principal diagnosis followed by any congenital anomaly codes ( ) 51 C15-Newborn (Perinatal) Guidelines ( ) General Perinatal Guidelines 1 Before birth through the 28 th day following birth 52 2 b. False 52 3 The appropriate V30 code for the birth episode followed by 52 codes from any other chapter that provides additional detail 4 Due to the birth process and the code from chapter should be used 5 Clinical evaluation; therapeutic treatment, diagnostic procedure, extended length of hospital stay or increasing nursing care and/or monitoring has implication for future health care needs 52 Use of Code V30-V39 1 As a principal diagnosis and assigned only once to a newborn at the time of birth 53 Newborn Transfers 1 V30 series is not used at the receiving hospital Lisa L. Campbell 21

22 Use of Category V29 1 To identify those instances when a healthy newborn is 53 evaluated for a suspected condition that is determined after study not to be present 2 b. False 53 Use of Other V-Codes 1 May be used as a principal or first listed diagnosis for specific types of encounters or for readmissions or encounters when the V30 code no longer applies 53 Maternal Causes of Perinatal Morbidity 1 Only when the maternal condition has actually affected the fetus or newborn 54 Congenital Anomalies in Newborns 1 b. False 54 Coding of Additional Perinatal Diagnosis 1 Require treatment or further investigation that prolongs the 54 length of stay or require resource utilization 2 b. False Lisa L. Campbell 22

23 3 If the diagnoses have been documented by the responsible provider at the time of transfer or discharge as having affected the fetus or newborn 54 Prematurity and Fetal Growth Retardation 1 It is documented 55 2 Recorded birth weight and estimated gestational age 55 3 An additional code with category 764 and codes from and to specify weeks of gestation as documented by the provider in the record 55 Newborn Sepsis C17-Injury and Poisoning ( ) Coding of Injuries 1 A combination code is provided in which case the 55 combination code is assigned 2 Information for a more specific code is not available 55 3 b. False 55 4 a. True 55 5 The primary injury is sequenced first with additional code 56 front categories Injury to nerves and spinal cord and Injury to blood vessels 6 That injury should be sequenced first Lisa L. Campbell 23

24 Coding of Traumatic Fractures 1 The provisions within categories and the level of 56 detail furnished by medial record content 2 Insufficient detail in the medical record when the reporting 56 form limits the number of codes that can be used in reporting pertinent clinical data or when there is insufficient specificity at the fourth digit or fifth digit level 3 Acute fracture code ( ) while the patient is receiving 56 active treatment for the fracture 4 Completed active treatment of the fracture and is receiving 56 routine care for the fracture during the healing or recovery phase 5 With the appropriate complication codes 56 6 With the appropriate codes 56 7 Assigned to subcategory Coded to that category 57 9 Individually by site Bilateral fractures of both upper limbs (819) and both lower 57 limbs (828) but without any detail at the fourth digit level other than open and closed type of fracture 11 Severity of the fracture The order of Severity 57 Coding of Burns 1 a. Depth 57 b. Extent c. Agent 2 First degree, second degree, and third degree 57 3 Sequence first the code that reflects the highest degree of 57 burn when more than one burn is present 4 Reflects the burn of the highest degree 57 5 Circumstances of admission govern the selection of the principal diagnosis or first listed diagnosis Lisa L. Campbell 24

25 6 Of admission govern the selection of the principal or first 57 listed diagnosis 7 Subcategory identifying the highest degree recorded in the 58 diagnosis 8 Non-healing burns are coded as acute burns 58 9 Not elsewhere classified as an additional code for any 58 documented infected burn site 10 b. False Specified or when there is a need for additional data When needed to provide data for evaluating burn mortality, 58 such as that needed by burn units 13 The percentage of total body surface involved in a burn; 58 The percentage of body surface involved in third-degree burn; when less than 10 percent or when no body surface is involved 14 Rule of Nines in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, genitalia one percent and posterior trunk 18 percent 15 The residual condition; The appropriate late effect code A current burn code may be assigned on the same record (when both a current burn and sequelae of an old burn exist) 59 Coding of Debridement of Wound, Infection, or Burn 1 Surgical removal or cutting away, as opposed to a 59 mechanical debridement ; Adverse Effects, Poisoning and Toxic Effects 1 The reaction plus the appropriate code from the E930- E949 Series Lisa L. Campbell 25

26 2 Tachycardia, delirium, gastrointestinal hemorrhaging; 59 vomiting, hypokalemia, hepatitis, renal failure or respiratory failure; E930-E949 series 3 Differences among patients such as age, sex, disease, and generic factors, (2) drug related factor such as type of drug, route of administration, duration of therapy, dosage and bio-availability series 60 5 A poisoning ( ) 60 6 Classified as a poisoning 60 7 First; A code for the manifestation 60 8 Poisoning 60 9 An additional code Toxic Effect First, followed by the code(s) that identify the result of the 61 toxic effect 12 External cause code E980-E982 for undermined, E860-E869 for accidental exposure, E950.6 or E950.7 for intentional harm, E962 for assault 61 Complications of Care 1 Providers documentation of the relationship between the 61 condition and the procedure 2 Complications and rejection of transplanted organs 61 3 The function of the transplanted organ 61 4 Two codes: The appropriate code from subcategory and secondary code that indentifies the complication 5 Affect the function of the transplanted organs Post kidney transplant patients who have chronic kidney 62 (CKD) unless a transplant complication (such as transplant failure or rejection is documented) 8 Query the provider 62 9 Ventilator associated pneumonia The patient has pneumonia and is not on mechanical ventilator but the provider has not specifically stated that the pneumonia is ventilator-associated pneumonia Lisa L. Campbell 26

27 for the pneumonia diagnosed at the time of admission 12 Underlying condition such as an injury, should be assigned followed by code But it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition the provider should be queried C18-Classification of Factors Influencing Health Status & Contact with Health Services (V01-V90) 1 a. A person who is not currently sick encounters the health 64 services for some specific reason, such as to act as an organ donor, to receive prophylactic care such as inoculations or health screening or to receive counseling on health related issues b. A person with a resolving disease or injury or a chronic, long term condition requiring continuous care, encounters the health care system for specific aftercare of that disease or injury. A diagnosis/symptom code should be used whenever a current acute, diagnosis is being treated or a sign or symptom is being studied. c. Circumstances or problems influence a person s health status but are not in themselves a current illness or injury d. Newborns, to indicate birth status 2 Any healthcare settings 64 3 No 64 4 A corresponding procedure code must accompany a V code 64 to describe the procedure performed 5 a. Contact/Exposure-patients who didn t show any signs or systems of a disease b. Inoculations and Vaccinations-patient is being seen to receive a prophylactic inoculation against a disease c. Status-carrier of a disease d. History of-past medical condition that no longer exists Lisa L. Campbell 27

28 e. Screening-testing of disease f. Observation-observed for a suspected condition that is ruled out g. Aftercare-requires continued care h. Follow Up-condition fully treated and no longer exists i. Donor-living individuals donating blood or other body tissue j. Counseling-receive assistance in aftermath of illness or injury k. Obstetrics and related conditions-none of the problems exists l. Newborn, infant and child-see Section I.C.15 m. Routine and administrative examinations-routine exams for administrative purposes n. Miscellaneous V codes-other health care encounters o. Nonspecific V codes-nonspecific or redundant with other codes C19-Supplemental Classification of External Causes of Injury & Poisoning (E000-E999) 1 Those that are currently collecting E codes in order that 79 there will be standardization in the process 2 b. False 79 3 b. False 79 4 To provide data for injury research and evaluation of injury prevention strategies 79 5 a. How the injury or poisoning happened 79 b. Intent c. The place where the event occurred General E-Code Guidelines 1 b. False Lisa L. Campbell 28

29 2 Subsequent Treatment 80 3 Describe the cause, the intent and the place of occurrence if 80 applicable for all injuries, poisonings and adverse effects of drugs 4 Assign as many E codes as necessary to fully explain each 80 cause 5 Index to external causes which is located after the 80 alphabetical index to diseases and by inclusion and exclusion notes in the Tabular List 6 a. True 80 7 The patient also has an injury, poisoning or adverse effect of drugs 81 Place of Occurrence 1 The patient s activity at the time of the event 82 2 b. No 82 Adverse Effects of Drugs, Medicinal and Biological Substances Guidelines 1 b. False 82 2 As many codes as necessary 82 3 Assign the code only once 82 4 Code each individually; the combination code is listed in the 82 table of drugs and chemicals 5 Poisoning codes and E-codes for both 83 6 The one most related to the principal diagnosis 81 7 E930-E Lisa L. Campbell 29

30 Multiple Cause E-Code Guidelines 1 The first-listed E code should correspond to the cause of the most serious diagnosis due to an assault, accident, or selfharm, following the order of hierarchy per the guidelines 81 Child and Adult Abuse Guidelines 1 E960-E E Unknown or Suspected Intent Guidelines 1 E980- E E980-E Undetermined Cause 1 E As the documentation in the medical record in both the inpatient outpatient and other settings should normally provide sufficient detail to determine the cause of the injury Lisa L. Campbell 30

31 Late Effects of External Cause Guidelines 1 Injuries; Poisonings; Adverse effects of drugs, 84 misadventures and surgical complication 2 E929, E959, E969, E977, E989 or E Current nature of injury code 84 4 When a late effect of the initial injury or poisoning is being 84 treated 5 There is no late effect E code for adverse effects of drugs 84 Misadventures and Complications of Care Guidelines 1 E870-E E878-E Terrorism Guidelines 1 E Inclusion note at E E E Lisa L. Campbell 31

32 Chapter 2 Selection of Principal and Secondary Diagnoses 1 Is defined in the uniform hospital discharge data set as that 86 condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 2 Uniform Hospital Discharge Data Set 86 3 When a related definitive diagnosis has been established 87 4 Either condition may be sequenced first, unless the 87 circumstances of the admission the therapy provided 5 Determined by the circumstances of admission, diagnostic 87 work up and/or therapy provided and the Alphabetic Index Tabular list 6 They are coded as if the diagnoses were confirmed and the 87 diagnoses are sequenced according to the circumstance of the admission 7 The symptom code is sequenced first and should be coded 87 as additional diagnoses 8 Sequence as the principal diagnosis the condition which 87 after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances Code the condition as if it existed or was established The medical condition which led to the hospital admission The Uniform Hospital Discharge Data Set (UHDDS) definition 88 of principal diagnosis as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 13 a. If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. b. If no complication or other condition is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis. c. If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis Lisa L. Campbell 32

33 14 Clinical evaluation, therapeutic treatment, diagnostic 89 procedures or extended length of hospital stay, increasing nursing care 15 The UHDDS item #11-b defines Other Diagnoses as all 89 conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay 16 a. Yes If the historical condition or family history has an impact on 89 current care or influences treatment 18 Are not coded and reported unless the provider indicates 89 their clinical significance 19 Code the condition as if it existed or was established Lisa L. Campbell 33

34 Chapter 3- Guidelines for Outpatient Services 1 Hospitals/providers in coding and reporting hospital 90 based outpatient services and provider-based office visit 2 b. False 90 3 b. False 90 4 Principal diagnosis 90 5 The coding conventions of ICD-9-CM as well as the 91 general and disease specific guidelines take precedence over the outpatient guideline 6 Two or more visits before the diagnosis is confirmed 91 7 Never begin searching initially in the Tabular List as this 91 will lead to coding errors 8 Code the reason for the surgery 91 9 Assign a code for the medical condition Code the reason for the surgery as the first, followed 91 by codes for the complications through V The patient s condition using terminology which 91 includes specific diagnoses as well as symptoms, problems or reason for the encounter through For reporting purposes when a diagnosis has not been established by the provider 15 The supplementary classification of factors influencing 92 health status and contact with Health Services (V01.0- V91.99) 16 3, 4, Invalid The ICD-9-CM for the diagnosis, condition, problem, or 92 other reason for encounter/visit 19 Do not code diagnoses Chronic diseases treated on an ongoing basis may be 92 coded and reported as many times as the patient receiving treatment 21 Code conditions that were previously treated and no longer exist Lisa L. Campbell 34

35 22 May be used as secondary codes if the historical 93 condition or family history has an impact on current care or influences treatment 23 Condition, problem, or other reason for encounter or 93 visit shown in medical record codes for other diagnose may be sequenced as additional diagnosis 24 V72.5 and/or a code from subcategory V V code and the code describing the reason for the nonroutine 93 test 26 Code any confirmed or definitive diagnosis (es) 93 documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. 27 Sequence first the diagnosis condition, problem or other 93 reason for encounter/visit shown in the medical record. Codes for other diagnoses may be sequenced as additional diagnoses. 28 When the primary reason for the admission encounter 93 is chemotherapy, radiation therapy or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed second. 29 First a code from category V72.8 is assign for the 93 condition. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. 30 The diagnosis for which the surgery was performed Select the postoperative diagnosis for coding since it is 94 the most definitive 32 V Lisa L. Campbell 35