4665 Business Center Drive Fairfield, California 94534 DIAGNOSIS CODING TIPS INDEX Coding Tip Page 1. Diabetes 3 2. Asthma 3 3. Hypertention 3 4. Highest Specificity 5 th Digit Pain or Arthritis 3 5. Neoplasm 3 6. Chronic Pain 4 7. Depression with Anxiety 4 8. Fracture 4 9. Highest Specificity 4 th and 5 th Digits Diabetes 4 10. Diabetes with Renal Manifestation 4 11. Sequencing of Codes 4 12. Non Specific Abnormal Findings 5 13. Osteoarthritis 5 14. Combination Codes Hypertension 5 15. Allergic Rhinitis 5 16. BPH Benign Prostatic Hypertrophy 6 17. Urinary System 6 18. Overweight and Obesity 6 19. Hypertensive Heart Disease 6 20. Contact Dermatitis 6 21. Combination Codes Used With Two Diagnoses 7 22. Coding Diabetes 4 th and 5 th Digit 7 23. Lipoid Metabolism 8 24. Ischemic Heart Disease 8 25. Chronic Ulcer of the Skin 8 26. Top Ten Diabetes manifestation Codes 8 27. Unspecified Code Usage 9 28. Diseases of the Endocardium 10 29. Proper documentation 10 30. Coding Fever 5 th Digit 10 31. New Secondary Diabetes Mellitus 5 th Digit 11 Partnership HealthPlan of California Coding Tips 1
DIAGNOSIS CODING TIPS INDEX - Continued 32. Gout 11 33. Acute/chronic Venous embolism 11 34. Influenza 12 35. Voice and resonance disorders 13 36. Poisoning by psychotropic/psychostimulant agents 13 37. V-Code 14 38. Aortic Ectasia 15 39. Incontinence of Feces 15 40. Signs and symptoms involving cognition 15 Partnership HealthPlan of California Coding Tips 2
Coding Tip #1 When coding Diabetes with a manifestation you need to use a separate code for the manifestation. For example Diabetes Type II with Retinopathy 250.50 and 362.01 for the retinopathy. Code the Diabetes first then the manifestation. These codes can be found in the ICD-9 CM book in the section on diabetes. Coding Tip #2 According to the 2007 ICD9-CM coding book the code 496 (COPD) cannot be used with any code from categories 491-493. If you have a patient who has Asthmatic Bronchitis or Asthma with COPD there is a combination code 493.2* (requires fifth digit of 0-unsp, 1-w/status asthmaticus, 2-acute exacerbation). Coding Tip #3 When coding hypertension there needs to be documentation that a blood pressure was taken and if the hypertension is benign (401.1) or malignant (401.0) this needs to be documented as well. Otherwise you should use the hypertension unspecified (401.9) or elevated blood pressure without a diagnosis of hypertension (796.2). Coding Tip #4 When coding to the highest specificity the 5 th digit is very important. When a patient has pain or arthritis there are specific 5 th digits that refer to different body areas. The code range for these specific sub-classifications is 715-719. Here are the 5 th digits and the body areas: 0= site unspecified 1= shoulder region 2= upper arm 3= forearm 4= hand 5= pelvic region and thigh 6= lower leg (knee) 7= ankle and foot 8= other specified sites 9= multiple sites Coding Tip #5 When determining a diagnosis code for a patient with cancer, do not use the codes for neoplasm of unspecified nature (239). These codes should be used only for a patient with a growth or mass that is not otherwise specified, for example if a patient has a current diagnosis of breast cancer use the code 174.9 for neoplasm, breast, unspecified. If there is a personal history of cancer the appropriate V code can be used, such as Partnership HealthPlan of California Coding Tips 3
V10.3 for a personal history of breast cancer. If there is definitive cancer diagnoses use the code range 140-199 with the appropriate 4 th or 5 th digit to define the location. Coding Tip #6 There are new pain codes in the 2007 ICD-9 book for acute pain and chronic pain. They start with 338 and need to have 4 th and/or 5 th digits added depending on the cause of the pain. These are great codes to use for post-op pain or pain due to trauma, also chronic pain syndrome is included in this group of codes. The code for generalized pain (780.96) is still a good one to use if the pain is localized, and unspecified. Coding Tip #7 When coding a patient with a diagnosis of depression with anxiety use code 300.4 not the codes for major depressive disorder (296 series). There needs to be documentation that the patient has major depressive disorder and whether it is a single or recurrent event and also whether it is mild, moderate, severe in order for the 296 codes to be used. Coding Tip #8 When coding a fracture only the initial provider who diagnoses the fracture can code it. All other visits related to the fracture are aftercare visits and the appropriate V code needs to be used depending on the location of the fracture. The V codes start with V54 and require two more digits, the fourth digit for traumatic or pathological fracture and the fifth digit for the actual location of the fracture. Coding Tip #9 The 4 th and 5 th digits are very important when coding to the highest specificity. This is especially important with certain codes because it can mean the difference between Diabetes Type II, not juvenile (250.00), Juvenile Diabetes Type I (250.01) and Diabetes Type II, uncontrolled (250.02). Each of these 5 th digits changes the definition of the code. Coding Tip #10 When coding diabetes with a renal manifestation a commonly missed manifestation code is Proteinuria (791.0), this code is not listed in the diabetes section of ICD-9-CM. Remember that if you use a diabetic code with a manifestation the manifestation code must be listed in addition to the diabetic code. Coding Tip #11 When coding to the highest specificity the sequencing of codes is very important. For example Late Effects of a CVA (438) should be the first diagnosis followed by the late effect code. This would only be relevant for late effects that are not listed in a combination code. The code for other paralytic syndrome (438.5*) is one of the codes Partnership HealthPlan of California Coding Tips 4
that should be followed by a code for the type of paralytic syndrome such as locked in state (344.81). The other example would be the diabetic codes with manifestations, these would be listed first then the second code would be the manifestation. Coding Tip #12 There are codes in the series 790-796 Nonspecific Abnormal Findings that are good to use when there is not a definitive diagnosis. For example (790.21) for impaired fasting glucose, or (796.2) elevated blood pressure reading without a diagnosis of hypertension. These codes are appropriate if the patient has not yet been diagnosed with diabetes or hypertension. Coding Tip #13 When coding Osteoarthritis (715) the 4 th and 5 th digits are important to determine the subcategory and subclassification of the disease. The 4 th digit will specify if the OA is generalized (0), localized-primary (1), secondary (2) or unspecified (3), not generalized (8), or unspecified as to whether generalized or localized (9). The 5 th digit will determine the body area (s) affected: 0= site unspecified 1= shoulder region 2= upper arm 3= forearm 4= hand 5= pelvic region and thigh 6= lower leg (knee) 7= ankle and foot 8= other specified sites 9= multiple sites Coding Tip #14 There are combination codes that can be used for a patient that have hypertension and another chronic illness. The hypertension codes are in the ICD-9 book under 401-405. These codes should be used if a patient has hypertensive heart disease (402) or hypertensive chronic kidney disease (403), or hypertensive heart and CKD (404) and also secondary hypertension (405). There are 4 th and 5 th digits which clarify the chronic illness as malignant, benign, unspecified and also the stage the illness is in and whether the patient has heart failure or not. Coding Tip #15 When coding for Allergic Rhinitis use the codes from the category 477. There needs to be a 4 th digit with this code to specify if the rhinitis is due to pollen (0), food (1), animal hair or dander (2), other allergen (8) or cause unspecified (9). Do not use code 995.3 Partnership HealthPlan of California Coding Tips 5
since this code is for an allergic reaction or hypersensitivity which is unspecified, such as a localized reaction to a bug bite. Coding Tip #16 When coding BPH-Benign Prostactic Hypertrophy (600.0*) the 5 th digit states whether the patient has LUTS-lower urinary tract symptoms or not. If you use (600.00) then there are no LUTS but if you use (600.01) there is LUTS and an additional code will be needed to specify the symptom for example, urinary frequency (788.41) or urinary retention (788.20). Coding Tip #17 There are some new codes in the category 788, symptoms involving the urinary system. One code is for urinary hesitancy (788.64) and the other for straining on urination (788.65). Also in this section are the codes for urinary incontinence (788.3*) with a 5 th digit of (0) unspecified, (1) urge and (2) stress, male. If the patient has female stress incontinence the code is (625.6). There are codes for urinary frequency (788.41) and many other codes for a multitude of urinary symptoms. Coding Tip #18 According to the ICD-9-CM coding book when coding for overweight and obesity category 278.0 you should use an additional code to identify the BMI-Body Mass Index, if known, from the V codes V85.0-V85.54. The fifth digits in this section are (0) unspecified, (1) morbid, and (2) for overweight. Coding Tip #19 According to the ICD-9-CM coding book when coding hypertensive heart disease and other chronic diseases you should include an additional diagnosis to specify the type of heart failure (428.0-428.43), or any other condition classifiable to (429.0-429.3, 429.8, 429.9) due to hypertension. For patients with hypertensive heart disease and chronic kidney disease use additional code to describe heart failure if known (428.0-428.43) and stage of chronic kidney disease (585.1-585.4, 585.9). Coding Tip #20 When coding contact dermatitis (692.*) the 4 th digit specifies what the dermatitis is due to, such as detergents (0), oils and greases (1), solvents (2), drugs and medicines in contact with the skin (3), other chemical products (4), food in contact with the skin (5), plants [except food] (6), solar radiation (7) if using the 4 th digit of seven you will need a 5 th digit as well, such as unspecified due to sun (0), sunburn (1), due to solar radiation (2), actinic reticuloid and actinic granuloma (3), other chronic dermatitis due to solar radiation (4), disseminated superficial actinic porokeratosis (5), sunburn of second degree (6), sunburn of third degree (7), and other dermatitis due to solar radiation (9). If using 692.8 you will need a 5 th digit to specify the cause such as, cosmetics (1), other Partnership HealthPlan of California Coding Tips 6
radiation (2), metals (3), animal dander (4), other (9). Finally if there is no specific cause use 692.9. Coding Tip #21 There are certain combination codes which encompass two diagnoses and do not need any other diagnosis codes. For example when coding COPD with asthma (493.20) you do not need to code COPD (496) since the combination code includes both. Another example would be diabetes with a manifestation such as (250.40) diabetes with a renal manifestation, you would not need to code diabetes (250.00) but you would need to code the manifestation. Last example is late effects of a CVA (438.**) just code the late effect, it is not necessary to also code (436) CVA. Coding Tip #22 When coding Diabetes the 4 th and 5 th digits are very important. The 4 th digit specifies if there are any manifestations/complications of the Diabetes and the 5 th digit specifies whether or not the Diabetes is Type I or Type II and whether it is uncontrolled or not stated as uncontrolled. A common error is to use the 5 th digit of (1) for a patient who is an insulin dependent Type II diabetic. The 5 th digit of (1) indicates the patient is a Type I (juvenile type diabetic) who is insulin dependent. The 5 th digits are as follows: 0 type II or unspecified type, not stated as uncontrolled-even if patient is insulin dependent 1 type I (juvenile type), not stated as uncontrolled 2 type II or unspecified type, uncontrolled-even if patient is insulin dependent 3 type I (juvenile type), uncontrolled The 4 th digit is important as well and they are as follows: 0 diabetes without mention of complication 1 diabetes with ketoacidosis 2 diabetes with hyperosmolarity 3 diabetes with other coma 4 diabetes with renal manifestation-use additional code for manifestation 5 diabetes with ophthalmic manifestation-use additional code for manifestation 6 diabetes with neurological manifestation-use additional code for manifestation 7 diabetes with peripheral circulatory disorders-use additional code for manifestation 8 diabetes with other specified manifestation-use additional code for manifestation 9 diabetes with unspecified complication Partnership HealthPlan of California Coding Tips 7
Coding Tip #23 When coding disorders of lipoid metabolism category 272 the 4 th digit is necessary to specify the type of disorder, such as, hypercholesterolemia (0), hyperglyceridemia (1), mixed hyperlipidemia (2), hyperchlyomicronemia (3), unspecified hyperlipidemia (4), lipoprotein deficiencies (5), lipodystrophy (6), lipidoses (7), other disorder of lipoid metabolism (8), unspecified disorder of lipoid metabolism (9). Coding Tip #24 There are some codes from the Ischemic Heart Disease Section (410-414) of ICD-9 that you may not be aware of, for example: Angina, unstable (preinfarction) (411.1) this code is also used for ACS-acute coronary syndrome, Old Myocardial Infarction (412), Angina Decubitus (413.0), Angina Pectoris (413.9), CAD/ASHD (414.0*) the fifth digit specifies where but if unknown use (0), Chronic Ischemic Heart Disease (414.9). The codes that begin with (410) Acute Myocardial Infarction need a 4 th digit to describe where it occurred and a 5 th digit to describe the episode of care-unspecified (0), initial episode (1), subsequent episode (2). Coding Tip #25 When coding from the Chronic Ulcer of the Skin Section (707) the 4 th digit of (0) is for decubitus ulcers and the 5 th digit denotes the site such as; unspecified site (0), elbow (1), upper back (2), lower back (3), hip (4), buttock (5), ankle (6), heel (7), and other site (9). If the 4 th digit is (1) this is for ulcer of lower limbs, except decubitus and the 5 th digits would be as follows; lower limb unspecified (0), thigh (1), calf (2), ankle (3), heel and midfoot (4), other part of foot (5), and other part of lower limb (9). Coding Tip #26 When coding diabetes with a manifestation an additional code is needed for the manifestation here are the top ten manifestations based on frequency of use; Renal manifestations 250.4* Chronic Kidney Disease-585.1-585.9 Nephropathy-583.81 Nephrosis-581.81 Proteinuria-791.0 Ophthalmic manifestations 250.5* Retinopathy-362.01-362.07 Partnership HealthPlan of California Coding Tips 8
Neurological manifestations 250.6* Peripheral neuropathy-337.1 Polyneuropathy-357.2 Gastroparesis-536.3 Peripheral circulatory disorders 250.7* Gangrene-785.4 Peripheral angiopathy-443.81 Please do not use the diabetes with unspecified manifestation (250.9*) unless the manifestation cannot be found in any of the other diabetes codes. Be sure if you use this particular code that there is a manifestation associated with diabetes coded on the same claim. There are additional codes in each category that are not listed here. The most important thing is that the manifestation code is used with the diabetes code. Coding Tip #27 Unspecified codes should be used when there is no specific code available or the specific diagnosis is not known at the time of the visit. For instance: If insomnia (780.52) is the diagnosis do not use unspecified sleep disorder (780.50) since insomnia has its own code. If a patient has a late effect of a CVA (438.**) don t use 436 (CVA). Use the codes from the 438 series and if needed an additional code for the late effect. If a migraine (346.90) is documented don t use the code for a headache (784.0). If a patient has abdominal pain (789.0*) the fifth digit will describe where the site of the pain is: (0) Unspecified (1) Right upper quadrant (2) Left upper quadrant (3) Right lower quadrant (4) Left lower quadrant (5) Periumbilic (6) Epigastric (7) Generalized (9) Other specified site Partnership HealthPlan of California Coding Tips 9
Coding Tip #28 Sections 424 (diseases of the endocardium) and 425 (cardiomyopathy) of the ICD9-CM book contain codes that are sometimes overlooked. Here are some of the most common codes from these two sections: 424.0- mitral valve disorders 424.1- aortic valve disorders 424.2- tricuspid valve disorders 424.3- pulmonary valve disorders 424.90- endocarditis, valve unspecified 424.91- endocarditis in diseases classified elsewhere (code underlying disease first) 425.0- endomyocardial fibrosis 425.1- hypertrophic obstructive cardiomyopathy 425.4- other primary cardiomyopathies 425.5- alcoholic cardiomyopathy 425.9- secondary cardiomyopathy, unspecified Coding Tip #29 Proper documentation is vital to coding correctly and to the highest specificity. If it isn t documented it didn t happen. During an audit the auditor will only look at the documentation for the date of service on the claim and if there are discrepancies between diagnoses on the claim and what is documented in the medical record that will be counted as an error. Diagnosis coding is the wave of the future and will determine the HCC score of each individual patient and in turn affect payment. Coding Tip #30 There are some new ICD9-CM codes for 2009 and the next few coding tips will highlight these. For example, the code for a fever (780.6) now requires a fifth digit; the additional digit will cover a broader range of temperature regulation disturbances. If the fifth digit is: (0) fever, unspecified (1) fever presenting with conditions classified elsewhere-code underlying condition first (2) postprocedural fever (3) postvaccination fever (4) chills (without fever) (5) hypothermia not associated with low temperature (environmental) Partnership HealthPlan of California Coding Tips 10
Coding Tip #31 Section 249 of the ICD-9-CM book is new codes for secondary diabetes mellitus. The fourth digits are the same as for the codes in section 250 the difference with the secondary diabetes codes are the fifth digits; there are only two of them, and the definition. Secondary diabetes includes diabetes mellitus (due to), (in), (secondary), (with): drug - induced or chemical induced infection The fifth digit: (0) not stated as uncontrolled, or unspecified (1) uncontrolled 249.0 Secondary diabetes mellitus w/o mention of complication 249.1 Secondary diabetes mellitus with ketoacidosis 249.2 Secondary diabetes mellitus with hyperosmolarity 249.3 Secondary diabetes mellitus with other coma 249.4 Secondary diabetes mellitus with renal manifestations 249.5 Secondary diabetes mellitus with ophthalmic manifestations 249.6 Secondary diabetes mellitus with neurological manifestations 249.7 Secondary diabetes mellitus with peripheral circulatory disorders 249.8 Secondary diabetes mellitus with other specified manifestations 249.9 Secondary diabetes mellitus with unspecified complication Coding Tip #32 Category (274) gout had some new codes added in the 2010 ICD-9 book, here they are: 274.00 gout arthropathy 274.01 Acute gouty arthritis 274.02 Chronic gouty arthropathy w/o tophus (tophi) 274.03 Chronic gouty arthropathy w/tophus (tophi) Coding Tip #33 In the 2010 ICD-9 book there were a few new categories added: (453.5*) Chronic Venous Embolism and thrombosis of deep vessels, lower extremity 453.50 Chr. Venous embolism and thrombosis of unsp deep vessels 453.51 Chr. Venous embolism and thrombosis of unsp deep vessels, of proximal 453.52 Chr. Venous embolism and thrombosis of unsp deep vessels, distal 453.6 venous embolism and thrombosis of superficial vessels of lower extremity Partnership HealthPlan of California Coding Tips 11
(453.7*) Chr. Venous embolism and thrombosis of other specified vessels 453.71 Chr. Venous embolism and thrombosis of of superficial veins of upper extremity 453.72 Chr. Venous embolism and thrombosis of unsp deep veins of upper extremity 453.73 Chr. Venous embolism and thrombosis of upper extremity, unsp 453.74 Chr. Venous embolism and thrombosis of axillary veins 453.75 Chr. Venous embolism and thrombosis of subclavian veins 453.76 Chr. Venous embolism and thrombosis of internal jugular veins 453.77 Chr. Venous embolism and thrombosis of other thoracic veins 453.79 Chr. Venous embolism and thrombosis of other specified veins (453.8*) Acute Venous embolism and thrombosis of superficial veins upper extremity 453.81 Acute Venous embolism and thrombosis of superficial veins upper ext 453.82 Acute Venous embolism and thrombosis of deep veins upper extremity 453.83 Acute Venous embolism and thrombosis of upper extremity, unsp 453.84 Acute Venous embolism and thrombosis of axillary veins 453.85 Acute Venous embolism and thrombosis of subclavian veins 453.86 Acute Venous embolism and thrombosis of internal jugular veins 453.87 Acute Venous embolism and thrombosis of other thoracic veins 453.89 Acute Venous embolism and thrombosis of other specified veins Coding Tip #34 There are new influenza codes in the 2011 ICD-9 book they are: 488.01 Infuenza due to identified avian influenza virus w/pneumonia 488.02 Influenza due to identified novel H1N1 influenza virus w/other respiratory manifestations 488.09 Influenza due to identified avian influenza virus w/other manifestation There are also new influenza codes in the 2012 ICD-9 book they are: 488.81 Influenza due to identified novel influenza A virus w/pneumonia 488.82 Influenza due to identified novel influenza A virus w/other respiratory manifestations 488.89 Influenza due to identified novel influenza A virus w/other manifestations Partnership HealthPlan of California Coding Tips 12
Coding Tip #35 There are some new codes for category (784.4) Voice and resonance disorders in the 2010 ICD-9 book. Also some changes were made to the definitions for a few existing codes. 784.40 (change) voice and resonance disorder, unspecified 784.41 (same) aphonia (loss of voice) 784.42 (new) dysphonia (hoarseness) 784.43 (new) hypernasality 784.44 (new) hyponasality 784.49 (change) other voice and resonance disorders (change in voice) Also category (784.5) other speech disturbance 784.51 (new) dysarthria 784.59 (new) other speech disturbance (dysphasia, slurred speech) Coding Tip #36 In the 2010 ICD-9 book there are some new codes for category (969) Poisoning by psychotropic agents. They are as follows: 969.00 antidepressant, unspecified 969.01 monoamine oxidase inhibitors (MAOI) 969.02 selective serotonin and norepinephrine reuptake inhibitors (SSNRI) 969.03 selective serotonin reuptake inhibitors (SSRI) 969.04 tetracyclic antidepressants 969.05 tricyclic antidepressants 969.09 other antidepressants Also category (969.7*) poisoning by psychostimulants 969.70 psychostimulant unspecified 969.71 caffeine 969.72 amphetamines (methamphetamines) 969.73 methylphenidate 969.79 other psychostimulants Partnership HealthPlan of California Coding Tips 13
Coding Tip #37 When using a V-code it is vitally important to refer to the tabular list in the ICD-9-CM book to check if the diagnosis is a primary (highlighted in green) or a secondary (highlighted in purple) code. If the diagnosis is primary, it must appear in the diagnosis list in the first position only and consequently if it is a secondary diagnosis it cannot be listed in the first position. Some examples of primary and secondary only codes are as follows: Primary DX only V20.0-V20.32 V22.0 and V22.1 V24.0-V24.2 V26.81 V30.**-V39.** V56.0 V57.0-V57.9 V58.11 and V58.12 V59.0-V59.9 V70.0-V70.9 V71.0*-V71.9 Secondary DX only V14.0-V14.9 V15.01-V15.89 V21.0-V21.9 V22.2 V26.51 and V26.52 V27.0-V27.9 V42.0-V42.9 V43.0 and V43.1 V43.21 V43.3-V43.5 V43.6-V43.69 V43.7 V43.8-V43.89 V44.0-V44.9 V45.00-V45.69 V45.61 and V45.69 V45.81-V45.89 V58.61-V58.69 V62.21-V62.29 V62.3-V62.9 V64.00-V64.43 V85.0 and V85.1 V85.21-V85.54 These are not all but some of the most commonly used V-codes that need to be primary or secondary diagnoses only. Partnership HealthPlan of California Coding Tips 14
Coding Tip #38 In the 2011 ICD 9 book there are some new codes for Aortic ectasia (447.7*), they are as follows: 447.70 aortic ectasia, unspecified site 447.71 thoracic aortic ectasia 447.72 abdominal aortic ectasia 447.73 thoracoabdominal aortic ectasia Coding Tip #39 In the 2011 ICD 9 book there are some new codes for Incontinence of feces (787.6*), they are as follows: 787.60 full incontinence of feces 787.61incomplete defecation 787.62 fecal smearing 787.63 fecal urgency Coding Tip #40 In the 2011 ICD 9 book there are some new codes for Signs and symptoms involving cognition (799.5*), they are as follows: 799.51 Attention or concentration deficit 799.52 cognitive communication deficit 799.53 visuospatial deficit 799.54 psychomotor deficit 799.55 frontal lobe and executive function deficit 799.59 other signs and symptoms involving cognition Partnership HealthPlan of California Coding Tips 15