Documentation & Coding Tools

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Chronic Kidney Disease Reporting ICD-9-CM coding for Chronic Renal Failure, Category 585, changed in 2006. The Renal Physicians Foundation along with the National Kidney Foundation promoted code Category 585 being renamed and expanded to reflect the new clinical practice standards for treating Chronic Kidney Disease. (CKD) Chronic Kidney Disease is defined as either: 1 2 Kidney damage - pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. OR GFR (Glomerular Filtration Rate) < than 60 ml/min/1.73m for > than 3 months. The new code assignments, describe the different stages in the progression of Chronic Kidney Disease. The new staging system is based on estimates of the glomerular filtration rate at each stage, with each stage defined by level of kidney function. Higher stages represent lower GFR levels. 585.1 Chronic Kidney Disease, Stage I Glomerular Filtration Rate (GFR) 90mL/min or more Healthy kidneys or kidney damage with normal or high GFR Plenty of Kidney function but may have protein or albumin in their urine. 585.2 Chronic Kidney Disease, Stage II Mild Glomerular Filtration Rate (GFR) 60-89mL/min Kidney damage and mild decrease in GFR 585.3 Chronic Kidney Disease, Stage III Moderate Glomerular Filtration Rate (GFR) 30-59 ml/min Moderate decrease in GFR 585.4 Chronic Kidney Disease, Stage IV Severe Glomerular Filtration Rate (GFR) 15-29 ml/min Severe decrease in GFR Chronic Kidney Disease Stages 585.5 Chronic Kidney Disease, Stage V Glomerular Filtration Rate (GFR) less than 15 ml/min or on dialysis Kidney Failure Append V45.1 if appropriate 585.6 End Stage Renal Disease End-stage renal disease (ESRD) is an administrative term in the United States, based on the conditions for payment for health care by Medicare ESRD Program. ESRD includes patients treated by dialysis or transplantation, irrespective of the level of GFR. Dialysis Status Append V45.1 if appropriate 585.9 Chronic Kidney Disease, Unspecified Includes: Chronic Renal Disease, Chronic Renal Failure NOS, and Chronic Renal Insufficiency ICD-9-CM instructs the coder to use an additional code to identify Kidney Transplant Status if applicable (V42.0). A kidney transplant may not fully restore kidney function, therefore, patients who have undergone a kidney transplant may still have some form of Chronic Kidney Disease. Code V42.0, Kidney replaced by transplant, may be assigned with the appropriate CKD code, based on the patient s post-transplant stage. Patients that have had a kidney transplant where documentation indicates the presence of failure or rejection, assign code 996.81 Complication of kidney transplant followed by the appropriate CKD code. http://kidneynotes.blogspot.com/2005/10/chronic-renal-failure-is-no-more-new.html Sources: Renal Physicians Foundation, National Kidney Foundation K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification In addition, for Stage V and ESRD, use code V45.1, if appropriate. Diagnosis Coding and Documentation Patient: Jane Doe Date of Service: 10/30/06 Reason for visit: S: Voices no complaint except that she wishes she could visit her sister, who is hospitalized. States she is able to get around, including bathroom and cafeteria, without difficulty. Denies any pain or shortness of breath. No change in bowel or bladder habits. O: Patient alert, oriented to person, disoriented to place and time. No acute distress. Cardiac: RRR no rubs, gallops or murmurs noted Lungs CTA bilat. No cough or wheezing noted. Abd soft non tender to palpitation with Colostomy intact, skin dry and intact surrounding pink-red stoma, liquid brown feces. Diminished sensation LE bilaterally, skin cool with rubor. Old incision for L great toe amputation dry and intact. Able to ambulate to toilet and cafeteria with walker. A: 250.70 Diabetes with peripheral circulatory disorders, currently controlled; with 443.81 peripheral vascular disease due to diabetes; and 250.60 diabetes with neurologic manifestations of 357.2 diabetic polyneuropathy. Finger stick blood sugar ranges 125-175 in past 2 weeks. Diabetes controlled on current regimen a.c. & h.s. insulin; sliding scale insulin if needed. V44.3 Functioning colostomy, no change in plan of care. V49.71 Old amputated L great toe stable. 290.40 Mild senile dementia (see notes October 10, 2006) 733.00 Osteoporosis, unspecified 733.13 Osteoporetic vertebral fractures (see notes September 13, 2006). P: Continue current diet & insulin regimen. Retain sliding scale order for prn with notification parameters. Continue current activity level. Authenticated by: Joseph A. Williams MD Model Progress Note 1 10

9 The Mechanics The of of Chart Documentation Documentation validates that services were provided, ensures continuity of care, supports medical necessity and verifies that services provided are reported with accuracy. Good documentation supports the level of service billed resulting in appropriate reimbursement. * The physician s signature and credentials must be on each chart entry. * The patient name and the date of service must be on each page of the patient chart. * The medical record must be complete and legible. * Only standard medical abbreviations should be used. * Use SOAP format when applicable. * Note all acute and chronic diagnoses with the current status and treatment plans in the progress note. ICD-9-CM Guidelines and Tips * Current year version of ICD-9-CM 2008 must be used for accurate diagnostic coding. * Superbills need to be managed, updated, expanded and revised yearly. * Diagnosis codes must be accurate and specific. If a code offers 5 digits in ICD-9-CM, five digits must be used. Each digit adds specificity. * Avoid unspecified codes.9 unless there is not a more specific code available. * Code both the etiology (underlying disease) and the manifestation of the disease. The underlying disease would be coded first, with the manifestation of the disease in 2 nd place. Example: Kaposi s sarcoma due to HIV 042 (HIV) underlying disease 176.0 Kaposi s sarcoma (manifestation) * When a combination code is offered in ICD-9-CM to classify two diagnoses, it must be used. Example: Malignant Hypertensive Chronic Kidney Disease Chronic Kidney Disease Stage V 403.01 Hypertensive chronic kidney disease, malignant, with ckd stage V or end stage renal disease 585.5 Chronic kidney disease, Stage V Coding Valid 10/01/06 to 10/01/07 Stroke and Late Effects of Prior Stroke One of the most common coding errors seen in chart audit is the assignment of a stroke code in the present tense when the coder is actually trying to code for the residual conditions left behind by a prior stroke. Acute stroke is only coded during the initial episode of care. Cerebrovascular Accidents (Stroke) In a CVA, there is a decreased supply of blood to the brain that can result in an area of infarction (necrotic cerebral tissue). CVA occurs because of thrombosis, embolism, occlusion (code categories 433 or 434) or hemorrhage (Category 430 to 432). There are codes for each type of CVA. The fourth and fifth digits of these codes indicate either with or without infarction. Unless otherwise stated, CVA/stroke is considered an assumed ischemic infarction and is coded 434.91. The fifth digit of 1 indicates infarction. After the Initial Acute Care Episode of Stroke After an initial stroke incident has occurred, generally one of two scenarios will exist. Either the patient will have deficits from the stroke (conditions left behind such as paralysis) or will make a recovery without any long lasting effects. If the patient recovers without any lingering problems related to the stroke, the code would be V12.54 Stroke NOS without residual deficits. If the patient has deficits present after the discharge from the initial acute care episode, all deficits are coded to Late Effects (Category 438). Prior to October 2004, CVA not otherwise specified was coded to Category 436. In the current 2008 ICD-9- CM there is an exclusionary note specifically stating not to use this code for a cerebrovascular accident. Post-Operative Cerebrovascular Hemorrhage or Infarction A post-operative cerebrovascular hemorrhage or infarction that occurs as a result of medical intervention is coded 997.02 Complications affecting specified body systems: Iatrogenic cerebrovascular infarction or hemorrhage. In addition, the specific type of infarction must be coded. The Time Line is Significant Example 1: Stroke initial incident Acute embolic CVA with infarction Example 2: Stroke initial incident; prior stroke with no deficits Acute embolic CVA, prior stroke with no deficits V12.54 Example 3: Stroke initial incident with deficits from prior stroke Acute embolic CVA with infarction; previous CVA with residual dysphagia 438.82 Example 4: Follow-up for evaluation of dysphagia. The dysphagia was due to a stroke. Office visit to evaluate dysphagia from a stroke one month ago 438.82 Example 5: The patient suffered a post-operative stroke; acute embolic CVA with infarction 997.02 2

Correctly Reporting Cancer Diagnoses: Current Cancer vs. History of Cancer To correctly report a diagnosis of cancer, one must determine whether the patient s cancer has been eradicated or is currently being treated. The neoplasm table in the ICD-9-CM code book establishes three categories of malignancy: primary, secondary and in-situ. Neoplasms should be coded to such and unknown sites must also be coded. Current Cancer Patients with cancer who are receiving active treatment for the condition should be reported with the malignant neoplasm code corresponding to the affected site. This applies even when a patient has had cancer surgery, but is still receiving active treatment for the disease. Example: Malignant neoplasm of kidney, 189.0 Secondary Site with an Unknown Primary Site Example: Metastatic carcinoma from lung 162.9 (Primary site lung) + 199.1 (secondary site unknown) Secondary Site with Active Primary Site A patient is admitted with metastatic bone cancer. The patient had a mastectomy 2 months ago and is having radiation treatments for the breast cancer. The neoplasm was located in the upper outer quadrant. Example: Code 198.5 Neoplasm, bone, secondary Code 174.4 Neoplasm, breast, upper outer quadrant History of Cancer Patients with a history of cancer and no evidence of current cancer should be reported as Personal history of malignant neoplasm using a code from the V10 series. These codes require additional digits to identify the type of cancer and should be reported only when there is no evidence of current cancer and a patient s presenting problem, signs, or symptoms may be related to the cancer history or impact the plan of care. These codes should not be reported routinely. Example: Personal history of malignant neoplasm, kidney, V10.52 3 Coding Clinic, 4 th Quarter 2002; Part-B News, Faye Brown s ICD-9-CM Coding Handbook, 2007 Aftercare Following Surgery for Neoplasm Visits to determine the effectiveness of cancer surgery that fall within the global post-operative period should be reported as Aftercare following surgery for neoplasm, code V58.42 and a second aftercare code to fully identify the reason for the encounter. Example: Aftercare following surgery for malignant neoplasm, kidney, V58.42; Aftercare following surgery of the digestive system, V58.75 Follow-up for Patients with History of Cancer Follow up exams to determine if there is any evidence of recurring or metastasizing cancers that result in no evidence of malignancy should be reported as Follow-up exam using a code from the V67 category to identify the most recent therapy carried out. Example: Follow-up exam following chemotherapy, V67.2 Cancer Drugs prescribed for reason other than Malignancy Patients with no history of cancer who take prophylactic cancer drugs should not be reported with an active cancer diagnosis or a personal history of malignant neoplasm. Instead, code the reason for the prescription. Example: Family history of malignant neoplasm, kidney V16.51 References: AHA Coding Clinic, July-August 1985; AHA A Comprehensive Diagnostic Patient Profile The Wave of the Future! Good coding and documentation clearly depicts the level of disease severity, co-morbidities, underlying disease and other factors that contribute to the level of complexity for the patient encounter. Per the ICD-9-CM Official Guidelines and Reporting: Code all documented conditions that coexist at the time of the encounter/visit, and require or effect patient care treatment or management. CMS reimbursement is increasingly leaning toward the principle of illness burden. Diagnosis codes are the criteria used for determining severity of illness, risk and resource utilization. Diagnostic coding influences the level of risk in determining CPT coding assignment. Moderate risk is equivalent to: a) One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment, or b) Two or more chronic stable illnesses High risk relates to: a) One or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or b) Acute or chronic illnesses or injuries that pose a threat to life or body function Status Codes do indicate and contribute to the complexity level of the encounter: Consider these V codes: Renal Dialysis Status V45.1 Tracheostomy Status V44.0 Respirator Dependence V46.XX Lower Limb Amputee V49.7X Artificial Openings for Feeding or Elimination V44.X Major Organ Transplant V42.X and V42.XX Asymptomatic HIV Status V08 The presence of one or more of these conditions would be taken into account by the physician in the decision making process and could effect patient care, treatment and management. Other diagnosis codes that are not often reported, although the patient is being treated for the conditions, are: Protein Calorie Malnutrition 263.X Major Depression 296.XX Drug Dependence & Alcohol Dependence 303.XX and 304.XX History of Heart Attack 412 Good documentation is reflective of the thought process of the physician in treating patients. All conditions effecting the patient should be documented and coded. 8

PATIENT NAME CHART # DATE OF SERVICE BLOOD BLOOD DISEASE DISEASE 285.21 Anemia in Chr Kidney Disease 280.9 Anemia, Iron Deficiency, unspec 285.9 Anemia, NOS 281.0 Anemia, Pernicious 280.0 Anemia, Sec Blood Loss CARDIOVASCULAR/ / CARDIOLOGY CARDIOLOGY 410.91 Acute MI, Initial Episode, NOS 410.92 Acute MI, Sub Episode, NOS 413.0 Angina Decubitus 413.9 Angina Pectoris, NOS 411.1 Angina, Unstable 427.31 Atrial Fibrillation 427.9 Cardiac Dysrhythmia, NOS 425.4 Cardiomyopathies, Primary, NOS 428.0 Congestive Heart Failure 414.2 Occlusion, Coronary Artery, Complete 414.00 Coronary Atherosclerosis, unspec 414.9 Heart Disease Ischemic, Chronic 428.9 Heart Failure, unspec 429.0 Myocarditis, unspec 412 Old MI 427.81 Sick Sinus Syndrome 427.0 Tachycardia, Atrial Parox. 427.1 Tachycardia, Ventric Parox. CEREBROVASCULAR 437.0 Cerebral Atherosclerosis 436 Cerebrovascular Disease, Ill Defined, Acute 434.91 CVA/Stroke (Not for Office Use) 437.1 Ischemic Cerebrovascular Disease 435.9 TIA Late Effects 438.20 Hemiplegia, Side unspec 438.21 Hemiplegia, Dom. Side 438.22 Hemiplegia, Non-dom. Side 438.41 Monoplegia, L-Limb, Dom. Side 438.42 Monoplegia, L-Limb, Non-dom. Side 438.40 Monoplegia, L-Limb, unspec Side 438.31 Monoplegia, U-Limb, Dom. Side 438.32 Monoplegia, U-Limb, Non-dom. Side 438.30 Monoplegia, U-Limb, unspec Side 438.10 Speech / Language Deficits, unspec VASCULAR VASCULAR DISEASES DISEASES 453.40 DVT, NOS 458.0 Hypotension, Orthostatic 440.4 Occlusion, Extr Artery, Total, Chronic 443.9 Peripheral Vascular Disease, NOS 451.11 Phlebitis, Femoral Vein 451.19 Phlebitis, Lower Extr, Deep 454.0 Varicose Lower Extr. w/ulcer 459.81 Venous Insufficiency, Chronic, NOS DERMATOLOGY DERMATOLOGY 706.1 Acne, Other 702.0 Actinic Keratosis 701.9 Atrophoderma 691.8 Dermatitis, Atopic & Eczema 692.9 Dermatitis, NOS 054.9 Herpes Simplex w/o Comp. 053.9 Herpes Zoster w/o Comp. 702.11 Seb Keratosis, Inflamed 702.19 Seb Keratosis, NOS 110.1 Tinea of Nail ENDOCRINOLOGY ENDOCRINOLOGY 259.2 Carcinoid Syndrome 276.51 Dehydration 250.00 DM Type II Controlled 250.01 DM Type I Controlled 250.02 DM Type II Uncontrolled 250.03 DM Type I Uncontrolled (Add 5 th digits 0, 1, 2, or 3 to following DM Codes. Also, Use Additional Code to Identify Manifestations as Exemplified Under Each Code Category) 250.4x DM w/ Renal Manifestation(s) 585.x CKD or Chronic Renal Failure 583.81 Nephritis / Nephropathy 581.81 Nephrotic Syndrome 403.91 Nephropathy w/ HTN & CRF 791.0 Proteinuria 250.5x DM w/ Ophthalmic Manifestation(s) 366.41 Cataracts (Type I Only) 362.01 Diabetic Retinopathy, NOS 365.44 Glaucoma 362.02 Prolif Diabetic Retinopathy 250.6x DM w/ Neurological Manifestation(s) 337.1 Autonomic (Peripheral) Neuropathy 536.3 Gastroparesis 607.84 Impotence 7SENIOR SENIOR PATIENT PATIENT 2008 2008 713.5 Neurogenic / Neuropathic Arthropathy. 357.2 Polyneuropathy in DM / Neuritis 707.1x Ulcers of Lower Limbs, Except Decubitus 250.7x DM w/ Peripheral Circulatory Disease 785.4 Gangrene 607.84 Impotence 443.81 Peripheral Angiopathy 707.1x Ulcers of Lower Limbs, Except Decubitus 250.8x DM w/ Other Chronic Manifestation(s) 731.8 Osteomyelitis (Also, Append the Appropriate Code from Category 730, Osteomyelitis, Periostitis, and Other Infections Involving Bone). (Ulcers: Assign to 250.8 when Ulcers are not due to Neuropathy or PVD) 272.0 Hypercholesterolemia 272.2 Hyperlipidemia, Mixed 252.00 Hyperparathyroidism, Unspec 276.7 Hyperpotassemia 242.90 Hyperthyroidism w/o Crisis 272.1 Hypertriglyceridemia 257.2 Hypogonadism, Testicular 276.1 Hyponatremia 276.8 Hypopotassemia 244.0 Hypothyroidism, Postsurgical 244.9 Hypothyroidism, unspec 278.01 Obesity, Morbid 278.00 Obesity, unspec 263.9 Protein-Calorie Malnutrition GASTROENTEROLOGY 789.06 Abdominal Pain, Epigastric 789.07 Abdominal Pain, General 789.04 Abdominal Pain, Left Lower 789.02 Abdominal Pain, Left Upper 789.03 Abdominal Pain, Right Lower 789.01 Abdominal Pain, Right Upper 574.20 Cholelithiasis w/o Obstruction 571.2 Cirrhosis, Alcoholic 571.5 Cirrhosis, Non-Alcoholic, Liver 564.00 Constipation, unspec 555.9 Crohn s Disease, NOS 562.11 Diverticulitis, Colon w/o Hem. 562.10 Diverticulosis, Colon w/o Hem. 536.8 Dyspepsia 560.39 Fecal Impaction 558.9 Gastroenteritis, Noninfectious 530.81 Gastroesophageal Reflux 569.3 Hemorrhage, Rectum / Anus 455.6 Hemorrhoids, NOS 571.1 Hepatitis, Alcoholic Acute 571.40 Hepatitis Chronic, unspec 070.9 Hepatitis, Viral, NOS 564.1 Irritable Bowel Syndrome 578.1 Melena 577.0 Pancreatitis, Acute 556.9 Ulcerative Colitis, unspec GENITOURINARY DISEASE 592.0 Calculus of Kidney 592.1 Calculus of Ureter Note: For CKD Below, Code First Hypertensive Chronic Kidney Disease if Applicable, (403.00-403.91, 404.00-404.93) 585.1 Chronic Kidney Disease, Stage I 585.2 Chronic Kidney Disease, Stage II 585.3 Chronic Kidney Disease, Stage III 585.4 Chronic Kidney Disease, Stage IV 585.5 Chronic Kidney Disease, Stage V 585.6 End Stage Renal Disease 585.9 Chronic Kidney Disease, unspec 595.0 Cystitis, Acute 599.7 Hematuria 593.9 Renal Disease, NOS 584.9 Renal Failure Acute, unspec 597.80 Urethritis, unspec 599.0 Urinary Tract Infection, unspec GU GU DISORDERS / / FEMALE 795.04 Abn. Pap Smear w/ HGSIL 795.03 Abn. Pap Smear w/ LGSIL 795.08 Abn. Pap Smear, Unsatisfactory 611.72 Breast Lump / Mass 112.1 Candidiasis, Vulva & Vagina 616.0 Cervicitis 627.2 Menopausal Symptoms 620.2 Ovarian Cyst, NOS 616.10 Vaginitis, NOS GU DISORDERS GU DISORDERS / MALE / MALE 600.01 BPH w/ Obstruction Use additional code to identify the symptom(s) 600.00 BPH w/o Obstruction 604.90 Epididymitis / Orchitis, unspec 607.84 Impotence, Organic Origin 602.9 Prostatosis HYPERTENSIVE DISEASE DISEASE (Heart Failure Identify Type of Failure; CKD Identify Stage of Disease) 401.1 Hypertension Essential, Benign 401.0 Hypertensive Essential, Malignant 401.9 Hypertension, unspec 403.90 Hypertensive CKD, w/ CKD Stage I-IV, or unspec 403.91 Hypertensive CKD w/ CKD Stage V, or ESRD, or unspec 404.91 Hypertensive Heart & CKD w/ Heart Failure & CKD Stage I-IV, unspec 404.93 Hypertensive Heart & CKD w/ Heart Failure & CKD Stage V, or ESRD, or unspec 404.90 Hypertensive Heart & CKD, w/o Heart Failure w/ CKD Stage I-IV, unspec 404.92 Hypertensive Heart & CKD, w/o Heart Failure, w/ CKD Stage V, or ESRD, or unspec 402.91 Hypertensive Heart Disease w/ Heart Failure, unspec (Use Additional Code with 402.91 to Identify the Heart Failure) 402.90 Hypertensive Heart Disease w/o Heart Failure, unspec INFECTIOUS INFECTIOUS DISEASE DISEASE 682.6 Cellulitis, Leg 682.9 Cellulitis, NOS 042 HIV V08 HIV, Asymptomatic 795.5 PPD Positive 079.99 Viral Infection, NOS MUSCULOSKELETAL 714.0 Arthritis, Rheumatoid 726.5 Bursitis, Hip 726.60 Bursitis Knee, NOS 726.10 Bursitis Shoulder, NOS 723.4 Cervical Radiculitis 717.7 Chondromalacia Patella 924.20 Contusion, Foot 923.20 Contusion, Hand 920 Contusion, Head 924.11 Contusion, Knee 924.10 Contusion, Lower Leg 923.00 Contusion, Shoulder 722.4 DDD Cervical 722.52 DDD Lumbar / Lumbosacral 722.10 Displacement, Lumbar Disc 812.20 FX Arm Upper, NOS, Closed 821.00 FX Femur, unspec, Closed 816.00 FX Finger(s), unspec, Closed 820.8 FX, Hip, NOS, Closed 826.0 FX Toe(s), Closed 733.13 FX Vertebrae, Pathologic 814.00 FX Wrist, NOS, Closed 274.0 Gouty arthropathy 719.40 Joint Pain, unspec 724.2 Low Back Pain 724.4 Lumbosacral Neuritis 729.1 Myalgia / Myositis, NOS 715.97 Osteoarthrosis, Ankle & Foot 715.94 Osteoarthrosis, Hand 715.96 Osteoarthrosis, Lower Leg 715.90 Osteoarthrosis, NOS, unspec 715.91 Osteoarthrosis, Shoulder 733.00 Osteoporosis, unspec 729.5 Pain in Limb 728.71 Plantar Fasciitis 725 Polymyalgia Rheumatica 845.00 Sprain / Strain Ankle 845.10 Sprain / Strain Foot 842.10 Sprain / Strain Hand 843.9 Sprain / Strain / Hip 844.9 Sprain / Strain Knee & Leg 847.2 Sprain / Strain Lumbar 847.0 Sprain / Strain Neck 840.9 Sprain / Strain Shoulder 842.00 Sprain / Strain Wrist 726.32 Tendonitis, Elbow 726.90 Tendonitis, NOS 727.00 Tenonsynovitis, NOS 733.6 Tietze s Disease NEUROLOGY NEUROLOGY 331.0 Alzheimer s Disease Use Additional Code, where Applicable, to Identify: w/ Behavioral Disturbance (294.11), w/o Behavioral Disturbance (294.10) 354.0 Carpal Tunnel Syndrome 345.90 Epilepsy, unspec 346.10 Headache, Migraine 332.0 Parkinson s Disease 356.9 Peripheral Neuropathy, unspec 199.0 Malig Neo Disseminated 185 Malig Neo Prostate 199.1 Malig Neo w/o Spec Site OPHTHALMOLOGY OPHTHALMOLOGY 366.9 Cataract, unspec 372.00 Conjunctivitis, Acute, unspec 372.14 Conjunctivitis, Allergic 930.9 FB Eye External, NOS OTOLARYNGOLOGY OTOLARYNGOLOGY 380.4 Cerumen Impacted 381.81 Eustachian Tube Dysfunction 380.10 Otitis Externa, Infective 381.01 Otitis Media, Serous, Acute 381.10 Otitis Media, Serous, Chronic 382.00 Otitis Media, Suppurative, Acute 462 Pharyngitis, Acute 461.0 Sinusitis Acute, Maxillary 473.9 Sinusitis Chronic, NOS PSYCHIATRY PSYCHIATRY 303.90 Alcoholism, Chronic 300.00 Anxiety State, unspec 311 Depressive Disorder, NEC 304.90 Drug Dependence, unspec 300.4 Dysthmic Disorder 296.20 Major Depressive disorder, Single episode, unspec 296.30 Major Depressive disorder, Recur episode, unspec 296.90 Mood Disorder, episodic, unspec 294.8 Organic Brain Syndrome PULMONARY PULMONARY 415.0 Cor Pulmonale, Acute 415.19 Pulm Embol / Infarct, Other 416.9 Pulm Heart Disease Chronic, unspec RESPIRATORY RESPIRATORY 493.90 Asthma, unspec 493.92 Asthma, unspec, w/ Acute Exacerbation 466.0 Bronchitis, Acute 491.9 Bronchitis, Chronic, unspec 496 COPD 492.8 Emphysema, NOS 486 Pneumonia, unspec 477.0 Rhinitis, Allergic, Pollen 472.0 Rhinitis, Chronic 461.0 Sinusitis, Maxillary, Acute 465.9 URI, Acute, NOS SIGNS SIGNS & SYMPTOMS & SYMPTOMS 786.50 Chest Pain, unspec 786.2 Cough 787.91 Diarrhea, NOS 780.4 Dizziness and Giddiness 787.20 Dysphagia, unspec 786.00 Dyspnea, unspec 782.3 Edema 796.2 Elevated BP w/o Hypertension 785.6 Enlargement Lymph Nodes 780.6 Fever 785.4 Gangrene 784.0 Headache 786.01 Hyperventilation 780.51 Insomnia w/ Sleep Apnea 780.52 Insomnia, unspec 780.79 Malaise and Fatigue, Other 787.01 Nausea and Vomiting 785.1 Palpitations 780.39 Seizures, NOS 782.0 Skin Sensation Disturbance 780.2 Syncope and Collapse 788.30 Urinary Incontinence, unspec 783.21 Weight Loss Abnormal 786.07 Wheezing V CODES V CODES V49.70 Amputation, Lower Limb, unspec V67.9 Follow-up Exam, unspec V67.00 Post-Op Exam V72.84 Pre-Op Exam V45.1 Renal Dialysis Status V76.2 Screen Mal Neo, Cervix V76.49 Screen Mal Neo, NOS V76.47 Screen Mal Neo, Vagina V74.5 Screen Venereal Disease V44.3 Status Colostomy V58.32 Suture Removal OTHER DIAGNOSIS ONCOLOGY ONCOLOGY 198.5 Malig Neo Bone, Secondary COMMENTS 174.1 Malig Neo Breast, Central 174.9 Malig Neo Breast, unspec 162.9 Malig Neo Bronchus / Lung 153.6 Malig Neo Colon Ascending 153.2 Malig Neo Colon Descending 153.1 Malig Neo Colon Transverse Codes Valid 10/01/2007 to 10/01/2008 Coding Revision 10/01/07 In order to improve the reporting of malnutrition among the elderly, it is important for physicians to document the condition in the medical record and for coders to be aware of malnutrition as a potential diagnosis. Code Categories 262 and 263. The most severe malnutrition problems are associated with Protein Calorie Malnutrition (PCM), also known as Protein Energy Malnutrition (PEM), which occurs in both chronic and acute forms. Subjective Global Assessment (SGA) for PEM includes 6 clinical parameters, followed by a personal judgement as to whether the patient has (A) no malnutrition, (B) possible or mild malnutrition, or (C) significant malnutrition. 1. unremitting, involuntary weight loss that is greater than 10% in the previous months, and especially in the last few weeks 2. Food intake is severely curtailed 3. Muscle wasting and fat loss, with attention to the presence of edema, or ascites present on physical examination 4. Persistent, essentially daily gastrointestinal symptoms such as anorexia, nausea, vomiting, or diarrhea in the previous 2 weeks 5. Marked reduction in physical capacity 6. Presence of metabolic stress due to trauma, inflammation or infection *Any combination of these conditions (especially the first 3) indicates that the patient has significant PEM. Protein-Calorie Malnutrition Other standards are used and accepted as indicators of Protein Calorie Malnutrition: Body Weight as a value relative to the established norms in the general population; Body Mass Index (BMI) which can define Protein Calorie Malnutrition as well as Obesity; and a General Weight Loss Standard. The overall opinion is that no gold standard for the assessment of nutritional status exists. Protein-calorie malnutrition may accompany illnesses such as: Cancer Pancreatitis Alcohol Abuse and/or Dependence Liver Disease Chronic Kidney Disease Drug Abuse and/or Dependence Obesity (Post Bariatric Surgery) ESRD Alcoholic Hepatitis Cirrhosis Celiac Disease Cystic Fibrosis Anemia Depression References: CMAJ Nov 13, 2001 Clinical Nutrition: 1. Energy Malnutrition in the inpatient 4

5 Does at least one (1) of the following apply? Depressed mood most of the day, nearly everyday, as indicated by either subjective report (e.g., feels sad or empty) or observation made by other (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). Do at least four (4) of the following apply? Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gain. Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely selfreproach or guilt about being sick). Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. YES YES YES Diagnosis of Major Depression may be assigned. DETERMINING MAJOR DEPRESSION Do all of the following apply? The symptoms do not meet criteria for Mixed Episode (i.e., Major Depression and Mania). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of concern. The symptoms are not due to the direct physiological effects of a substance. The symptoms are not better accounted for by bereavement. The patient has had symptoms present for the same two week period. NO NO NO Does not meet diagnosis criteria for Major Depression. Does not meet diagnosis criteria for Major Depression. Does not meet diagnosis criteria for Major Depression. ICD-9 Diagnosis 296.2x Major Depression, Single Episode or 296.3x Major Depression, Recurrent Source: DSM-IV, 4 th Edition Sharp HealthCare Corporate Compliance 12/06 Diabetes Mellitus Diagnoses Codes and Associated Manifestations Diabetes Mellitus Diagnoses Codes and Associated Manifestations Fifth-digit subclassifications for use with category 250: Fifth-digit subclassifications for use with category 250: 0 Type 0II Type (NIDDM), II (NIDDM),Unspec type, not stated as as uncontrolled 1 Type 1I (IDDM), Type I (IDDM), not not stated stated as as uncontrolled 2 Type II (NIDDM),unspecified type, uncontrolled (adult-onset diabetic patients, 2 Type II (NIDDM), unspecified uncontrolled (adult-onset diabetic patients, even if patient requires insulin) (even if patient requires insulin) 3 Type 3I (IDDM), Type I (IDDM), uncontrolled uncontrolled Write the number (fifth digit) on the space provided Write the number (fifth digit) in the space provided 250.0 250.1 250.2 250.3 250.4 DM without mention of Complication Diabetes with Ketoacidosis 250.6 Diabetes with Neurological Manifestations Indicate fifth digit subclassification (0,1,2,3) Diabetes with Hyperosmolarity Diabetes with Other Coma Use additional code to identify manifestations: 337.1 Peripheral autonomic neuropathy in disorders classified elsewhere Diabetes with Renal Manifestations 354.0 Carpal tunnel syndrome Must specify kidney manifestation 354.1 Other lesion of median nerve 583.81 Nephritis and nephropathy, not spec as acute or 354.2 Lesion of ulnar nerve chronic, in diseases classified elsewhere 354.3 Lesion or radial nerve 581.81 Nephrotic syndrome in disease classified elsewhere 354.4 Causalgia of upper limb 250.5 Diabetes with Ophthalmic Manifestation Indicate fifth digit subclassification (0,1,2,3) Use additional codes to identify manifestations: 354.5 Mononeuritis multiplex 354.8 Other mononeuritis of upper limb 354.9 Mononeuritis of upper limb, unspecified 355.0 Lesion of sciatic nerve 362.01 Background diabetic retinopathy 355.1 Meralgia paresthetica 362.02 Proliferative diabetic retinopathy 355.2 Other lesion of femoral nerve 362.83 Retinal edema 355.3 Lesion of lateral popliteal nerve 365.44 Glaucoma associated with systemic syndromes 355.4 Lesion of medial popliteal nerve 366.41 Diabetic cataract 355.5 Tarsal tunnel syndrome 369.01 Better eye: total impairment; lesser eye: total impairment 355.6 Lesion of plantar nerve 369.02 Better eye: near total impairment; lesser eye: not further specified 355.71 Causalgia of lower limb 369.03 Better eye: near total impairment; lesser eye: total impairment 355.79 Other mononeuritis of lower limb 369.04 Better eye: near-total impairment; lesser eye: near total-impairment 355.8 Mononeuritis of lower limb, unspecified 369.05 Better eye: profound impairment: lesser eye: not further specified 355.9 Mononeuritis of unspecified site 369.06 Better eye: profound impairment; lesser eye: total impairment 357.2 Polyneuropathy in diabetes 369.07 Better eye: profound impairment; lesser eye: near-total impairment 358.1 Myasthenic syndromes in diseases classified elsewhere 369.08 Better eye: profound impairment; lesser eye: profound impairment 713.5 Arthropathy associated with neurological disorders 369.10 Impairment level not further specified 369.11 Better eye: severe impairment; lesser eye: blind, not further specified 369.12 Better eye: severe impairment; lesser eye: total impairment Indicate fifth digit subclassification (0,1,2,3) 369.13 Better eye: severe impairment; lesser eye: near-total impairment Use additional code to identify manifestations: 369.14 Better eye: severe impairment; lesser eye: profound impairment 785.4 Gangrene 369.15 Better eye: moderate impairment; lesser eye: blind, not further specified 443.81 Peripheral angiopathy in diseases classified elsewhere 369.16 Better eye: moderate impairment; lesser eye: total impairment 369.17 Better eye: moderate impairment; lesser eye: near total impairment 369.18 Better eye: moderate impairment; lesser eye: profound impairment Indicate fifth digit subclassification (0,1,2,3) 369.20 Impairment level not further specified Use additional code to identify manifestations: 369.21 Better eye: severe impairment; lesser eye: not further specified 707.10 Ulcer of lower limb, unspecified 369.22 Better eye: severe impairment; lesser eye: severe impairment 707.11 Ulcer of thigh 369.23 Better eye: moderate impairment; lesser eye: not further specified 707.12 Ulcer of calf 369.24 Better eye: moderate impairment; lesser eye: severe impairment 707.13 Ulcer of ankle 369.25 Better eye: moderate impairment; lesser eye: moderate impairment 707.14 Ulcer of heel and midfoot 369.3 Unqualified visual loss, both eyes 707.15 Ulcer of other part of foot 369.4 Legal blindness, as defined in U.S.A. 707.19 Ulcer of other part of lower limb 369.60 Impairment level not further specified 707.8 Chronic ulcer of other specified sites 369.61 One eye: total impairment; other eye: not specified 707.9 Chronic ulcer of unspecified site 369.62 One eye: total impairment; other eye: near normal vision 731.8 Other bone involvement in diseases classified elsewhere 369.63 One eye: total impairment; other eye: normal vision 369.64 One eye: near-total impairment; other eye: not specified 250.9 Diabetes with Unspecified Complications 369.65 One eye: near-total impairment; other eye: near normal vision Indicate fifth digit subclassification (0,1,2,3) 369.66 One eye: near-total impairment; other eye: normal vision 369.67 One eye: profound impairment; other eye: not specified 648.00 Diabetes Mellitus in Pregnancy, 369.68 One eye: profound impairment; other eye: near normal vision Unspec. Episode of care or N/A 369.69 One eye: profound impairment; other eye: normal vision 369.70 Impairment level not further specified 648.03 Diabetes Mellitus in Pregnancy, 369.71 One eye: severe impairment; other eye: not specified Antepartum condition or complication 369.72 One eye: severe impairment; other eye: near-normal vision 276.52 Hypovolemia 369.73 One eye: severe impairment; other eye: normal vision 359.2 Myotonic Disorders 369.74 One eye: moderate impairment; other eye, not specified 244.3 P-Amniosalicylic Acid (pas) 369.75 One eye: moderate impairment; other eye, near normal vision 657.03 Polyhdramnios 369.76 One eye: moderate impairment; other eye; normal vision 642.43 Pre-Eclampsia 250.7 Diabetes with Peripheral circulatory disorders 250.8 Diabetes with Other Specified Manifestations 369.8 Unqualified visual loss, one eye In addition report code from category 250 to indicate type of diabetes involved 369.9 Unspecified visual loss **PLEASE NOTE THIS IS NOT AN INCLUSIVE MANIFESTATION LIST** 6