ICD-9-CM Volumes 1 and 2 Diagnosis Coding for Outpatient Facilities. Chapter 4. Chapter Outline

Transcription

1 ICD-9-CM Volumes 1 and 2 Diagnosis Coding for Outpatient Facilities Chapter 4 1 Introduce students to Chapter Outline 1. Medical terms associated with ICD-9-CM coding 2. Format of ICD-9-CM code book 3. Coding conventions 4. Basic guidelines for coding certain conditions 2 1

2 Medical Terms Ancillary Services-Diagnostic and therapeutic procedures performed primarily by other trained medical personnel who assist the attending physician in the diagnosis and treatment of the patient. Physicians may also provide these services Diagnosis-Refers to the identification and/or recognition of a disease, condition or medical status, pertaining to a patient Medical Necessity-Refers to services and/or items that are reasonable and necessary for the diagnosis and /or treatment of an illness or injury, or to improve the function of a deformed member of the body (CMS national policy definition) Neoplasm-Abnormal tissue that grows by cellular proliferation more rapidly than normal tissue and continues to grow after the stimuli that initiated the new growth ceases Primary Diagnosis-ICD-9-CM code providing the primary reason for the care provided to the patient. The primary diagnosis is the first diagnosis listed on the insurance claim form 3 Locating Codes In ICD-9-CM ICD-9-CM is published in three (3) volumes Volume 1 Tabular List: Diagnosis Volume 2 Alphabetic Index: Alphabetic Index to Diseases (Diagnosis) Volume 3 Alphabetic Index and Tabular List: Procedures Main terms in the Alphabetic Index Usually reference the disease, condition, or symptom Subterms modify the main term describing differences in Site, etiology or clinical type Subterms add further modification to the main term To reduces the risk of error Always verify the codes in Volume 1 (Tabular List) ICD-9-CM diagnosis codes explain Why the patient required service These codes required for most insurance carriers 4 2

3 Locating Codes In ICD-9-CM Physicians, freestanding Ambulatory Surgery Centers (ASCs), hospitals, and other facilities Use Volume 1 and 2 to assign diagnosis codes Volume 3 includes procedure codes Typically used by inpatient hospital facilities Hospitals use volume 3 in the outpatient facility for Tracking purposes only ICD-9-CM/PCS (Procedural Coding System) Historically renewed every 10 years with annual updates published each October 5 Locating Codes In ICD-9-CM ICD-9-CM diagnosis codes Explain why the patient required service Although Medicare does not require ICD-9-CM procedure codes on outpatient claims Many other payers do require them and most facilities record these procedure codes in order to: Avoid preparing a separate bill for secondary payers Archive data on these services 6 3

4 Medical Necessity Establishing medical necessity First step in third-party reimbursement Payers require the following information to determine the need for care Knowledge of the emergent nature or severity of the patient s complaint or condition All the facts regarding signs, symptoms, complaints, or background facts describing the reason for care --- such as required follow-up care These facts must be substantiated by the patient s medical record, and that record must be available to payers on request. Always obtain a signed release from your patient authorizing you to release information to the payer To justify and identify medical necessity of services provided The diagnosis code serves a crucial purpose to describe the patient's condition 7 Medical Necessity 1. List the primary diagnosis, condition, problem, or other reason for the medical service or procedure. 2. Assign the code to the highest level of specificity (fourth or fifth digit specificity, when available). The patient s medical status may also require multiple ICD-9-CM codes to accurately describe the medical condition. 3. If the diagnosis has not been confirmed never code rule out, probable, suspected, or likely as a definitive diagnosis. 4. Code signs and symptoms if a definitive diagnosis is unknown; do not code rule out statements. 5. Be specific in describing the condition, illness, or disease of the patient. 8 4

5 Medical Necessity 6. When appropriate, distinguish between acute and chronic conditions. 7. Identify the acute nature of any emergency situation (eg, coma, loss of consciousness, or hemorrhage). 8. Identify chronic complaints, or secondary diagnoses, only when treatment is provided. 9. Identify how injuries occur by using E codes from the subsection Supplementary Classification of External Causes of Injury and Poisoning (E800 E999). 10. Use V codes, when appropriate. 9 Volume 1: Tabular List Tabular listing of diseases and injuries 17 Chapters The tabular list contains Three digit codes and their titles, called category codes Some three digit codes are very specific and are not subdivided These three digit codes can stand alone to describe the condition being coded Most three-digit categories (rubrics) have been further subdivided The fourth digit provides specificity or more information regarding such things as Each etiology site or manifestation Four digit subcategory codes take precedence over a three digit category codes Fourth and fifth digits Required where indicated They are not optional 10 5

6 Volume 1: Tabular List Supplementary Classification Classification of Factors Influencing Health Status and Contact with Health Services: V01- V91 Classification of External Causes of Injury: E000-E999 Appendices A: Morphology of Neoplasms consists of coded descriptions for morphology C: Classification of drugs by American Hospital Formulary Service List Number and ICD-9-CM Equivalents assists in the coding of adverse effects D: Classification of Industrial Accidents used to provide information about employment injuries E: List of three digit categories contains the three-digit categories and all related sub-categories 11 ICD-9-CM Conventions Category 3-digit code that represents a single condition or disease Rubric Subcategory 4-digit code that provides a higher level of specificity-further defines site, cause, manifestation Subclassification 5-digit code that adds additional information and specificity Conventions [ ] Brackets used to enclose synonyms, alternate wording, or explanatory phrases Code First Underlying Disease used in categories not intended to be the principal diagnosis NEC Not Elsewhere Classified NOS Not Otherwise Specified See directs you to a more specific term under which the correct code can be found 12 6

7 Volume 2: Alphabetic Index The alphabetic index is divided into three sections: Index to Diseases Alphabetic Index to Poisoning and External Causes of Adverse Effects of Drugs and Other Chemical Substances (Table of Drugs and Chemicals) Alphabetic Index to External Causes of Injury and Poisoning (E Codes) 13 Unspecified ICD-9-CM Codes An unspecified diagnosis code may be the most appropriate code to report when Documentation lacks detail or Specific type of a condition is unknown at the time of the encounter Generally end with the fifth digit 9 May not clearly identify the medical necessity for a service or procedure 14 7

8 Code First the Underlying Disease or Use an Additional Code Certain conditions have both: Underlying etiology and Multiple system manifestation due to the underlying etiology (cause) For such conditions ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation Wherever such a combination exists, there is instruction to: Use an additional code when referencing the etiology code and Code first instruction for the manifestation code Instructional notes indicate proper sequencing order of the codes, the etiology followed by manifestation 15 Code First the Underlying Disease or Use an Additional Code In most cases, the manifestation will have in the code title, in diseases classified elsewhere Codes with this title are a component of the etiology/manifestation convention Code title indicates that it is a manifestation code In disease classified elsewhere Codes are never permitted to be used as the principal diagnosis Must be used in conjunction with an underlying condition code Must be listed secondarily to the underlying condition 16 8

9 The ICD-9-CM Coding Process To determine the correct ICD-9-CM code, always use both Volume 1 and 2 Locate the main term in the Alphabetic Index, Volume 2 Use a medical dictionary at any one of the preceding stages to aid in accurate coding Code to the highest degree of specificity Combination code-- Assign only combination code when that code fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs Multiple coding of diagnoses is required for certain conditions not subject to the rules for combination codes Uncertain diagnosis Do not code diagnoses as probable, suspected, questionable, or rule out Instead, code signs, symptoms, abnormal test results, other reason for the visit 17 The ICD-9-CM Coding Process Sequence codes correctly when using multiple diagnoses Codes for symptoms, signs, and ill-defined conditions are not to be used as principal diagnosis when a related definitive diagnosis has been established Chronic conditions treated on an ongoing basis may be coded as many times as required for treatment and care of the patient or when applicable to the patient s care plan Do not code conditions previously treated or those that no longer exist A history of previous conditions should be coded if they affect patient care or provide the need for a patient to seek medical attention 18 9

10 The ICD-9-CM Coding Process For surgical procedures Code the diagnosis applicable to the procedure If the postoperative diagnosis is different from the preoperative diagnosis, use the postoperative diagnosis code When physicians report diagnostic codes on a claim form, payers look for a Direct relationship between the diagnostic codes and the procedural codes submitted for payment Billing forms should be revised periodically to Contain only accurate and complete codes It is important to identify the main term within the diagnostic statement that Describes the patient s current condition or symptoms in the medical record, operative report or on the patient encounter form 19 Symptoms, Signs and Ill-Defined Conditions (Chapter 16) You can use the codes from Chapter 16 when: No more specific diagnoses can be made after investigation Signs and symptoms existing at the time of the initial encounter proved to be transient or cause could not be determined A patient fails to return and all you have is a provisional diagnosis A case is referred elsewhere before a definitive diagnosis could be made A more precise diagnosis was not available for any other reason Certain symptoms that represent important problems in medical care exist and that it might be desired to classify in addition to a known cause 20 10

11 Hypertension Table Found under H in alphabetic index, Volume 1 Complete listing of all conditions due to or associated with hypertension At the top of the heading are the following words Malignant, Benign, Unspecified Note that some descriptions have a code listed under each category Other descriptions have only one code listed under just one column This information is only found in the Hypertension Table By initially looking for a code in the table: Choose the correct code from the Tabular List It is still necessary to verify the code that is located within the table 21 Hypertension with Heart Disease Heart conditions (425.8, , 429.8, 429.9) are assigned a code from category 402 when A causal relationship is stated (due to hypertension) or implied (hypertensive) Use an additional code from category 428 to identify the type of heart failure in patients with heart failure More than one code may be assigned if the patient has systolic or diastolic failure and congestive heart failure The same heart conditions (428.5, , 429.8, 429.9) with hypertension but without a stated causal relationship Coded separately Circumstances of the admission/encounter determine sequencing 22 11

12 Hypertensive Disease with Chronic Kidney Disease Assign codes from category 403 Hypertensive renal disease, when conditions classified to categories 585 are present Unlike hypertension with heart disease ICD-9-CM presumes a cause-and-effect relationship and classifies renal failure with hypertension as hypertensive renal disease Fifth digits for category 403 should be assigned Appropriate code from category 585 (chronic kidney disease) CKD should be reported as a secondary diagnosis with a code from category 403 to identify the stage of CKD 23 Hypertensive Heart and Chronic Kidney Disease Assign codes from combination category 404 when both Hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis Assume a relationship between the hypertension and the chronic kidney disease Whether or not the condition is so designated Assign additional code from category 428 to identify the type of heart failure Appropriate code from category 585 should be used as a secondary code with a code from category 404 to identify the stage of the chronic kidney disease 24 12

13 Assign codes: Hypertensive Cerebrovascular Disease From , Cerebrovascular disease; and Appropriate hypertension code from categories Hypertensive Retinopathy Two codes are necessary to identify the condition First assign the code from subcategory , Hypertensive retinopathy Second, the appropriate code from categories to indicate type of hypertension 26 13

14 Hypertension, Secondary Two codes required One to identify the underlying etiology One from category 405 to identify the hypertension Reason for admission/encounter determines code sequencing 27 Hypertension, Transient Assign code Elevated blood pressure reading without diagnosis of hypertension Unless patient has an established diagnosis of hypertension Assign code 642.3X for transient hypertension of pregnancy 28 14

15 Hypertension, Controlled Assign appropriate code from categories This diagnostic statement usually refers to existing state of hypertension under control by therapy 29 Hypertension, Uncontrolled Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen Assign the appropriate code from categories to designate the stage and type of hypertension 30 15

16 Elevated Blood Pressure For a statement of elevated blood pressure without further specificity Assign code Elevated blood pressure reading without diagnosis of hypertension 31 Neoplasm Table Located under N in the alphabetic index Table lists anatomic sites alphabetically Where the neoplasm is found Using the table, neoplasms are broken it four main categories Malignant, benign, uncertain behavior, unspecified Under the heading of malignant, there are three categories to describe types of malignancy Primary, secondary, Ca in situ 32 16

17 Types of Neoplasms: Neoplasm Table Malignant A severe form of neoplasm having the property for destructive growth and metastasis. Primary Original location or presumed site of a malignant neoplasm. Secondary Area when neoplasm metastasizes or spreads. Carcinoma In Situ Neoplasms that are contained or confined to the original site or location. Benign A nonmalignant neoplasm. Uncertain Behavior Pathology has been unable to determine the type of neoplasm due to features that are present. Unspecified Physician has insufficient data to be able to categorize the neoplasm. 33 Admission/Encounters Involving Chemotherapy and Radiation Therapy When an episode of care involves the surgical removal of a neoplasm, primary and secondary site, followed by chemotherapy or radiation treatment The neoplasm code should be assigned as principal or first listed diagnosis When an episode of inpatient care involves surgical removal of a primary site or secondary site malignancy followed by adjunct chemotherapy or radiotherapy Code the malignancy as the principal diagnosis using codes in the series or the series If a patient admission/encounter is solely for the administration of chemotherapy or radiation therapy Code V58.0 Encounter for radiation therapy or V58.11 Encounter for chemotherapy as the principal diagnosis If a patient receives chemotherapy and radiation therapy Both codes should be listed in either order of sequence 34 17

18 Admission/Encounters Involving Chemotherapy and Radiation Therapy When a patient is admitted for the purpose of radiotherapy or chemotherapy and develops Complications such as uncontrolled nausea and vomiting or dehydration The principal diagnosis is V58.0 or V58.11 When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis The primary malignancy or appropriate metastatic site is designated as the principal or first listed diagnosis Coding Tip: When information regarding the primary site is not available, ICD-9-CM code is used Its definition is malignant neoplasm without specification of site, other Note: When a neoplasm is removed or is in remission and no longer being treated, a V code from the range, V10.x, Personal history of malignant neoplasm is used 35 Table of Drugs and Chemicals List of specific types of agents that: May cause a reaction or poisoning if taken in the wrong dosage or taken in error It also identifies: Intoxication or poisoning by a drug or other chemical substance The Table contains an extensive list of drugs, set in a six column format, that includes Industrial solvents, corrosive gases, noxious plants, pesticides and other toxic agents The first column provides: The codes for the substance involved The next five columns are: Grouped under the heading External Causes (E codes) and Identify the circumstances of poisoning Volume 2, Section 3 of the ICD-9-CM 36 18

19 Poisoning and Adverse Effect of Drugs E-codes can be used to distinguish between Poisoning and adverse effects of drugs Adverse Effect happens when a correct drug is taken and a reaction to the medication is developed When coding, order matters 1. Manifestation(s) due to adverse effects (condition) 2. Identify the drug causing the reaction with a code from the Therapeutic Use column (E-code) Poisoning occurs when the wrong drug or an incorrect dosage of a correct drug is ingested When coding, order matters: 1. Identify the drug causing the reaction with a code from the Poisoning column 2. Manifestation(s) due to poisoning (condition) 3. E Code to indicate circumstance 37 Multiple Injuries and Trauma When coding multiple injuries: Assign separate codes for each injury unless a combination code is provided The code for the most serious injury, as determined by the physician, is sequenced first Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) from categories , injury to nerves and spinal cord, and/or , injury to blood vessels The cause of the injury should be identified with an E code. E codes are coded in addition to primary and secondary diagnoses and never alone. Identifying and matching the diagnosis code to the procedure code is the most important factor in establishing medical necessity for injuries and trauma An open wound should be identified by site and complexity. E codes are used to identify the cause of the wound. The code for an open wound would be located under the main term Wound, open in the Alphabetic Index 38 19

20 Open Wounds Identify wounds by Site Complexity Distinguish between Open wounds Animal bites, avulsions, cuts, lacerations, puncture wounds, traumatic amputations Superficial wounds Abrasions, blisters, insect bites, removal of a superficial foreign body Superficial wounds codes Open wounds codes Wounds with mention of Delayed healing, delayed treatment, presence of foreign body, or major infection may warrant complicated designation Example: 2.5 cm laceration of the hand requiring simple repair: This is an open wound. First locate wound, open in the Alphabetic Index, then identify the site, and finally the size will be described in the CPT code not the ICD-9-CM code Correct code: 882.0, open wound of hand except finger(s) alone, without mention of complication 39 Fracture Care Coding Category Contains the codes assigned for fractures caused by trauma A dislocation and fracture of the same bone Would be coded to the fracture site only Fractures are classified according to Particular bone(s) involved, the type of fracture, whether it is opened or closed Open fracture--a fracture site that has been exposed to the outside elements An open fracture should not be coded Unless it is documented in the medical record A provider may choose to treat a closed fracture with an open or incisional treatment, but The approach for treatment should not be confused with an open fracture 40 20

21 Fracture Care Coding Fractures are coded as long as active treatment is rendered which includes Surgical treatment Emergency Department Encounter Evaluation and treatment by a new physician Complication codes are reported if Complication occurs during healing or recovery phase using the appropriate complication code(s) Malunion of a fracture is reported with Nonunion of a fracture is reported with Fracture Care Coding Multiple unilateral or bilateral fractures of the same bone, but assigned to different fourth digit subcategories within the same three digit category, are coded individually by site AHA Coding Clinic, 1986, 3rd/4th Qtr Multiple fractures are sequenced according to the severity of the fracture. It is, therefore, imperative that the severity of the fracture(s) be documented by the physician AHA Coding Clinic, 1986, 3rd/4th Qtr 42 21

22 Pathological Fractures Common fracture seen in the elderly Usually occur spontaneously or with slight trauma Pathological fractures are coded to 733.1X with the fifth digit identifying the site 43 Pathological Fractures Common underlying causes: Osteoporosis Metastatic cancer Osteomyelitis Bone cysts Paget s disease Disuse atrophy Nutritional or congenital disorders 44 22

23 Coding for Late Effects When a patient is being treated for a condition that is a late effect of an earlier injury or disease The reference late from Volume 2 is used A late effect is the residual effect That remains after the acute phase of an illness or injury has terminated The residual effect may be apparent Early after an acute phase of an illness as in a cerebrovascular accident or It may occur much later, one year or more, as with a previous injury or illness, eg, following an auto accident The residual effect Is coded first and Is followed by the late effect code to show the cause of the late effect condition It may be necessary for the coder to go to the Index for External Causes to identify and reference the appropriate late effect of an external cause with an E code The documentation in the medical record Should support the manifestation or residual effect as well as the cause 45 Diabetes Mellitus Three digit subclassification: 250-Diabetes Mellitus Fourth digit: identifies complications Fifth digit indicates: Type (I or II), whether the diabetes is documented as controlled or uncontrolled There are two types of diabetes: Type 1 and Type II Fifth digit indicates whether a diabetic condition is In control or is in an uncontrolled state Manifestations that may appear with diabetes are identified by fourth digit and include Renal, ophthalmic, neurological, peripheral, circulatory and other manifestations such as diabetic hypoglycemia and hypoglycemic shock The diabetes mellitus code with the specified manifestation Should be listed as a primary diagnosis and the specific manifestation reported as a secondary diagnosis 46 23

24 Insulin Pump Malfunction Underdose of insulin due insulin pump failure An underdose of insulin due to an insulin pump failure should be assigned , Mechanical complication due to insulin pump, as the principal or first listed code Followed by the appropriate diabetes mellitus code based on documentation Overdose of insulin due to insulin pump failure The principal or first listed code for an encounter due to an insulin pump malfunction resulting in an overdose of insulin Should be , Mechanical complication due to insulin pump Followed by code 962.3, Poisoning by insulins and antidiabetic agents, and The appropriate diabetes mellitus code based on documentation 47 Secondary Diabetes Secondary diabetes is coded to category 249. As with category 250, a fifth digit is required to identify whether the diabetes is controlled or uncontrolled. Diabetes mellitus can also result from other specific disease processes such as: Cushing s syndrome Malignant neoplasm Genetic disorders Late effect of poisoning Sepsis 48 24

25 Secondary Diabetes Secondary diabetes is always caused by another condition or event (eg, cystic fibrosis, malignant neoplasm of pancreas, pancreatectomy, adverse effect of drug, or poisoning). When assigning codes for secondary diabetes and its associated conditions (e.g. renal manifestations), the code(s) from category 249 must be sequenced before the codes for the associated conditions. 49 Secondary Diabetes The secondary diabetes codes and the diabetic manifestation codes that correspond to them are paired codes that follow the etiology/manifestation convention of the classification The sequencing of the secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the reason for the encounter, applicable ICD-9-CM sequencing conventions, and chapter-specific guidelines 50 25

26 Drug and Alcohol Dependency Alcohol dependency Chronic and deadly condition that progresses over time The patient becomes increasingly tolerant and dependent on alcohol Codes from category 303 describe alcohol dependency Many times, associated physical conditions Such as cirrhosis, are manifested as a result of continuous alcohol use An additional ICD-9-CM code should be reported to depict associated physical and mental conditions The fourth digit indicates the type of alcoholism The fifth digit identifies the pattern of use 51 Drug and Alcohol Dependency Fifth digit identifies: 0 Unspecified Indicates the pattern of use is unknown or unspecified in the documentation in the medical record. 1 Continuous Refers to the daily intake of large amount of alcohol or regular, heavy drinking on weekends or days off work. For drugs, it is daily or almost daily use. 2 Episodic Refers to alcoholic binges that last weeks or months, with sobriety following for long periods of time afterward. For drugs, it is the use of drugs on weekends or short periods of time between drug use. 3 In Remission Refers to either complete cessation of alcohol or drug intake or a length of time during which there is a gradual decrease toward cessation

27 Mental Disorders Coding mental disorders Complicated by the availability of another set of widely used codes in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) published by the American Psychiatric Association DSM-IV should be used as a reference to assist in the determination of a diagnosis Lists the specific DSM-IV code along with a description of the problem, any diagnostic or associated features The codes in this manual are similar to those in the ICD-9- CM section of mental disorders and conditions There are differences such as unique fourth and fifth digits 53 Mental Disorders The DSM-IV manual uses a multiaxial coding system. The terms and definitions used for this coding system are: Axis I Clinical disorders and other conditions Axis II Personality disorders; mental retardation Axis III General medical condition Axis IV Psychosocial problems Axis V Global assessment of functioning 54 27

28 Circulatory System Code range in ICD-9-CM Volume 1 Covers diseases of the circulatory system An adjunct to this range of codes is the Hypertension Table, which is a Volume 2 tabular supplement that classifies the disease according to Type (malignant, benign or unspecified) Includes codes of rubric 642 (hypertension complicating pregnancy, childbirth and the puerperium) 55 Cholelithiasis and Cholecystitis The codes describe A calculus of the gallbladder with different types of cholecystitis Acute, chronic or both, or without cholecystitis and with or without an obstruction The obstruction is usually A calculus that has lodged in the neck of the gallbladder or the cystic duct A fifth digit has been added to indicate the presence or absence of obstruction For postpartum cholecystitis, when the medical documentation clearly states the condition is a true postpartum condition Code should be assigned as the primary diagnosis The appropriate code from category 574.XX should be assigned as the secondary diagnosis 56 28

29 Obstetrical Care For routine care Supervision of normal first pregnancy (V22.0) or supervision of other normal pregnancy (V22.1) is coded If the provider is charging a global fee for prenatal care and delivery Office visits are included in the global concept If the patient is seen for an unrelated condition, such as a fracture Incidental to pregnancy (V22.2) may be used as an additional diagnosis Fifth digit subclassification is for use with categories to denote the current episode of care Valid fifth digits are in [brackets] under each code 57 Prenatal, Postpartum and Perinatal Complications The following information is helpful in coding complications of pregnancy and childbirth: The time when the complication occurred must be determined according to the medical record. This information is required to choose appropriate ICD-9-CM codes including the selection of additional digits Appropriate fifth digits are enclosed within brackets and located directly below the selected code The patient who is at risk during the prenatal period may have an uncomplicated delivery The patient who has no problem during the prenatal period may have a complicated delivery 58 29

30 Prenatal, Postpartum and Perinatal Complications The following information is helpful in coding complications of pregnancy and childbirth (continued): The stage where the risk or complication occurs is what influences the final code selection. If a pregnant patient presents with a problem unrelated to her pregnancy, the complaint should be coded as the primary reason for the visit V22.2 Pregnancy, incidental as a secondary diagnosis The following information is helpful in coding complications of pregnancy and childbirth continued A patient may present to a provider during an office visit or a hospital admission with complications associated with pregnancy and the obstetrical complication should be coded as the primary diagnosis along with any associated diagnoses 59 Congenital Anomalies Assign an appropriate code(s) from categories Congenital anomalies, when Anomaly is documented May be the first listed diagnosis on a record or a secondary diagnosis Use additional secondary codes from other chapters to specify conditions associated with the anomaly, if applicable Codes from chapter 14 may be used throughout the life of the patient If a congenital anomaly has been corrected Personal history code should be used to identify the history of the anomaly 60 30

31 Perinatal (Newborn) Guidelines Use of Codes V30-V39 When coding the birth of an infant, assign a code from categories V30-V39 According to the type of birth A code from this series is assigned as a principal diagnosis Assigned only once to a newborn at the time of birth Newborn Transfers If the newborn is transferred to another institution V30 series is not used as the receiving hospital 61 Perinatal (Newborn) Guidelines Use of Category V29: Assign a code from category V29 Observation and evaluation of newborns and infants for suspected conditions not found to identify A healthy newborn evaluated for a suspected condition that is determined after study not to be present When the patient has identified signs or symptoms of a suspected problem Code the sign or symptom and not V29 A V29 code is a secondary code after the V30 Outcome of delivery code It may also be assigned as a principal code for admissions or encounters when the V30 code no longer applies It is for use only for healthy newborns and infants for which no condition after study is found to be present 62 31

32 Perinatal (Newborn) Guidelines Maternal Causes of Perinatal Morbidity Codes from categories Maternal causes of perinatal morbidity and mortality are assigned Only when the maternal condition has affected the fetus or newborn Congenital Anomalies Guidelines Assign an appropriate code(s) from categories , Congenital Anomalies When an anomaly is documented A congenital anomaly may be the principal/first listed diagnosis on a record or a secondary diagnosis Use additional secondary codes from other chapters to specify conditions associated with the anomaly, if applicable Codes from Chapter 14 may be used throughout the life of the patient Perinatal (Newborn) Guidelines Congenital Anomalies Guidelines continued If a congenital anomaly has been corrected A personal history code should be used to identify the history of the anomaly For the birth admission The appropriate code from category V30, Liveborn infants, according to type of birth should be sequenced as the principal diagnosis Followed by any congenital anomaly codes, Coding of Additional Perinatal Diagnoses Assign codes for conditions that require Treatment or further investigation, prolong the length of stay, require additional resources and for conditions that the physician specifies may have implications for future health care needs Assign a code for Newborn conditions originating in the perinatal period (categories ), as well as Complications arising during the current episode of care classified in other chapters 32

33 Abortions Fifth digits are required for abortion categories Fifth digit 1, incomplete Indicates that all of the products of 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 A code from categories and May be used as additional codes with an abortion code to indicate The complication leading to the abortion Fifth digit 3 is assigned with codes from these categories Codes from the series are not to be used for complications of abortion Code 639 is to be used for all complications following abortion 65 Human Immunodeficiency Virus (HIV) Code only confirmed cases of HIV infection/illness Confirmation does not require documentation of positive serology or culture for HIV The physician s diagnostic statement that the patient is HIV positive or has an HIV-related illness is sufficient Selection and Sequencing If a patient is admitted for an HIV related condition The principal diagnosis should be 042 Followed by additional diagnosis codes for all reported HIV-related conditions. If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury) The code for the unrelated condition code should be the principal diagnosis Other diagnoses would be 042 followed by additional diagnosis codes for all reported HIV-related condition 66 33

34 Human Immunodeficiency Virus (HIV) Selection and Sequencing continued V08 Asymptomatic human immunodeficiency virus (HIV) infection is applied: When the patient without any documentation of symptoms is listed as being HIV positive, known HIV, HIV test positive, or similar terminology Do not use this code if the terms AIDS is used or if the patient is treated for any HIV-related illness; use 042 in these cases Patients with inconclusive HIV serology, but not definitive diagnosis or manifestations of the illness may be assigned code Inconclusive serologic test for (HIV) Previously Diagnosed HIV-Related Illness Known prior diagnosis of an HIV-related illness should be coded to 042 Once a patient has developed an HIV-related illness, the patient s condition should be assigned code 042 on every subsequent admission/encounter 67 HIV in Pregnancy, Childbirth and the Puerperium Asymptomatic HIV infection status during pregnancy, childbirth or the puerperium: Should be coded using 647.6X Other specified infectious and parasitic diseases in the mother classifiable elsewhere, but complicating the pregnancy, childbirth or the puerperium followed by V08. When the patient presents with an HIV related illness, 042 is primary and the code for the HIV-related illness. Codes from chapter fifteen always take sequencing priority 68 34

35 HIV Testing If a patient is being seen to determine HIV status, use code V73.89 Screening for other specified viral disease Should a patient with signs or symptoms of illness, or a confirmed HIV related diagnosis be tested for HIV Code the signs and symptoms or the diagnosis The HIV counseling code (V65.44) may be used if counseling is provided for patients with positive test results 69 Burn Coding Guidelines All burns are coded with Highest degree of burn sequenced first Burns of same local site (three-digit category level ) but of different degrees Classify to subcategory identifying highest degree recorded in the diagnosis Always list the code for the deepest level of burn first when there are burns to multiple areas Avoid 949.X whenever possible Use for infected burn sites Assign codes from category 948, which classifies burns according to extent of body surface involved 70 35

36 Burn Coding Guidelines Non-healing burns Coded as acute burns Necrosis of burned skin Coded as a non-healed burn When coding burns Assign separate codes for each burn site Category 946 for burns of multiple specified sites Should only be used if location of the burns are not documented Diagnosis Code Assignment For Outpatient Facilities Physicians, freestanding Ambulatory Surgery Centers (ASCs), hospitals and other facilities use Volume 1 and 2 to assign diagnosis codes Volume 3 includes procedure codes Typically used by inpatient facilities only The ICD-9-CM/PCS (Procedural Coding System) has been renewed every ten (10) years with annual updates published each October ICD-9-CM diagnosis codes explain Why the patient required service, with these codes required for most insurance carriers 36

37 Diagnosis Coding Guidelines For Outpatient Reporting A. Selection of first listed condition In the outpatient setting, the first-listed diagnosis is used in lieu of principal diagnosis In determining the first-listed diagnosis the coding conventions of ICD- 9-CM, as well as the general and disease specific guidelines Take precedence over the outpatient guidelines B. The appropriate code or codes from through V91.99 must be used to identify diagnoses, signs, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit 73 Diagnosis Coding Guidelines For Outpatient Reporting C. For accurate reporting of ICD-9-CM diagnosis codes, the documentation should describe the patient s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-9-CM codes to describe all of these situations D. The selection of codes through will frequently be used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries, e.g. infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions 74 37

38 Diagnosis Coding Guidelines For Outpatient Reporting E. Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the physician. Chapter 16 of ICD-9-CM, Symptoms, Signs, and Illdefined Conditions (codes ) contain many, but not all codes for symptoms F. ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V01.0- V91.99) are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems 75 Diagnosis Coding Guidelines For Outpatient Reporting G. Level of Detail in Coding ICD-9-CM is composed of codes with three, four or five digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater specificity. Where fourth digit subcategories and/or fifth digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits (highest level of specificity) required for that code H. List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any co-existing conditions 76 38

39 Diagnosis Coding Guidelines For Outpatient Reporting I. Do not code diagnoses documented as probable, suspected, questionable, rule out or working diagnosis. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results or other reason for the visit J. Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s) 77 Diagnosis Coding Guidelines For Outpatient Reporting K. Code all documented conditions that co-exist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment L. For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses, eg, chronic conditions, may be sequenced as additional diagnoses 78 39

40 Diagnosis Coding Guidelines For Outpatient Reporting M. For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses, eg, chronic conditions, may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation or rehabilitation N. For patient s receiving preoperative evaluations only, sequence a code from subcategory V72.8, Other specified examinations, to describe the preoperative consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the preoperative evaluation 79 Diagnosis Coding Guidelines For Outpatient Reporting O. For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive P. For routine outpatient prenatal visits when no complications are present codes V22.0, supervision of normal first pregnancy and V22.1, Supervision of other normal pregnancy should be used as principal diagnoses. These codes should not be used in conjunction with Chapter 11 codes 80 40

41 Diagnostic Tests with Signs And Symptoms When patients receive diagnostic services during an encounter/visit Sequence first the diagnosis, condition, problem, or other reason for the encounter documented in the medial record chiefly responsible for the outpatient service provide during the visit Codes for other diagnosis (chronic conditions) may be sequenced as additional diagnoses 81 Diagnostic Tests with Signs And Symptoms If the physician has confirmed a diagnosis based on the results of the diagnostic test The physician interpreting the test should code that diagnosis If a final report is available at the time of coding and a confirmed or definitive diagnosis is documented in the interpretation Only the definitive diagnosis is reported Sign and/or symptoms or the reason for the test is not reported as additional diagnoses This differs from Coding practices in the inpatient hospital setting regarding abnormal finding on test results 82 41

42 Diagnostic Tests with Signs And Symptoms If the results of the diagnostic test are normal or nondiagnostic, and the referring physician records a diagnosis preceded by words that indicate uncertainty Then the interpreting physician should not code the referring diagnosis On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information It is appropriate to obtain the information directly from the patient or the patient's medical record if it is available However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician 83 Incidental Findings Diagnostic Tests with Signs And Symptoms Should never be listed as primary diagnoses Unrelated/Co-Existing Conditions/Diagnoses May be reported as additional diagnoses by the physician interpreting the diagnostic test 84 42

43 Diagnostic Tests without Signs and/or Symptoms When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury The physician interpreting the diagnostic test should report the reason for the test as the primary ICD-9-CM diagnosis code The results of the test, if reported, may be recorded as additional diagnoses Use of ICD-9-CM to the greatest degree of accuracy and completeness Is of the utmost importance for outpatient facility coding 85 Determine the Reason for Test As specified in 4317(b) of the Balanced Budget Act (BBA) Referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered As further indicated in 42 CFR All diagnostic tests must be ordered by the physician who is treating the beneficiary of the Medicare Carrier Manual (MCM) An order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary 86 43

44 Determine the Reason for Test An order may include the following forms of communication A written document signed by the treating physician/practitioner that is hand-delivered, mailed, or faxed to the testing facility A telephone call by the treating physician/practitioner or his/her office to the testing facility An electronic mail by the treating physician/practitioner or his/her office to the testing facility 87 Determine the Reason for Test Coders Tip: If the order is communicated via telephone, both the treating physician/practitioner or his/her office and the testing facility must document the telephone call in their respective copies of the beneficiary s medical records

45 Incidental Findings Should never be listed as primary diagnoses If reported, incidental findings may be reported as Secondary diagnoses by the physician interpreting the diagnostic test 89 Unrelated/Coexisting Conditions/Diagnoses Unrelated and coexisting conditions/diagnoses may be reported as Additional diagnoses by the physician interpreting the diagnostic test 90 45

46 Diagnostic Tests Without Signs and/or Symptoms For routine laboratory/radiology testing in the absence of signs/symptoms or a confirmed diagnosis Assign either V72.5 (Radiological examination, not elsewhere classified), or V72.6 (Laboratory examination If routine testing is performed during the same encounter to evaluate a sign/symptom, or diagnosis May assign the appropriate V code along with the code describing the reason for the non-routine test/examination 91 The End 92 46