ICD-9-CM. 201 Expert. for Home Health Services and Hospices Volumes 1, 2, & 3

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1 ICD-9-CM for Home Health Servies and Hospies Volumes 1, 2, & Expert International Classifiation of Diseases 9th Revision Clinial Modifiation Sixth Edition OptumInsight is ommitted to providing you with the ICD-9-CM ode update information you need to ode aurately and to be in ompliane with HIPAA regulations. In ase of adoption of additional ICD-9-CM ode hanges effetive April 1, 201, OptumInsight will provide these ode hanges to you at no additional ost! Just hek bak at to review the latest information onerning any new ode hanges. Codes Valid Otober 1, 201, through September 30, 201

2 Index to Diseases A AAT (alpha-1 antitrypsin) defiieny AAV (disease) (illness) (infetion) see Human immunodefiieny virus (disease) (illness) (infetion) Abatio see Abortion, indued Abatus venter see Abortion, indued Abarognosis Abasia (-astasia) atatia horei hysterial paroxysmal trepidant spasti trembling trepidans Abderhalden-Kaufmann-Ligna syndrome (ystinosis) Abdomen, abdominal see also ondition aordion aute S angina burst onvulsive equivalent (see also Epilepsy) S heart musle defiieny syndrome obstipum Abdominalgia S periodi Abdution ontrature, hip or other joint see Contration, joint Aberrombie s syndrome (amyloid degeneration) Aberrant (ongenital) see also Malposition, ongenital adrenal gland blood vessel NEC arteriovenous NEC erebrovasular gastrointestinal lower limb renal spinal upper limb breast endorine gland NEC gastrointestinal vessel (peripheral) hepati dut lower limb vessel (peripheral) panreas parathyroid gland peripheral vasular vessel NEC pituitary gland (pharyngeal) renal blood vessel sebaeous glands, muous membrane, mouth spinal vessel spleen testis (desent) thymus gland thyroid gland upper limb vessel (peripheral) Aberratio latis testis Aberration see also Anomaly hromosome see Anomaly, hromosome(s) distantial mental (see also Disorder, mental, nonpsyhoti) Abetalipoproteinemia Abionare Abiotrophy Ablatio plaentae see Plaenta, ablatio retinae (see also Detahment, retina) Ablation pituitary (gland) (with hypofuntion) plaenta see Plaenta, ablatio uterus Ablepharia, ablepharon, ablephary Ablepsia see Blindness Ablepsy see Blindness Ablutomania see also Anomaly aid-base balane fetus or newborn see Distress, fetal adaptation urve, dark alveolar ridge amnion S anatomial relationship NEC apertures, ongenital, diaphragm auditory pereption NEC autosomes NEC or D E G ballistoardiogram basal metaboli rate (BMR) biosynthesis, testiular androgen blood level (of) obalt opper iron lead lithium magnesium mineral zin blood pressure elevated (without diagnosis of hypertension) low (see also Hypotension) reading (inidental) (isolated) (nonspeifi) blood sugar bowel sounds breathing behavior see Respiration alori test ervix (aquired) NEC ongenital in pregnany or hildbirth S ausing obstruted labor S hemistry, blood NEC hest sounds horion S hromosomal NEC analysis, nonspeifi result autosomes (see also Abnormal, autosomes NEC) fetal, (suspeted) affeting management of pregnany S sex linial findings NEC ommuniation see Fistula onfiguration of pupils oronary artery vein ortisol-binding globulin ourse, Eustahian tube reatinine learane dentofaial NEC funtional speified type NEC development, developmental NEC bone entral nervous system diretion, teeth Dynia (see also Defet, oagulation) Ebstein ehoardiogram ehoenephalogram ehogram NEC see Findings, abnormal, struture eletroardiogram (ECG) (EKG) eletroenephalogram (EEG) eletromyogram (EMG) oular eletro-oulogram (EOG) eletroretinogram (ERG) erythroytes see also Anomaly ontinued erythroytes ontinued ongenital, with perinatal jaundie [774.0] Eustahian valve exitability under minor stress fat distribution fees fetal heart rate see Distress, fetal fetus NEC affeting management of pregnany see Pregnany, management affeted by, fetal ausing disproportion S ausing obstruted labor S findings without manifest disease see Findings, abnormal fluid amnioti erebrospinal peritoneal pleural synovial vaginal fores of labor NEC S affeting fetus or newborn form, teeth funtion studies auditory bladder brain ardiovasular endorine NEC kidney liver nervous system entral peripheral oulomotor panreas plaenta pulmonary retina speial senses spleen thyroid vestibular gait hysterial gastrin seretion globulin ortisol-binding thyroid-binding gluagon seretion gluose in pregnany, hildbirth, or puerperium S fetus or newborn non-fasting gravitational (G) fores or states hair NEC hard tissue formation in pulp head movement heart rate fetus, affeting liveborn infant intrauterine newborn shadow sounds NEC Abnormal, abnormality, abnormalities see also Anomaly ontinued hemoglobin (see also Disease, hemoglobin) trait see Trait, hemoglobin, abnormal hemorrhage, uterus see Hemorrhage, uterus histology NEC inrease in appetite development involuntary movement jaw losure karyotype knee jerk labor NEC S affeting fetus or newborn laboratory findings see Findings, abnormal length, organ or site, ongenital see Distortion liver funtion test loss of height loss of weight lung shadow mammogram alifiation alulus miroalifiation Mantoux test membranes (fetal) ompliating pregnany S menstruation see Menstruation metabolism (see also ondition) movement disorder NEC sleep related, unspeified speified NEC head involuntary speified type NEC musle ontration, loalized myoglobin (Aberdeen) (Annapolis) narrowness, eyelid optokineti response organs or tissues of pelvis NEC in pregnany or hildbirth S affeting fetus or newborn ausing obstruted labor S origin see Malposition, ongenital palmar reases Papaniolaou (smear) anus with atypial squamous ells annot exlude high grade squamous intraepithelial lesion (ASC-H) of undetermined signifiane (ASC-US) ytologi evidene of malignany high grade squamous intraepithelial lesion (HGSIL) low grade squamous intraepithelial lesion (LGSIL) glandular speified finding NEC ervix with atypial squamous ells annot exlude high grade squamous intraepithelial lesion (ASC-H) of undetermined signifiane (ASC-US) ytologi evidene of malignany high grade squamous intraepithelial lesion (HGSIL) Index AAT Abnormal, abnormality, abnormalities S Additional Digit Required Refer to the Tabular List for Digit Seletion 2 Subterms under main terms may ontinue to next olumn or page 2013 ICD-9-CM wx Revised Text l New Line s Revised Code Volume 2 1

3 Diseases of the Cirulatory System Tabular List Diseases of the Cirulatory System b 403 Hypertensive hroni kidney disease 1 arteriolar nephritis arterioslerosis of: kidney renal arterioles arteriosleroti nephritis (hroni) (interstitial) hypertensive: nephropathy renal failure uremia (hroni) nephroslerosis renal slerosis with hypertension any ondition lassifiable to 585 wand 587x with any ondition lassifiable to aute kidney failure ( ) renal disease stated as not due to hypertension renovasular hypertension ( with fifth-digit 1) The following fifth-digit sublassifiation is for use with ategory 403: 0 with hroni kidney disease stage I through stage IV, or unspeified 1 with hroni kidney disease stage V or end stage renal disease AHA: 4Q, 06, 84-86; 4Q, 05, 68; 4Q, 92, 22; 2Q, 92, 5 TIP: Assign whenever a patient has both hroni kidney disease and hypertension (presumed ause-and-effet relationship) Malignant [0-1] Benign [0-1] Unspeified [0-1] AHA: For ode : 1Q, 08, 10; 2Q, 07, 3; 4Q, 06, 86; For ode : 1Q, 08, 7; 4Q, 05, 69; 1Q, 04, 14; 1Q, 03, 20; 2Q, 01, 11; 3Q, 91, 8 I12.9 HTN CKD w/stage I thru IV CKD/UNS CKD b 404 Hypertensive heart and hroni kidney disease 1 disease: ardiorenal ardiovasular renal any ondition lassifiable to 402 with any ondition lassifiable to 403 Use additional ode to speify type of heart failure ( ), if known The following fifth-digit sublassifiation is for use with ategory 404: 0 without heart failure and with hroni kidney disease stage I through stage IV, or unspeified 1 with heart failure and with hroni kidney disease stage I through stage IV, or unspeified 2 without heart failure and with hroni kidney disease stage V or end stage renal disease 3 with heart failure and hroni kidney disease stage V or end stage renal disease AHA: 4Q, 06, 84-86; 4Q, 05, 68; 4Q, 02, 49; 3Q, 90, 3; J-A, 84, Malignant [0-3] Benign [0-3] Unspeified [0-3] I13.0 HTN heart & CKD HF & stage I thru IV CKD UNS CKD b 405 Seondary hypertension DEF: High arterial blood pressure due to or with a variety of primary diseases, suh as renal disorders, CNS disorders, endorine, and vasular diseases. AHA: 3Q, 90, 3; S-O, 87, 9, 11; J-A, 84, Malignant Renovasular Other Benign Renovasular Other Unspeified Renovasular Other AHA: 3Q, 00, 4 Ishemi Heart Disease ( ) 1 that with mention of hypertension Use additional ode to identify presene of hypertension ( ) AHA: 3Q, 91, 10; J-A, 84, 5 b 410 Aute myoardial infartion 1 ardia infartion oronary (artery): embolism olusion rupture thrombosis infartion of heart, myoardium, or ventrile rupture of heart, myoardium, or ventrile ST elevation (STEMI) and non-st elevation (NSTEMI) myoardial infartion any ondition lassifiable to speified as aute or with a stated duration of 8 weeks or less The following fifth-digit sublassifiation is for use with ategory 410: 0 episode of are unspeified Use when the soure doument does not ontain suffiient information for the assigment of fifth-digit 1 or 2. 1 initial episode of are Use fifth-digit 1 to designate the first episode of are (regardless of faility site) for a newly diagnosed myoardial infartion. The fifth-digit 1 is assigned regardless of the number of times a patient may be transferred during the initial episode of are. 2 subsequent episode of are Use fifth-digit 2 to designate an episode of are following the initial episode when the patient is admitted for further observation, evaluation or treatment for a myoardial infartion that has reeived initial treatment, but is still less than 8 weeks old. DEF: A sudden insuffiieny of blood supply to an area of the heart musle; usually due to a oronary artery olusion. TIP: Assign an aute MI ode with a fifth digit of 1, initial episode of are, for all are provided before the AMI has resolved, regardless of type or number of transfers between failities. AHA: 2Q, 06, 9; 4Q, 05, 69; 3Q, 01, 21; 3Q, 98, 15; 4Q, 97, 37; 3Q, 95, 9; 4Q, 92, 24; 1Q, 92, 10; 3Q, 91, 18; 1Q, 91, 14; 3Q, 89, Of anterolateral [0-2] ST elevation myoardial infartion (STEMI) of anterolateral AHA For Code : 4Q, 09, 129; 4Q, 08, Of other anterior anterior () NOS (with ontiguous portion of anteroapial intraventriular anteroseptal septum) ST elevation myoardial infartion (STEMI) of other anterior AHA: For ode : 3Q, 03, Of inferolateral [0-2] ST elevation myoardial infartion (STEMI) of inferolateral 3 CD Dx = Dx with fifth digit 2 Requires fifth digit. Valid digits are in [brakets] under eah ode. See appropriate ategory for odes and definitions. 8 Newborn Age: 0 9 Pediatri Age: 0-17 x Maternity Age: y Adult Age: * Non Routine Supply Dx wx Revised Text l New Code s Revised Code Title 142 Volume 1 Otober ICD-9-CM

4 Tabular List Diseases of the Cirulatory System Aute Myoardial Infartion Anatomi Sites Anterolateral Anteroseptal Apial Other lateral Inferoposterior Other and septum Posterobasal Posterolateral Atrium only Septum only Papillary musle Of inferoposterior [0-2] ST elevation myoardial infartion (STEMI) of inferoposterior Of other inferior diaphragmati (with ontiguous portion of NOS intraventriular inferior () NOS septum) ST elevation myoardial infartion (STEMI) of other inferior AHA: w3q, 09,10;x 1Q, 00, 7, 26; 4Q, 99, 9; 3Q, 97, 10; For ode : 2Q, 01, 8, 9 I21.19 STEMI invlv oth oronary artery of inferior Of other lateral apial-lateral basal-lateral high lateral posterolateral ST elevation myoardial infartion (STEMI) of other lateral AHA: For ode : w3q, 09, 9x True posterior infartion posterobasal stritly posterior ST elevation myoardial infartion (STEMI) of true posterior Subendoardial infartion [0-2] Non-ST elevation myoardial infartion (NSTEMI) Nontransmural infartion AHA: 1Q, 00, 7; For ode : 4Q, 05, 71; 2Q, 05, 19 I21.4 Non-ST elevation (NSTEMI) myoardial infartion Of other speified sites [0-2] Infartion of: atrium papillary musle septum alone ST elevation myoardial infartion (STEMI) of other speified sites Unspei fied [0-2] Aute myoardial infartion NOS Coronary olusion NOS Myoardial infartion NOS AHA: 1Q, 96, 17; 1Q, 92, 9; For ode : 2Q, 05, 18; 3Q, 02, 5 I21.3 ST elevation myoardial infartion of uns site b 411 Other aute and subaute forms of ishemi heart disease AHA: 4Q, 94, 55; 3Q, 91, Postmyoardial infartion syndrome Dressler's syndrome DEF: Compliation developing several days/weeks after myoardial infartion; symptoms inlude fever, leukoytosis, hest pain, periarditis, pleurisy, and pneumonitis; tendeny to reur Intermediate oronary syndrome Impending infartion Preinfartion syndrome Preinfartion angina Unstable angina 2 angina (petoris) (413.9) deubitus (413.0) DEF: A ondition representing an intermediate stage between angina of effort and aute myoardial infartion. It is often doumented by the physiian as unstable angina. AHA: 3Q, 07, 9; 4Q, 05, 105; 2Q, 04, 3; 1Q, 03, 12; 3Q, 01, 15; 2Q, 01, 7, 9; 4Q, 98, 86; 2Q, 96, 10; 3Q, 91, 24; 1Q, 91, 14; 3Q, 90, 6; 4Q, 89, 10 TIP: Do not assign ode on the same episode of are as an aute myoardial infartion (ategory 410). Assign for aelerated angina. I20.0 Unstable angina Other AHA: 3Q, 91, 18; 3Q, 89, Aute oronary olusion infartion Aute oronary (artery): embolism obstrution olusion thrombosis without or not resulting in myoardial infartion 2 obstrution without infartion due to atheroslerosis ( ) olusion without infartion due to atheroslerosis ( ) DEF: Interrupted blood flow to a portion of the heart; without tissue death. AHA: 3Q, 91, 24; 1Q, 91, Other Coronary insuffiieny (aute) Subendoardial ishemia AHA: 3Q, 01, 14; 1Q, 92, Old myoardial infartion Healed myoardial infartion Past myoardial infartion diagnosed on ECG [EKG] or other speial investigation, but urrently presenting no symptoms AHA: 2Q, 03, 10; 2Q, 01, 9; 3Q, 98, 15; 2Q, 91, 22; 3Q, 90, 7 TIP: Assign for any aute myoardial infartion stated to be older than 8 weeks. I25.2 Old myoardial infartion b 413 Angina petoris DEF: Severe onstriting pain in the hest, often radiating from the preordium to the left shoulder and down the arm, due to ishemia of the heart musle; usually aused by oronary disease; pain is often preipitated by effort or exitement Angina deubitus Noturnal angina DEF: Angina ourring only in the reumbent position Prinzmetal angina Variant angina petoris DEF Angina ourring when patient is reumbent; assoiated with ST-segment elevations. AHA: 3Q, 06, Other and unspeified angina petoris Angina: Anginal syndrome NOS Status anginosus ardia Stenoardia equivalent Synope anginosa of effort Use additional ode(s) for symptoms assoiated with angina equivalent 2 preinfartion angina (411.1) AHA: 2Q, 08, 16; 3Q, 02, 4; 3Q, 91, 16; 3Q, 90, 6 TIP: For patients with both angina and oronary artery disease, sequene the CAD (subategory 414.0) ode first. I20.9 Angina petoris unspeified without myoardial Diseases of the Cirulatory System CD Dx = Dx with fifth digit 2 Requires fifth digit. Valid digits are in [brakets] under eah ode. See appropriate ategory for odes and definitions. b Additional Digit Required Clinial Dimension Dx Unspeified Code Other Speified Code Manifestation Code 2013 ICD-9-CM February 2012 Volume 1 143

5 Chapter 7: Diseases of the Cirulatory System ( ) Coding Guidane Very speifi guidelines and instrutions affet assignment of odes within this ategory. Pay areful attention to instrution notes in both the alphabeti index and the tabular list. Many of the onditions within this hapter are omplex and interrelated. Physiians may use a variety of terms and phrases to desribe a diagnosis. Aute Rheumati Fever ( ) Rheumati fever is a febrile disease ourring mainly in hildren or young adults following throat infetion by Group A Streptooi. Symptoms inlude sudden ourrene of fever and joint pain; followed by lesions of the heart, blood vessels, and joint onnetive tissue, abdominal pain, skin hanges, and horea. The instrutional notes below eah of the subategories further define and larify the subategory. These instrutional notes assist the user to assign odes aurately even though a variety of terms and phrases may be used to desribe diagnosis. For example, the Inludes notes below ategory 390 indiate that the onditions rheumati arthritis (aute or subaute), rheumati fever (ative or aute), and artiular rheumatism (aute or subaute) are inluded in this ategory. Exludes notes under ategory 392 indiate that if the medial doumentation states the ondition to be horea, NOS, or Huntington s horea, a ode from ategory 392 is not an appropriate assignment. Chroni Rheumati Heart Disease ( ) Heart disease as a onsequene of aute rheumati fever ommonly involves damage to the heart valves during the aute phase of the streptooal infetion. ICD-9-CM makes the presumption that ertain onditions of the mitral valve suh as stenosis, stenosis with insuffiieny, and failure of unknown etiology are of rheumati fever origin. None of the disorders of the aorti valve are presumed to be of rheumati origin, however, and must be speified by doumentation as rheumati to be lassified to these ategories. However, when disorders to both mitral and aorti valves are desribed with the terms stenosis, stenosis with insuffiieny, and failure, then ICD-9-CM presumes rheumati origin. Hypertensive Disease ( ) Hypertension is the ondition of abnormally elevated arterial blood pressure. The blood pressure range onsidered to be hypertensive varies, but most ommonly a 140/ 90 mm. Hg. is onsidered hypertensive. Hypertension is lassified using three axes: First, by type (i.e., primary or seondary); seond is by nature of hypertension (i.e., benign, malignant, or unspeified); and third indiates assoiated heart disease, renal disease, or both heart and renal disease. Refer to instrutional notes in oding hypertension. There are many diagnosti terms used to desribe the types of hypertension. The hypertension table, a omplete list of diagnoses assoiated with or due to hypertension, is loated in the alphabeti index under the main term Hypertension. Three terms malignant, benign, and unspeified, serve as headings in the table to assist the user to selet the most speifi ode to desribe the diagnosis. They are defined as follows: Malignant: This type of hypertension is onsidered the most severe and diffiult to treat. A malignant diagnosis is made when the patient s diastoli blood pressure is onsistently greater than 140 and if other linial features are present, suh as ardia and renal involvement, and neuroretinopathy. Benign: This type of hypertension is onsidered relatively mild and usually is hroni or ours over a prolonged period of time. Unspeified: This term is seleted when the physiian does not speify the type of hypertension as benign or malignant. If the physiian has not speified the type, request larifiation of the diagnosis. Essential hypertension (401) is also referred to as primary, idiopathi, or systoli hypertension, and is defined as hypertension without apparent ause. The physiian must doument in the medial reord whether the hypertension is malignant or benign to assign a fourth digit of 0 or 1 respetively. When no entry in the medial reord supports either designation, assign a fifth digit of 9, unspeified. Hypertensive heart disease is assigned to ategory 402. Chroni elevated blood pressure often produes hanges in the heart myoardium as a result of the inreased workload against the elevated blood pressure in the vessels. Hypertensive heart disease inludes ardiomegaly, ardiopathy, ardiovasular disease, and heart failure. The first axis of oding is the kind of hypertension (i.e., malignant, benign, or unspeified). The seond axis indiates hypertension, with or without heart failure. In order to assign a ode from the 402 ategory, the diagnosti statement must indiate a ausal relationship between the hypertension and the heart disease. Phrases suh as due to hypertension and hypertensive indiate a ausal relationship. For example, hypertensive heart disease without heart failure, unspeified, is oded A diagnosti statement with hypertension does not indiate a asual relationship between the heart disease and the hypertension and the ombination ode 402 is inappropriate. In this ase, ode the heart disease and the hypertension separately. For example, ongestive heart failure with hypertension, unspeified, is oded 428.0, Heart disease in ombination with an assoiated hypertensive heart ondition lassifiable to 428, , 429.8, is presumed by ICD-9-CM to be hypertensive. For example, ongestive heart failure with unspeified hypertensive ardiovasular disease is oded A ausal relationship between hypertension and kidney disease is assumed when the diagnosti statement indiates both onditions, even though the statement does not speify hypertensive kidney disease. Hypertensive hroni kidney disease is assigned to the ategory 403. Fourth-digit assignment, as with other hypertension subategories, indiates malignant (0), benign (1), or unspeified (9). Fifth-digit assignment indiates without mention of hroni kidney disease (0) or with hroni kidney disease (1). To report hroni renal insuffiieny (CRI) with hypertension, assign Hypertensive hroni kidney disease stage I through stage IV, or unspeified and ode Chroni kidney disease, unspeified. Category 404 inludes onditions of hypertensive heart and kidney disease. This ategory is reviewed when the diagnosti statement indiates both hypertensive heart disease (402) and hypertensive kidney disease (403). Fifth-digit assignment in this ategory indiates the presene of ongestive heart failure, hroni kidney disease, both onditions, or neither. Assign odes from ombination ategory 404 Hypertensive heart and kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the kidney disease, whether or not the ondition is so designated. A patient may have an elevated blood pressure reading during an outpatient visit without having a known diagnosis of hypertension. In this situation, ode 796.2, whih desribes an elevated blood pressure reading that may be the result of emotional problems or stress. This diagnosis ode an be found in the alphabeti index under the main term Elevation and subterms blood pressure, reading, and no diagnosis of hypertension. For hypertensive erebrovasular disease, first assign odes from Cerebrovasular disease, then the appropriate hypertension ode from ategories Hypertensive retinopathy requires two odes to identify the ondition. First assign the ode from subategory Hypertensive retinopathy, then the appropriate ode from ategories to indiate the type of hypertension. Seondary hypertension defined as high blood pressure due to or with a variety of primary diseases requires two odes: one to identify the underlying etiology and one from ategory 405 to identify the hypertension. The terms ontrolled or unontrolled hypertension refer to whether the hypertension is responding to urrent therapeuti regimen or not. In either ase, ode to the type of hypertension, and assign an appropriate ode from ategories Diseases of the Cirulatory System b Additional Digit Required Clinial Dimension Dx Unspeified Code Other Speified Code Manifestation Code 2013 ICD-9-CM Volume 1 137