ICD-9-CM. for Hospitals Volumes 1, 2 & 3. International Classification of Diseases 9th Revision Clinical Modification Sixth Edition

Transcription

1 ICD-9-CM for Hospitls Volumes 1, 2 & Expert Interntionl Clssifiction of Diseses 9th Revision Clinicl Modifiction Sixth Edition Edited by: Anit C. Hrt, RHIA, CCS, CCS-P Melind S. Stegmn, MBA, CCS Beth Ford, RHIT, CCS Optum is committed to providing you with the ICD-9-CM code updte informtion you need to code ccurtely nd to be in complince with HIPAA regultions. In cse of doption of dditionl ICD-9-CM code chnges effective April 1, 2015, Optum will provide these code chnges to you t no dditionl cost! Just check bck t to review the ltest informtion concerning ny new code chnges. Codes Vlid October 1, 2014, through September 30, 2015

2 Diseses of the Circultory System Tbulr List Diseses of the Circultory System Diseses of Pulmonry Circultion ( ) b 415 Acute pulmonry hert disese Acute cor pulmonle 2 cor pulmonle NOS (416.9) DEF: A hert-lung disese mrked by diltion nd filure of the right side of hert; due to pulmonry embolism; ventiltory function is impired nd pulmonry hypertension results. CC Excl: 415.0, , c Pulmonry embolism nd infrction Pulmonry (rtery) (vein): Pulmonry (rtery) (vein): poplexy infrction (hemorrhgic) embolism thrombosis 2 chronic pulmonry embolism (416.2) personl history of pulmonry embolism (V12.55) tht complicting: bortion ( with.6, 639.6) ectopic or molr pregnncy (639.6) pregnncy, childbirth, or the puerperium ( ) DEF: Embolism: Closure of the pulmonry rtery or brnch; due to thrombosis (blood clot). DEF: Infrction: Necrosis of lung tissue; due to obstructed rteril blood supply, most often by pulmonry embolism. AHA: 4Q, 90, Itrogenic pulmonry embolism nd infrction Use dditionl code for ssocited septic pulmonry embolism, if pplicble, CC Excl: , 416.2, , AHA: 4Q, 95, 58 TIP: Do not report code Other respirtory complictions, with code Septic pulmonry embolism Septic embolism NOS Code first underlying infection, such s: septicemi ( ) 2 septic rteril embolism (449) CC Excl: See code: AHA: 4Q, 07, Sddle embolus of pulmonry rtery CC Excl: See code AHA: 4Q, 11, Other CC Excl: See code: AHA: 3Q, 10, 10; 4Q, 09, 86 I26.99 Other pulmonry emb w/o cute cor pulmonle b 416 Chronic pulmonry hert disese Primry pulmonry hypertension A Idiopthic pulmonry rteriosclerosis Pulmonry hypertension (essentil) (idiopthic) (primry) 2 pulmonry hypertension NOS (416.8) secondry pulmonry hypertension (416.8) DEF: A rre increse in pulmonry circultion, often resulting in right ventriculr filure or ftl syncope. CC Excl: , 416.0, , , I27.0 Primry pulmonry hypertension Kyphoscoliotic hert disese A DEF: High blood pressure within the lungs s result of curvture of the spine. CC Excl: , , Chronic pulmonry embolism A Use dditionl code, if pplicble, for ssocited long-term (current) use of nticogulnts (V58.61) 2 personl history of pulmonry embolism (V12.55) DEF: A long-stnding condition commonly ssocited with pulmonry hypertension in which smll blood clots trvel to the lungs repetedly over mny weeks, months, or yers, requiring continution of estblished nticogulnt or thrombolytic therpy. CC Excl: , 416.2, , AHA: 4Q, 09, 85, Other chronic pulmonry hert diseses Pulmonry hypertension NOS Pulmonry hypertension, secondry AHA: w1q, 12, 17;x 1Q, 11, 10; 2Q, 10,10 I27.89 Other specified pulmonry hert diseses Chronic pulmonry hert disese, unspecified Chronic crdiopulmonry disese Cor pulmonle (chronic) NOS b 417 Other diseses of pulmonry circultion Arteriovenous fistul of pulmonry vessels A 2 congenitl rteriovenous fistul (747.32) DEF: Abnorml communiction between blood vessels within lung. CC Excl: Aneurysm of pulmonry rtery A 2 congenitl neurysm (747.39) congenitl rteriovenous neurysm (747.32) CC Excl: See code: Other specified diseses of pulmonry circultion Pulmonry: Pulmonry: rteritis Rupture Stricture endrteritis of pulmonry vessel Unspecified disese of pulmonry circultion Other Forms of Hert Disese ( ) b 420 Acute pericrditis 1 cute: medistinopericrditis myopericrditis pericrdil effusion pleuropericrditis pneumopericrditis 2 cute rheumtic pericrditis (391.0) postmyocrdil infrction syndrome [Dressler's] (411.0) DEF: Inflmmtion of the pericrdium (hert sc); pericrdil friction rub results from this inflmmtion nd is herd s scrtchy or lethery sound Acute pericrditis in diseses clssified elsewhere A Code first underlying disese, s: ctinomycosis (039.8) mebisis (006.8) chronic uremi (585.9) nocrdiosis (039.8) tuberculosis (017.9) uremi NOS (586) 2 pericrditis (cute) (in): Coxsckie (virus) (074.21) gonococcl (098.83) histoplsmosis ( with fifth-digit 3) meningococcl infection (036.41) syphilitic (093.81) CC Excl: 391.0, 393, , , c Other nd unspecified cute pericrditis Acute pericrditis, unspecified A Pericrditis (cute): Pericrditis (cute): NOS sicc infective NOS CC Excl: See code: AHA: 2Q, 89, Acute idiopthic pericrditis A Pericrditis, cute: Pericrditis, cute: benign virl nonspecific CC Excl: See code: HAC when reported with procedure codes , 81.51, 81.52, nd POA = N 8 Newborn Age: 0 9 Peditric Age: 0-17 x Mternity Age: y Adult Age: Mjor CC Condition A CC Condition 7 HIV Relted Dx 140 Volume 1 October ICD-9-CM

3 Tbulr List Diseses of the Circultory System Superior ven cv Aortic vlve Right trium Tricuspid vlve Right ventricle Inferior ven cv Antomy Aort Blood Flow Pulmonry rtery Pulmonry vein Pulmonry vlve Left trium Mitrl vlve Chord tendine Left ventricle Other A Pericrditis (cute): pneumococcl purulent stphylococcl streptococcl suppurtive Pneumopyopericrdium Pyopericrdium 2 pericrditis in diseses clssified elsewhere (420.0) CC Excl: See code: b 421 Acute nd subcute endocrditis DEF: Bcteril inflmmtion of the endocrdium (intrcrdic re); mjor symptoms include fever, ftigue, hert murmurs, splenomegly, embolic episodes nd res of infrction Acute nd subcute bcteril endocrditis 7 Endocrditis (cute)(chronic) (subcute): bcteril infective NOS lent mlignnt purulent septic ulcertive vegettive Infective neurysm Subcute bcteril endocrditis [SBE] Use dditionl code to identify infectious orgnism [e.g., Streptococcus 041.0, Stphylococcus 041.1] CC Excl: 391.1, 397.9, , , AHA: 4Q, 08, 73; 1Q, 99, 12; 1Q, 91, 15 I33.0 Acute nd subcute infective endocrditis Acute nd subcute infective endocrditis in diseses clssified elsewhere Code first underlying disese, s: blstomycosis (116.0) Q fever (083.0) typhoid (fever) (002.0) 2 endocrditis (in): Coxsckie (virus) (074.22) gonococcl (098.84) histoplsmosis ( with fifth-digit 4) meningococcl infection (036.42) monilil (112.81) CC Excl: See code: Acute endocrditis, unspecified 7 Endocrditis Myoendocrditis cute or subcute Periendocrditis 2 cute rheumtic endocrditis (391.1) CC Excl: See code: b 422 Acute myocrditis 2 cute rheumtic myocrditis (391.2) DEF: Acute inflmmtion of the musculr wlls of the hert (myocrdium) Acute myocrditis in diseses clssified elsewhere Code first underlying disese, s: myocrditis (cute): influenzl (487.8, , ) tuberculous (017.9) 2 myocrditis (cute) (due to): septic, of newborn (074.23) Coxsckie (virus) (074.23) diphtheritic (032.82) meningococcl infection (036.43) syphilitic (093.82) toxoplsmosis (130.3) CC Excl: 391.2, 398.0, , 429.0, , c Other nd unspecified cute myocrditis Acute myocrditis, unspecified 7 Acute or subcute (interstitil) myocrditis Idiopthic myocrditis 7 Myocrditis (cute or subcute): Fiedler's gint cell isolted (diffuse) (grnulomtous) nonspecific grnulomtous Septic myocrditis 7 Myocrditis, cute or subcute: pneumococcl stphylococcl Use dditionl code to identify infectious orgnism [e.g., Stphylococcus 041.1] 2 myocrditis, cute or subcute: in bcteril diseses clssified elsewhere (422.0) streptococcl (391.2) CC Excl: See code Toxic myocrditis 7 DEF: Inflmmtion of the hert muscle due to n dverse rection to certin drugs or chemicls reching the hert through the bloodstrem Other 7 b 423 Other diseses of pericrdium 2 tht specified s rheumtic (393) Hemopericrdium A DEF: Blood in the pericrdil sc (pericrdium). CC Excl: , Adhesive pericrditis A Adherent pericrdium Pericrditis: Fibrosis of pericrdium Milk spots dhesive oblitertive Soldiers' ptches DEF: Two lyers of serous pericrdium dhere to ech other by fibrous dhesions. CC Excl: See code: Constrictive pericrditis A Concto's disese Pick's disese of hert (nd liver) DEF: Inflmmtion identified by rigid, thickened nd sometimes clcified pericrdium; ventricles of the hert not dequtely filled; congestive hert filure my result. CC Excl: See code: Diseses of the Circultory System b c Additionl Digit Required Uncceptble PDx Mnifesttion Code Hospitl Acquired Condition wx Revised Text l New Code s Revised Code Title 2015 ICD-9-CM Volume 1 141

4 Procedures nd Interventions, Not Elsewhere Clssified Tbulr List Procedures nd Interventions, Not Elsewhere Clssified Intrvsculr imging of intrthorcic vessels Aort nd ortic rch Intrvsculr ultrsound (IVUS), intrthorcic vessels Ven cv (superior) (inferior) 2 dignostic ultrsound (non-invsive) of other sites of thorx (88.73) Intrvsculr imging of peripherl vessels Imging of: vessels of rm(s) vessels of leg(s) Intrvsculr ultrsound (IVUS), peripherl vessels 2 dignostic ultrsound (non-invsive) of peripherl vsculr system (88.77) Intrvsculr imging of coronry vessels Intrvsculr ultrsound (IVUS), coronry vessels 2 dignostic ultrsound (non-invsive) of hert (88.72) intrcrdic echocrdiogrphy [ICE] (ultrsound of hert chmber(s)) (37.28) AHA: 3Q, 06, Intrvsculr imging of renl vessels Intrvsculr ultrsound (IVUS), renl vessels Renl rtery 2 dignostic ultrsound (non-invsive) of urinry system (88.75) Intrvsculr imging, other specified vessel(s) Intrvsculr imging, unspecified vessel(s) b 00.3 Computer ssisted surgery [CAS] CT-free nvigtion Imge guided nvigtion (IGN) Imge guided surgery (IGS) Imgeless nvigtion Tht without the use of robotic(s) technology Code lso dignostic or therpeutic procedure 2 robotic ssisted procedures ( ) stereotctic frme ppliction only (93.59) TIP: CAS includes three key ctivities: surgicl plnning, registrtion, nd nvigtion; typiclly used in brin; crnil; er, nose nd throt (ENT); spinl; nd orthopedic surgeries Computer ssisted surgery with CT/CTA AHA: 4Q, 04, Computer ssisted surgery with MR/MRA AHA: 4Q, 04, Computer ssisted surgery with fluoroscopy Imgeless computer ssisted surgery Computer ssisted surgery with multiple dtsets Other computer ssisted surgery Computer ssisted surgery NOS b 00.4 Adjunct vsculr system procedures NOTE These codes cn pply to both coronry nd peripherl vessels. These codes re to be used in conjunction with other therpeutic procedure codes to provide dditionl informtion on the number of vessels upon which procedure ws performed nd/or the number of stents inserted. As pproprite, code both the number of vessels operted on ( ), nd the number of stents inserted ( ). Code lso ny: ngioplsty ( , 00.66, 39.50) therectomy ( ) endrterectomy ( ) insertion of vsculr stent(s) (00.55, , , 39.90) other removl of coronry rtery obstruction (36.09) AHA: 4Q, 05, Procedure on single vessel Number of vessels, unspecified 2 (orto)coronry bypss ( ) intrvsculr imging of blood vessels AHA: w4q, 11, ;x 4Q, 10, 113; 2Q, 10, 8-9; 3Q, 09, 13; 2Q, 09, 12; 1Q, 07, 17; 3Q, 06, 8; 4Q, 05, 71, 106 Stenting Techniques on Vessel Bifurction T Stent Double Brrel V Stent (double density) Trouser Y Stent Procedure on two vessels 2 (orto)coronry bypss ( ) intrvsculr imging of blood vessels AHA: 4Q, 06, 119; 4Q, 05, Procedure on three vessels 2 (orto)coronry bypss ( ) intrvsculr imging of blood vessels Procedure on four or more vessels 2 (orto)coronry bypss ( ) intrvsculr imging of blood vessels Procedure on vessel bifurction NOTE This code is to be used to identify the presence of vessel bifurction; it does not describe specific bifurction stent. Use this code only once per opertive episode, irrespective of the number of bifurctions in vessels. AHA: 4Q, 06, Insertion of one vsculr stent Number of stents, unspecified AHA: w4q, 11, 167;x 4Q, 10, 113; 3Q, 09, 13; 4Q, 05, Insertion of two vsculr stents AHA: 2Q, 09, 12; 4Q, 05, Insertion of three vsculr stents AHA: 4Q, 06, Insertion of four or more vsculr stents SuperSturted oxygen therpy Aqueous oxygen (AO) therpy SSO 2 SuperOxygention infusion therpy Code lso ny: injection or infusion of thrombolytic gent (99.10) insertion of coronry rtery stent(s) ( ) intrcoronry rtery thrombolytic infusion (36.04) number of vsculr stents inserted ( ) number of vessels treted ( ) open chest coronry rtery ngioplsty (36.03) other removl of coronry obstruction (36.09) percutneous trnsluminl coronry ngioplsty [PTCA] (00.66) procedure on vessel bifurction (00.44) trnsluminl coronry therectomy (17.55) 2 other oxygen enrichment (93.96) other perfusion (39.97) DEF: Method of reducing myocrdil tissue dmge vi infusion of super-oxygented blood directly to oxygen-deprived myocrdil tissue in MI ptients; typiclly performed s n djunct procedure during PTCA or stent insertion. AHA: 4Q, 08, Bilterl Procedure 4 Non-covered Procedure 3 Limited Coverge Procedure wx Revised Text l New Code s Revised Code Title 70 Volume 3 Februry ICD-9-CM

5 Tbulr List Opertions on the Digestive System b 46.1 Colostomy Code lso ny synchronous resection (45.49, , 45.8) 2 loop colostomy (46.03) tht with bdominoperinel resection of rectum (48.5) tht with synchronous nterior rectl resection (48.62) DEF: Cretion of opening from lrge intestine through bdominl wll to body surfce Colostomy, not otherwise specified Temporry colostomy Permnent colostomy Delyed opening of colostomy b 46.2 Ileostomy Code lso ny synchronous resection (45.34, ) 2 loop ileostomy (46.01) DEF: Cretion of rtificil nus by bringing ileum through bdominl wll to body surfce Ileostomy, not otherwise specified Temporry ileostomy Continent ileostomy DEF: Cretion of opening from third prt of smll intestine through bdominl wll, with pouch outside bdomen. AHA: M-J, 85, Other permnent ileostomy Delyed opening of ileostomy b 46.3 Other enterostomy Code lso ny synchronous resection ( ) Delyed opening of other enterostomy Percutneous (endoscopic) jejunostomy [PEJ] Endoscopic conversion of gstrostomy to jejunostomy Percutneous (endoscopic) feeding enterostomy 2 percutneous [endoscopic] gstrojejunostomy (bypss) (44.32) DEF: Percutneous feeding enterostomy: Surgicl plcement of (feeding) tube through the midsection of the smll intestine through the bdominl wll. DEF: Conversion of gstrostomy to jejunostomy: Endoscopic dvncement of jejunostomy tube through n existing gstrostomy tube into the proximl jejunum. AHA: 3Q, 10, Other Duodenostomy Feeding enterostomy AHA: 3Q, 89, 15 b 46.4 Revision of intestinl stom DEF: Revision of opening surgiclly creted from intestine through bdominl wll, to skin surfce Revision of intestinl stom, not otherwise specified Plstic enlrgement of intestinl stom Reconstruction of stom of intestine Relese of scr tissue of intestinl stom 2 excision of redundnt mucos (45.41) Revision of stom of smll intestine 2 excision of redundnt mucos (45.33) AHA: 2Q, '05, Repir of pericolostomy herni Other revision of stom of lrge intestine 2 excision of redundnt mucos (45.41) AHA: 2Q, 02, 9 TIP: Assign for reloction of stom. b 46.5 Closure of intestinl stom Code lso ny synchronous resection (45.34, 45.49, ) Closure of intestinl stom, not otherwise specified Closure of stom of smll intestine Closure of stom of lrge intestine Closure or tke-down of cecostomy Closure or tke-down of colostomy Closure or tke-down of sigmoidostomy AHA: 1Q, 09, 5; 2Q, '05, 4; 3Q, 97, 9; 2Q, 91, 16; N-D, 87, 8 b 46.6 Fixtion of intestine Fixtion of intestine, not otherwise specified Fixtion of intestine to bdominl wll Fixtion of smll intestine to bdominl wll Ileopexy Other fixtion of smll intestine Noble pliction of smll intestine Pliction of jejunum DEF: Noble pliction of smll intestine: Fixing smll intestine into plce with tuck in smll intestine. DEF: Pliction of jejunum: Fixing smll intestine into plce with tuck in midsection Fixtion of lrge intestine to bdominl wll Cecocoloplicopexy Sigmoidopexy (Moschowitz) Other fixtion of lrge intestine Cecofixtion Colofixtion b 46.7 Other repir of intestine 2 closure of: ulcer of duodenum (44.42) vesicoenteric fistul (57.83) Suture of lcertion of duodenum Closure of fistul of duodenum Suture of lcertion of smll intestine, except duodenum AHA: 1Q, 10, Closure of fistul of smll intestine, except duodenum 2 closure of: rtificil stom (46.51) vginl fistul (70.74) repir of gstrojejunocolic fistul (44.63) Suture of lcertion of lrge intestine Closure of fistul of lrge intestine 2 closure of: gstrocolic fistul (44.63) rectl fistul (48.73) sigmoidovesicl fistul (57.83) stom (46.52) vginl fistul ( ) vesicocolic fistul (57.83) vesicosigmoidovginl fistul (57.83) AHA: 3Q, 99, Other repir of intestine Duodenoplsty AHA: 3Q, 02, 11 TIP: Assign for duodenoplsty, typiclly performed for infnts with congenitl duodenl webs nd stenosis. b 46.8 Diltion nd mnipultion of intestine AHA: 1Q, 03, Intr-bdominl mnipultion of intestine, not otherwise specified Correction of intestinl Reduction of: mlrottion intestinl volvulus Reduction of: intussusception intestinl torsion 2 reduction of intussusception with: fluoroscopy (96.29) ionizing rdition enem (96.29) ultrsonogrphy guidnce (96.29) DEF: Correction of intestinl mlrottion: Repir of bnorml rottion. DEF: Reduction of: Intestinl torsion: Repir of twisted segment. Intestinl volvulus: Repir of knotted segment. Intussusception: Repir of prolpsed segment. AHA: 4Q, 98, 82 TIP: Do not ssign if the documenttion indictes only running or milking the bowel. This is n integrl component of other procedures. Opertions on the Digestive System b Additionl Digit Required Vlid OR Procedure Non-OR Procedure Adjunct Code 2015 ICD-9-CM Volume 3 133

6 Present on Admission (POA) Tutoril Present on Admission (POA) Tutoril Bckground The Deficit Reduction Act of 2005 (DRA), section 5001(C), requires tht CMS implement Present on Admission (POA) indictors for ll dignoses nd externl cuses of injury on Medicre clims for inptient cute cre dischrges beginning October 1, Criticl ccess hospitls, Mrylnd wiver hospitls, long term cre hospitls, cncer hospitls, nd children s inptient fcilities re exempt from this requirement. Clim Submission Requirements Beginning October 1, 2007, ll inptient cute cre hospitl dischrges were required to be reported using POA indictors on ll dignoses nd externl cuse of injury codes. The only exception is for select group of codes tht re designted s exempt from the POA regultions. This list of codes my be found t the end of this tutoril. Hospitls tht filed to submit clims for dischrges on or fter April 1, 2008, hd clims returned for completion with POA indictors. CMS is lso required to identify t lest two conditions will be designted such tht when the POA indictor reflects tht they developed during the dmission, they will not be recognized s mjor compliction/comorbidity (MCC) or compliction/comorbidity (CC) conditions under the DRG inptient prospective pyment system (IPPS). These conditions will hve met the following criteri: high cost nd/or high volume represent conditions tht could hve been voided using evidence-bsed prctice guidelines when present with other secondry dignoses on the clim result in higher DRG pyment weight Effective October 1, 2008 (FY2009), hospitls do not receive dditionl pyment for clims with codes tht represent one of the selected conditions when not indicted s present on dmission, mening it developed during the cute cre inptient sty. The regultion effectively dectivtes the CC or MCC sttus of the code, but hospitl stff should be wre tht other conditions on the cse my crry vlid CC or MCC sttus. Refer to pge 60 of this tutoril, which provides list of the 12 conditions tht CMS hs designted s Hospitl Acquired Conditions nd will be included in the policy for FY2011. Generl Guidelines The POA indictor guidelines re not intended to replce the officil ICD-9-CM reporting guidelines. Nor will the POA guidelines supersede the Uniform Hospitl Dischrge Dt Set (UHDDS) definition of principl dignosis. A principl dignosis remins defined s the condition estblished fter study to be chiefly responsible for occsioning the dmission of the ptient to the hospitl. The definition of Other Dignoses lso remins the sme. Coders must report ll conditions tht coexist t the time of dmission, develop subsequently, or tht ffect the tretment received nd/or the length of sty. This hs significnt impct on the prctice of ssigning the POA indictors. Becuse the POA indictor selection should ccurtely reflect the ptient s conditions upon dmission, review of POA guidelines nd officil coding guidelines is required. Consistent, complete documenttion in the medicl record is of the utmost importnce. Lck of complete documenttion my impct DRG cse grouping nd reimbursement. It is incumbent upon the provider to resolve ny documenttion issues. The following is summry of the bsic POA Indictor Guidelines: The POA indictor requirement pplies only to cute cre hospitl inptient dmissions or other fcilities, s required by regultion for public helth reporting. A POA condition is defined not only s one tht is clerly present t the time of dmission, but lso those tht were clerly present, but not dignosed until fter the time of dmission. Present on dmission is defined s present t the time the order for n inptient dmission is mde, regrdless of whether the ptient s episode of cre originted in the emergency deprtment, mbultory surgery re, or other outptient re. Conditions tht develop during n outptient encounter re considered present on dmission. The POA guidelines re not intended to replce ny of the other ICD-9-CM Officil Guidelines for Coding nd Reporting. Guidelines re not intended to determine whether or not condition should be coded, but rther how to pply the POA indictor. The following options should be used to indicte whether condition ws POA: Y Yes N No U Unknown W Cliniclly undetermined Unreported/not used (Exempt from POA reporting) CMS hs developed stndrd exempt list of conditions nd externl cuses. For these codes the POA indictor is left blnk, except on the UB-04 form where n indictor of 1 is indicted s the equivlent of blnk. On the UB-04 blnks re undesirble when submitting this dt vi the 4010A. Beginning on or fter Jnury 1, 2011, hospitls were required to begin reporting POA indictors using the 5010 electronic trnsmittl stndrds form. The 5010 formt elimintes the need to report POA indictor of 1 for codes tht re exempt from POA reporting. The POA field should insted be left blnk for codes exempt from POA reporting. See Appendix 1 of the ICD-9-CM Officil Coding Guidelines for Coding nd Reporting nd the end of this tutoril for the complete list of exempt codes. When using the options listed bove, the following definitions should be used: Y present t the time of inptient dmission N not present t the time of inptient dmission U documenttion is insufficient to determine if condition is present on dmission W Provider is unble to cliniclly determine whether condition ws present on dmission or not Most ICD-9-CM dignosis codes nd E codes require POA indictor ssignment. However, there re some dignoses tht re considered exempt from the POA reporting. To view exempt codes, refer to the ICD-9-CM Officil Guidelines for Coding nd Reporting nd the end of this tutoril. The list reflects those conditions tht either do not represent current disese or re lwys considered POA. Timefrme for POA Identifiction nd Documenttion There is no specific or required timefrme for which provider must identify or document condition to be present on dmission. In some clinicl situtions it my not be possible for provider to determine whether condition is POA t the point of dmission; review of lbortory or other results my be necessry. A condition my not be recognized or reported by the ptient for period of time fter dmission, but it does not necessrily men tht the condition ws not present on dmission. Determintion of whether the condition ws POA or not should be bsed on the pplicble POA guideline in the ICD-9-CM Officil Guidelines for Coding nd Reporting, or on the provider s best clinicl judgment. If it is not cler t the time of coding whether condition ws POA or not, it is pproprite to query the provider for further clrifiction. Specific Guidelines Complete nd ccurte medicl record documenttion is criticl spect of the pproprite ssignment of POA indictors. The ICD-9-CM Officil Guidelines for Coding nd Reporting indicte tht to chieve ccurte nd complete documenttion, code ssignment, nd reporting of dignoses nd procedures, documenttion must be collbortive effort between helthcre provider nd the coder. To ssist the coder in determining which documenttion in the medicl record my be used for code selection, n Officil Guidelines for Source Documenttion Tble is provided t the end of this section. Assignment of POA indictors my be confusing for severl types of cses, prticulrly if the documenttion is not cler. The following re exmples of POA guidelines nd cse scenrios illustrting vrious coding situtions: Note: As lwys, query the physicin for definitive dignosis when documenttion is inconsistent. The tips re presented s guide to wht informtion coder might review in the process of verifying dignosis before ssigning POA indictor. The HIM deprtment should work closely with the medicl stff to develop list of criteri for ll conditions tht re frequently queried. Combintion Codes: Assign N if ny prt of the combintion code ws not present t the time of dmission. If the combintion code only identifies the chronic condition nd not the ssocited cute excerbtion, ssign Y. Exmple: Obstructive chronic bronchitis with cute excerbtion Tips: The POA indictor N would be ssigned if the excerbtion did not hppen until fter the dmission (code ). Definition of cute excerbtion: the presence of one or more of the following findings re indictions of cute excerbtion: increse in sputum purulence, 54 Resources 2015 ICD-9-CM