Contents in Brief USER S GUIDE PART I INTRODUCTION TO ICD-9-CM 1 PART II CODING FOR SPECIFIC DISEASES AND DISORDERS 69

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Contents in Brief USER S GUIDE IX PART I INTRODUCTION TO ICD-9-CM 1 CHAPTER 1 Introduction to ICD-9-CM Coding 3 CHAPTER 2 Coding Conventions, Rules, and Guidelines 25 CHAPTER 3 Medical Records: The

1 Contents in Brief USER S GUIDE IX PART I INTRODUCTION TO ICD-9-CM 1 CHAPTER 1 Introduction to ICD-9-CM Coding 3 CHAPTER 2 Coding Conventions, Rules, and Guidelines 25 CHAPTER 3 Medical Records: The Basis for All Coding 41 PART II CODING FOR SPECIFIC DISEASES AND DISORDERS 69 CHAPTER 4 Coding for Symptoms, Signs, and Ill-Defined Conditions 71 CHAPTER 5 Coding for Endocrine, Nutritional, Metabolic, and Immune Disorders 91 CHAPTER 6 Coding for Infectious and Parasitic Diseases 121 CHAPTER 7 Coding for Digestive System Diseases 147 CHAPTER 8 Coding for Respiratory System Diseases 189 CHAPTER 9 Coding for Genitourinary System Diseases 225 CHAPTER 10 Coding for Skin and Subcutaneous Tissue Diseases 267 CHAPTER 11 Coding for Musculoskeletal System and Connective Tissue Diseases 295 CHAPTER 12 Coding for Diseases of the Nervous System and Sense Organs 329 CHAPTER 13 Coding for Diseases of the Circulatory System, Blood, and Blood-Forming Organs 371 CHAPTER 14 Coding for Neoplasms 429 CHAPTER 15 Coding for Complications of Pregnancy, Childbirth, and the Puerperium 471 CHAPTER 16 Coding for Conditions in the Perinatal Period and Congenital Anomalies 523 CHAPTER 17 Coding for Injury and Poisoning 559 xxi

2 xxii Contents in Brief CHAPTER 18 Coding for Complications of Surgical and Medical Care 611 CHAPTER 19 Coding for Mental Disorders 639 PART III THE IMPACT OF CODING ON HEALTH SERVICES ADMINISTRATION 667 CHAPTER 20 Managed Health Care and Health Information Management 669 APPENDIX 1 Medicare Severity-Adjusted Diagnosis-Related Groups (MS-DRGs) 687 APPENDIX 2 Laboratory Reference Range Values 703 APPENDIX 3 Medical Prefixes, Suffixes, and Combining Forms 723 APPENDIX 4 Common Medical Abbreviations and Acronyms 729 APPENDIX 5 ICD-9-CM Codes for APPENDIX 6 Answers to Testing Your Comprehension 747 APPENDIX 7 Student Answers to Coding Practice I: Chapter Review Exercises 755 INDEX 763

3 Expanded Contents PART I INTRODUCTION TO ICD-9-CM 1 CHAPTER 1 Introduction to ICD-9-CM Coding 3 History of the ICD-9-CM 4 Medical Coding Simplifies Reimbursement 5 Other Uses of Medical Coding 7 Format and Content of ICD-9-CM 8 Alphabetic Index to Diseases (Volume 2) 8 Tabular List of Diseases (Volume 1) 10 Alphabetic Index to Procedures and Tabular List of Procedures (Volume 3) 12 Coding Compliance 15 ICD-10-CM and ICD-10-PCS 15 Summary 22 References 22 Testing Your Comprehension 23 CHAPTER 2 Coding Conventions, Rules, and Guidelines 25 Coding Conventions 26 ICD-9-CM Disease and Procedure Index Conventions 26 ICD-9-CM Disease and Procedure Tabular Conventions 28 Uniform Hospital Discharge Data Set 31 UHDDS Rules and Definitions 31 General Coding Guidelines 32 Diagnosis Coding 32 Procedure Coding 35 V and E Codes (Supplementary Classifications) 36 Summary 37 Reference 37 Testing Your Comprehension 38 Coding Practice I 39 xxiii

4 xxiv Expanded Contents CHAPTER 3 Medical Records: The Basis for All Coding 41 Format of Medical Records 42 Content of Medical Records 43 Incomplete Medical Records 43 Ten Steps for Coding from Medical Records 43 Step 1: Review Face Sheet or Registration Record 44 Step 2: Review History and Physical, Emergency Department Report, and/or Consultant s Report 44 Step 3: Review Operative Reports, Special Procedure Reports, and/or Pathology Reports 45 Step 4: Review Physician s Progress Notes 45 Step 5: Review Laboratory, Radiology, and/or Special Test Reports 45 Step 6: Review Physician s Orders 46 Step 7: Review Medication Administration Record (MAR) 46 Step 8: Review Discharge Summary or Clinical Résumé 46 Step 9: Assign Codes 46 Step 10: Submit Physician/Coder Query/Clarification Form 46 Summary 51 Reference 51 Testing Your Comprehension 52 Coding Practice I 53 Coding Practice II 54 PART II CODING FOR SPECIFIC DISEASES AND DISORDERS 69 CHAPTER 4 Coding for Symptoms, Signs, and Ill-Defined Conditions 71 Inpatient Coding 72 Outpatient Coding 73 Abnormal Findings 74 Coding Symptoms Integral to Disease 75 Summary 75 Reference 75 Testing Your Comprehension 76 Coding Practice I 77 Coding Practice II 79 CHAPTER 5 Coding for Endocrine, Nutritional, Metabolic, and Immune Disorders 91 Endocrine Disorders 92 Diabetes Mellitus 92 Type 1 and Type 2 Diabetes 93 Hypothyroidism and Hyperthyroidism 96 Syndrome of Inappropriate Antidiuretic Hormone and Associated Hyponatremia 96 Cystic Fibrosis 96 Nutritional Disorders 97 Malnutrition 97 Vitamin and Mineral Deficiencies 98 Obesity, Morbid Obesity, and Overweight 98 Metabolic Disorders 99 Electrolytes: Sodium and Potassium 99 Volume Depletion 99 Hypercholesterolemia and Hypertriglyceridemia 100 Immune Disorders 100 Summary 101 Reference 101

5 Expanded Contents xxv Testing Your Comprehension 102 Coding Practice I 103 Coding Practice II 105 CHAPTER 6 Coding for Infectious and Parasitic Diseases 121 Septicemia 122 Urosepsis and Bacteremia 123 Resistant Organisms 124 Additional Codes for Bacterial and Viral Agents 124 Infectious Gastroenteritis with Dehydration 125 Respiratory Syncytial Virus 125 AIDS- and HIV-Related Conditions 126 Coding Infections or Diseases Related to HIV/AIDS 126 HIV Testing Codes 127 Viral Hepatitis 127 Meningitis 128 Tuberculosis 129 H1N1 Influenza Virus 129 Summary 129 Testing Your Comprehension 130 Coding Practice I 131 Coding Practice II 133 CHAPTER 7 Coding for Digestive System Diseases 147 Diverticulosis 148 Gastrointestinal Ulcers 150 Gastrointestinal Bleeding 152 Esophagitis, Gastritis, and Duodenitis 152 Gastroesophageal Reflux Disease 153 Gallbladder and Biliary Duct Diseases 153 Cholecystitis 154 Pancreatitis 156 Bowel Obstructions 156 Inflammatory Bowel Diseases 157 Appendicitis 158 Hernias 159 Inguinal Hernias 159 Ventral and Incisional Hernias 160 Hiatal Hernias 161 Angiodysplasia (or Arteriovenous Malformations) of the Gastrointestinal Tract 161 Diarrhea and Constipation 162 Summary 163 Testing Your Comprehension 164 Coding Practice I 165 Coding Practice II 167 CHAPTER 8 Coding for Respiratory System Diseases 189 Diagnosis Coding for Respiratory Diseases 190 Pneumonia 191 Gram-Positive Versus Gram-Negative Pneumonia 192 Aspiration Pneumonia 193 Chronic Obstructive Pulmonary Disease 194

6 xxvi Expanded Contents Asthma 194 Respiratory Failure 194 Pulmonary Edema 197 Atelectasis 198 Pleural Effusion 199 Adult Respiratory Distress Syndrome 200 Procedure Coding for Respiratory Diseases 200 Bronchial and Lung Biopsies 201 Thoracentesis 201 Chest Tube Insertion 201 Tracheostomy 201 Lung Resections, Lobectomy, or Complete Pneumonectomy 202 Endotracheal Intubation and Mechanical Ventilation 203 Summary 204 Reference 204 Testing Your Comprehension 205 Coding Practice I 206 Coding Practice II 208 Coding Practice III 222 CHAPTER 9 Coding for Genitourinary System Diseases 225 Genitourinary Symptoms 226 Genitourinary Infections and Inflammations 227 The Renal System and Associated Diseases 228 How the Renal System Works 229 Renal Hormones 231 Renal Failure: Acute Versus Chronic 231 Renal Failure With Hypertension 232 Renal Dialysis and Transplantation 233 Other Specified Renal Diseases 237 Renal Stones 238 Female Genitourinary Conditions 241 Endometriosis 241 Cervical Dysplasia 242 Genital Prolapse 242 Dysfunctional Uterine Bleeding 243 Breast Diseases 243 Male Genitourinary Conditions 244 Summary 245 Testing Your Comprehension 246 Coding Practice I 248 Coding Practice II 250 CHAPTER 10 Coding for Skin and Subcutaneous Tissue Diseases 267 Cellulitis 268 Skin Ulcers 271 Dermatitis 272 Erythematous Conditions 273 Debridement Procedures 274 Biopsies and Excisions of Skin Lesions 275 Repairs of the Skin 275 Summary 276 Testing Your Comprehension 277

7 Expanded Contents xxvii Coding Practice I 278 Coding Practice II 280 CHAPTER 11 Coding for Musculoskeletal System and Connective Tissue Diseases 295 Musculoskeletal Disorders 296 Arthritic Disorders 296 Chronic versus Traumatic Joint Derangements 301 Pathologic Versus Traumatic Bone Fractures 302 Stress Fractures 303 Osteomyelitis 303 Necrotizing Fasciitis 303 Costochondritis 303 Back and Spine Disorders 304 Connective Tissue Diseases 307 Systemic Lupus Erythematosus 307 Systemic Sclerosis 307 Summary 307 Testing Your Comprehension 308 Coding Practice I 310 Coding Practice II 312 CHAPTER 12 Coding for Diseases of the Nervous System and Sense Organs 329 Disorders of the Central Nervous System (CNS) 331 Inflammatory Disorders 331 Degenerative Diseases 333 Other Disorders of the CNS 334 Hemiplegia and Hemiparesis 335 Disorders of the Peripheral Nervous System (PNS) 338 Acute Infective Polyneuritis (Guillain-Barré Syndrome) 339 Disorders of the Eye and Adnexa 340 Anatomy and Physiology 340 Blindness 341 Cataracts 343 Glaucoma 343 Strabismus 344 Macular Degeneration 344 Retinal Detachment 344 Disorders of the Ear 345 Anatomy and Physiology 345 External Ear Conditions 346 Middle Ear Conditions 346 Inner Ear Conditions 347 Summary 347 References 347 Testing Your Comprehension 348 Coding Practice I 350 Coding Practice II 352 CHAPTER 13 Coding for Diseases of the Circulatory System, Blood, and Blood-Forming Organs 371 The Circulatory System 372 Diseases of the Circulatory System 375 Cardiovascular Disease 375

8 xxviii Expanded Contents Cerebrovascular Disease 395 Peripheral Vascular Diseases 396 Aneurysms 398 Miscellaneous Vascular Access Procedures 399 Blood and Blood-Forming Organ Diseases 399 Anemias 400 Pancytopenia 400 Coagulopathies 401 Summary 402 References 402 Testing Your Comprehension 403 Coding Practice I 405 Coding Practice II 407 CHAPTER 14 Coding for Neoplasms 429 Classifying Neoplasm Behaviors 430 Malignant Neoplasms 430 Primary and Secondary (Metastatic) Cancer 431 Carcinoma In Situ 431 Benign Neoplasms 431 Neoplasms of Uncertain Behavior 432 Unspecified Neoplasms 432 Morphology Codes 432 Grading and Staging of Cancer 433 Locating Neoplasm Codes 434 Coding Solid-Tumor Malignancies 435 Primary Versus Secondary (Metastatic) Malignancies 435 Contiguous Sites 437 Coding Hematopoietic and Lymphatic Malignancies 437 Cancers of the Blood and Bone Marrow 438 Cancers of the Lymphatic System 439 Identifying the Principal Diagnosis 440 Treatment of the Primary and Secondary Cancer 440 Treatment for Side Effects or Complications Only 441 Follow-Up Treatment 442 Cancer Protocols 443 Summary 444 References 444 Testing Your Comprehension 445 Coding Practice I 446 Coding Practice II 448 CHAPTER 15 Coding for Complications of Pregnancy, Childbirth, and the Puerperium 471 The Obstetric Record 472 Prenatal Section 473 Labor and Delivery Section 473 Postpartum Section 474 Distinguishing Time in Pregnancy Coding 474 Stages of Labor 475 Locating Pregnancy Codes in the Disease Index 476 Outcome-of-Delivery Codes 476 Uncomplicated Pregnancy with Normal Delivery 477 Complications of Pregnancy and Delivery 478 Common Complication Codes 480

9 Expanded Contents xxix Common Labor and Delivery Procedures 483 Delivery Prior to Admission 484 Pregnancy Supervision Codes 485 Admission or Encounter for Sterilization 486 Pregnancy With Abortive Outcome 487 Molar and Ectopic Pregnancy 489 Summary 490 Testing Your Comprehension 491 Coding Practice I 493 Coding Practice II 496 CHAPTER 16 Coding for Conditions in the Perinatal Period and Congenital Anomalies 523 Congenital Codes and Patient Age 524 Newborn Medical Record Format and Apgar Score 525 Newborn Identifying Information 525 Newborn Delivery and Assessment 525 Newborn Progress Notes 526 Admission-for-Birth Codes 526 Common Perinatal Conditions and Congenital Anomalies 527 Gestation Time and Birth Weight 528 Neonatal Jaundice 529 Perinatal Sepsis 530 Fetal Distress 530 Maternal Conditions Affecting the Fetus or Newborn 530 Rh Incompatibility 530 Respiratory Distress Syndrome 531 Fetal and Newborn Aspiration 531 Transitory Tachypnea of Newborn 532 Neonatal Apnea 532 Neonatal Cyanosis 532 Patent Ductus Arteriosus 532 Congenital Atrial and Ventricular Septal Defects 532 Congenital Pyloric Stenosis 534 Feeding Problems in the Newborn 535 Congenital Hydrocephalus 535 Hemangioma 536 Congenital Spina Bifida 536 Birth Before Admission 537 Newborn Supervision Code 537 Routine Neonatal Procedures 537 Summary 537 Testing Your Comprehension 538 Coding Practice I 539 Coding Practice II 542 CHAPTER 17 Coding for Injury and Poisoning 559 Sequencing Codes for Multiple Injuries 560 Using E Codes to Report Causes and Locations of Injuries 561 Using E Codes to Report Sentinel Events 562 Using E Codes to Classify Collisions 562 Fractures 563 Common Procedures for Treating Fractures 564 Dislocations 566 Common Procedures for Treating Dislocations 567

10 xxx Expanded Contents Sprains and Strains of Joints and Muscles 567 Open Wounds 567 Amputations 568 Intracranial Injuries 569 Injuries to Internal Organs 570 Superficial Injuries 570 Injuries to Blood Vessels, Nerves, and Spinal Cord 570 Contusions and Crushing Injuries 571 Foreign Body Entering Orifice 571 Burns 572 Sequencing Burn Codes 573 Early Complications of Trauma 573 Poisoning by Drugs and Adverse Effects of Drugs 575 Late Effects of Injuries and Poisonings 577 Classifying Child and Adult Abuse 578 Summary 579 Reference 579 Testing Your Comprehension 580 Coding Practice I 582 Coding Practice II 585 CHAPTER 18 Coding for Complications of Surgical and Medical Care 611 Nosocomial versus Iatrogenic Adverse Effects or Events 612 Medical Staff Bylaws 613 Sequencing Complication Codes 615 Complications of Medical Devices, Implants, and Grafts 615 Complications of Transplanted Organs 616 Nonspecific Complication Codes That Describe General Body Systems 617 Complications Causing Outpatient to Inpatient Admission Within 72 Hours 618 Other Indicators of Complications of Surgical and Medical Care 618 Summary 620 Testing Your Comprehension 621 Coding Practice I 622 Coding Practice II 625 CHAPTER 19 Coding for Mental Disorders 639 The Diagnostic and Statistical Manual of Mental Disorders 640 Types of Mental Disorders 641 Anxiety Disorders 642 Eating Disorders 642 Affective Psychoses 642 Delirium and Dementia 643 Schizophrenia 644 Substance-Related Disorders 644 Personality Disorders 647 Alzheimer s Disease 647 Psychogenic Disorders and Psychic Factors Associated with Diseases 648 Organic Brain Syndrome 648 Therapies for Mental Disorders, Including Treatments foralcohol and/or Drug Abuse 649 Summary 649 Testing Your Comprehension 650

11 Expanded Contents xxxi Coding Practice I 652 Coding Practice II 654 PART III THE IMPACT OF CODING ON HEALTH SERVICES ADMINISTRATION 667 CHAPTER 20 Managed Health Care and Health Information Management 669 Origin, Emergence, and Early Development Prepaid Health Care 670 Prepaid Health Care to Managed Health Care 672 Legislation Leading to Managed Care 672 Past and Present of Health Information Management 677 Types of Managed Care Organizations 679 Health Maintenance Organizations 679 Preferred Provider Organizations 679 Physician Hospital Organizations 679 Point-of-Service Plans 680 Independent Practice Associations 680 The Future of Managed Care and the Growing Role of Coding and Health Information Management 680 A Recent Addition to the Managed Care Jargon 683 Summary 684 References 684 Testing Your Comprehension 686 APPENDIX 1 Medicare Severity-Adjusted Diagnosis-Related Groups (DRGs) 687 APPENDIX 2 Laboratory Reference Range Values 703 APPENDIX 3 Medical Prefixes, Suffixes, and Combining Forms: The Building Blocks of Medical Language 723 APPENDIX 4 Common Medical Abbreviations and Acronyms 729 APPENDIX 5 ICD-9-CM Codes for APPENDIX 6 Answers to Testing Your Comprehension 747 APPENDIX 7 Student Answers to Coding Practice I: Chapter Review Exercises 755 INDEX 761

Episodes of Care Risk Adjustment

Episodes of Care Risk Adjustment Episode Types Wave 1 Asthma Acute Exacerbation Perinatal Total Joint Replacement Wave 2 Acute Percutaneous Coronary Intervention COPD Acute Exacerbation Non-acute Percutaneous