Coding ICD (Clinical Modification Revisions 9 and 10)

Coding ICD (Clinical Modification Revisions 9 and 10) Book contains two major sections: The Tabular List and the Index. Never code directly from the index. All codes taken from the index must be verified by reading their description in the tabular list, checking any instructions or exclusions, and assigning the required number of characters. CATEGORIES: Codes are listed in categories of first 3-characters. Usually there are category instructions, so scan up to the top of the category above the code and look for Code Also, Code First, Includes and Excludes notes and other instructions. In ICD-9-CM there are several major types of notes: Code Also note means that you should use an ADDITIONAL code if you have the Code Also condition. Code First is the same as Code Also but it indicates the additional code should be sequenced BEFORE the current code. This means there is an Etiology code and a Manifestation code (see Sequencing below). Includes note means that the code can be used for any or all of the included conditions. Examples of things covered by the code. Excludes note means that you should not use this code (use a different one) if you have the excluded condition. ICD-10-CM there are all of the above, but there are two types of Excludes notes: Excludes 1 : means that you DO NOT use this code (use a different one) if you have the excluded condition (same as ICD-9 Excludes ). Excludes 2 : (new to ICD-10) means that this code does not report the excluded condition and IF the patient concurrently has BOTH conditions, you should use an ADDITIONAL code to report the Excludes 2 condition (similar to Code Also but only necessary when BOTH conditions exist and they both apply). CHARACTERS: Always code to the highest level of specificity go to the number of characters required. Note: In ICD-9 the word digit was used instead of character. ICD-9-CM is numeric and can be from 3 to 5 characters. If an ICD-9-CM code needs a 5 th character, this means it ALSO must have a valid 4 th character. ICD-10-CM is alpha-numeric and can be from 3 to 7 characters.. If ICD-10-CM requires a 7 th character and the rest of the code is less than 6 characters long, one or two place-holder x characters are added to fill spots 5 and 6 or just 6, then the 7 th character is applied. Examples of ICD-10-CM listings with 7th character and place-holder: The appropriate 7th character is to be added to each code from category T36 "A"initial encounter "D"subsequent encounter "S" equela o T36.0 Poisoning by, adverse effect of and underdosing of penicillins o T36.0X Poisoning by, adverse effect of and underdosing of penicillins o T36.0X1 Poisoning by penicillins, accidental (unintentional) o Poisoning by penicillins NOS o T36.0X2 Poisoning by penicillins, intentional self-harm o T36.0X3 Poisoning by penicillins, assault o T36.0X4 Poisoning by penicillins, undetermined o T36.0X5 Adverse effect of penicillins

o T36.0X6 Underdosing of penicillins o= means needs 7th character added.additional characters often can be found below the code, or at the beginning of the three character diagnostic code Category. Scan down first, if it s not right there, go back to the 3-character category. Unspecified Dr. didn t specify (narrative was vague). Not Otherwise Specified (NOS). The doctor did not give a more specific description, so you are choosing a code that is non-specific, (in some instances be similar to other specified, depending on the codebook section). NOTE: Try to check for more information from reports or from the physician before selecting NOS codes. Other Specified Dr. said something other than what s listed in the book. Not Elsewhere Classified (NEC). The doctor gave you a description of a condition that is not specifically described in the ICD-9 or ICD-10 and you are picking the closest generic code. Recent Example: H1N1 flu the year before that new condition was added to the codebook. Etiology. An underlying disease that is direct cause of other diseases. Manifestation. A disease or condition with an underlying cause (Etiology) Italisized [brackets]. In the index this indicates an additional code to be used with the initial code and often gives the order in which they are to be listed. See Etiology and Manifestation. Symptom. The signs or complaints associated with a condition, but not a diagnosis. Eponym: Named for person or place: Spanish Influenza, Lou Gehrig s Disease, etc. AND means and/or so if can be either or both conditions. Use Additional or Code Also. You will need another code besides this code to report the condition and its manifestation or co-condition. Code First. Directs you to not only include the code for an underlying condition, but also to list that code before this code. General Sequencing Rules: Only list problems being treated or evaluated at this encounter. The primary diagnosis is either the one that required the most attention during the visit, or the etiology of the diagnosis that required the most attention. For example, in ICD-9, if a patient is being treated for hypertension briefly, but mainly for neuropathy due to diabetes, the condition is neuropathy, but the etiology is diabetes, and diabetes would be sequenced first, followed by neuropathy, and then hypertension. Multiple coding/combination coding is less common in ICD-10. ETIOLOGY before MANIFESTATION. Codes in Italics in tabular list: Never coded primary because they are Manifestation codes: Always code the underlying disease FIRST (often it suggests codes for the underlying disease under the code). Manifestation can never be primary or sole diagnosis. ACUTE usually before CHRONIC condition. If the code has an acute on chronic option for patients with an exacerbation of a chronic condition use that. Otherwise, acute listed before chronic. Diagnosed ILLNESS before BACTERIAL culture results. ILLNESS generally before health factor codes (ICD-9: V-Codes; ICD-10: Z-Codes), but not always, so reference the instructions for the code. Certain services, such as chemotherapy, radiation therapy, dialysis and aftercare are always coded with a factor code first. ILLNESS generally instead of SYMPTOMS (e.g. runny-nose and cough are unnecessary if diagnosis is naso-pharyngitis/cold) except when the symptom is unusual or signifies the severity (e.g., severe headache or high fever with naso-pharyngitis/cold). Symptoms and signs in ICD-9 are 78# and 79# codes; in ICD-10 S and T codes.

Possible/Rule-Out/Suspected/Probable should not be coded on outpatient claims as the are guesses and not diagnoses.. A real diagnosis should be billed. If there is no real diagnosis, you may bill the patients symptoms. Suspected conditions are coded on inpatient hospitalization claims only. Factors Affecting Health Status (ICD-9: V-Codes; ICD-10: Z-Codes). Person generally is NOT ILL. They may be used for: Well care, screening services, prevention/vaccination, donating tissue/organs, discussing a non illness-related problem, family planning, pregnancy supervision. Aftercare post-disease. No current illness but circumstance affecting health such as possible exposure to disease. Indicating birth status and number. Sometimes used by labs or radiology providers when the doctor does not give them the diagnosis (this should be seldom to never and absolutely never on Medicare). Common Main Terms for Factor Codes: Admission for, Aftercare, Attention to, Care of, Carrier, Contact, Contraception, Counseling, Dialysis, Donor, Encounter for, Examination, Fitting of, Follow-up, Health, History of, Maintenance, Maladjustment, Newborn, Observation, Problem, Prophylactic, Replacement, Routine, Screening, Status, Supervision, Test, Transplant, Vaccination. External/ Environmental Causes of Injury and Poisoning. (ICD-9: E-Codes; ICD-10: V,X,Y-Codes.) This is HOW it happened, not what s wrong. Mainly helps clarify place and cause of injury such as motor vehicle accident, Boiling Liquid Injury In Public Place, etc. Always the last in the series of codes, these help establish if there is a third party liability. Signs, Symptoms, Ill-defined conditions ICD-9 780-799.9; ICD-10 S00-T88. Outpatient, code only what has been proven. Don t code rule out, questionable, likely, probable diagnosis. Code only what is known using sign/symptom. Hospital inpatient code the rule out, questionable, likely, probable diagnosis, but only as Admitting Diagnosis, not as Principal Diagnosis. Examples painful respiration, abnormal chest sounds. ICD-9: Coding Late Effects (or SEQUELA): When the physician identified a current condition as a residual effect of a previous condition, most of the time, late effects will have two diagnostic codes: Condition (scarring, mental retardation, paralysis, etc.) PLUS Late Effect Code (ICD-9 905 909) PLUS ICD-9 E Code Late Effects Code ICD-10 Coding SEQUELA (formerly late effects ): Usually requires two codes: The condition or nature of the sequela followed by the actual sequela code indicating sequela to past condition. Additional characters often indicate a sequela, for example S may be required as the 7 th character of some codes to indicate it is a sequela, while others will have a numerical indicator for sequela. Reference the index for Sequela. Late effects cross references to sequela. ICD-10 LATERALITY: In some ICD-10 codes you must specify whether the condition was on the LEFT, RIGHT, BILATERAL (both sides) or Unspecified side. If the condition was bilateral and there are no codes for bilateral, assign both the right side and the left side code. Infectious Diseases When you are coding a disease and the organism responsible, code the disease first, the bug second; example: Tuberculosis due to mycobacterium bovis. Bacteremia: presence of bacteria in blood; abnormal blood culture. Contagious: any infectious condition that is spread communicably.

Infectious: any condition that can be transferred from one person to another. NOTE: All contagious diseases are infections, not all infectious diseases are contagious. Possible example: west Nile virus is not transferred from one person to another but is caught through mosquito bite. Human Immunodeficiency Virus (HIV) Someone who is HIV-positive and is asymptomatic code (ICD-9 V08; ICD-10 Z21) Someone who is HIV-positive with signs, symptoms, manifestations code (ICD-9 042; ICD-10 B20) (AIDS) Once a person is coded 042 or B20, they cannot be coded V08/Z21 again! Even when they return to being asymptomatic. Symptoms can involve pneumocystis carinii pneumonia, Kaposi s Sarcoma, or other manifestations of AIDS. Neoplasm Tumor, New Growth USE THE NEOPLASM TABLE Neoplasm is a tumor or abnormal mass. Table columns allow classification as benign or malignant, or uncertain behavior. Malignancies can be In Situ (no metastasis) or Primary location/organ or Secondary locations/organs (metastasis). See the Neoplasm chart in this handout. If the histology (type of cancer) is known, you may also find the code under the type of cancer in the index. Diabetes Mellitus (DM) Diabetes Mellitus is a chronic systemic disease that causes the body to improperly metabolize carbohydrates, proteins and fats. Secondary Diabetes: Diabetes caused by medication or other condition. Unless listed as secondary, diabetes is primary. Secondary DM is when a drug or other treatment is causing the diabetes. Type 1 DM: Sudden onset insulin deficiency, may occur at any age, but most often in childhood, also known as insulin-dependent DM (IDDM) or juvenile DM. Final character 1 if not stated uncontrolled; 3 if uncontrolled. Patient always on insulin, but don t assume all patients on insulin are Type 1!!!!! Type 2 DM: Occurs gradually, may develop at any age but most often after the age of 40; also known as non-insulin-dependent DM (NIDDM). Patient may or may not be on insulin. A factor code should be added for current use of insulin. Uncontrolled DM: current therapies and/or treatments are not maintaining a proper blood sugar level. If diagnosis of Ketoacidosis, assume uncontrolled. Otherwise, always assume controlled unless uncontrolled specified. Gestational DM: occurs during pregnancy usually temporarily; patient has increased risk of developing DM later on in life. ICD-9 Hypertension USE THE HYPERTENSION TABLE-INDEX: Essential Hypertension = no known cause or complication Malignant = life-threatening. Benign=not life-threatening. Unspecified (very common but not very precise). Elevated blood pressure without mention of condition or diagnosis of hypertension is ICD-9 796.2; ICD-10 R03.0 the patient may just have been late for their appointment and ran all the way up the stairs to the office! Gestational hypertension is listed as a complication of pregnancy code. ICD-10 hypertension coding is EASIER, no more Hypertension Table! For both ICD-9 and ICD-10: A medical condition described as Hypertensive or if you have Hypertension due to code with a single hypertension code. Hypertension with a heart condition that is not stated as due to hypertension or hypertensive should be codes as separate side-by-side conditions. However, hypertension with chronic kidney disease may be coded as one code as if listed as hypertensive as ICD assumes there is always a

cause and effect relationship between hypertension and kidney disease. An additional code is required to give the stage of the kidney disease. Fractures Fracture is the break of cartilage or bone. NOTE: Pathological fractures are not coded from the same category as traumatic fractures! Site of the body fractured Open/Closed Fracture. If it does not say Open or does not list any of the synonyms of open, you assume closed. Synonyms for open fracture include: compound/infected/missile/puncture/with foreign body. Segment: What particular part of the bone was affected? Dislocations: Dislocation is displacement of a limb, bone or organ from its customary position. Subluxation: a partial dislocation. For chiropractic purposes, subluxation in ICD-9 starts with 739.#. These are *tentatively* anticipated to be ICD-10 M99 codes, but Medicare will determine this. An OPEN dislocation may also be termed: compound, infected, with foreign body. A CLOSED dislocation may also be termed: Complete, dislocation NOS, Partial, simple, uncomplicated. Burns When coding burns, you will need at least three codes: Site and Severity. One code to indicate where on the body, and what extent (first, second or third degree burn severity). Third-degree burns can be described as necrosis. Second-degree burns will show blistering. First-degree burns will show redness. Note: Code with the highest degree of burns first in sequence! Extent: What percentage of the body has been burned? Use the rule of nines each limb is 9%, head and neck are 9%, chest is 9%, abdomen is 9%, upper back is 9%, lower back and buttocks are 9%, genitals are 1%. Calculate the total area as the 4 th character. The 5 th character is the total of 3 rd degree burns ONLY. This code starts with 948 in ICD-9; it starts with T31 in ICD-10. Infected burn site: add code for posttraumatic wound infection, NEC, to the other codes for the case. Non-healing burn: code as a current burn Scar (identified as the lasting effect of a burn): code as late effect of that burn. Poisoning & Adverse Effects TABLE OF DRUGS AND CHEMICALS Poisoning is a condition produced by a substance that harms or causes death. Adverse Effect is an unexpected result from a medical treatment. Toxic = poisonous. Table of Drugs and Chemicals coulumns indicate poisoning, accident, therapeutic use, suicide attempt, assault, or undetermined cause. Poisonings include mixing alcohol with prescription drugs. Poisoning is ICD-9 960-989; ICD-10 T36-T65. Intoxication is considered an adverse effect rather than poisoning. Is the poisoning a deliberate overdose, or the wrong drug is given or taken in error? Be very certain before you code suicide, assault or some sort of medical malpractice; these may have legal consequences if used incorrectly. If not certain, list as undetermined. Coding Poisonings: Poison: What drug or chemical caused the adverse reaction? Effect: What effect did the poison have on the patient (coma, nausea, rash, etc.)? Explanation (ICD-9 E code or ICD-10 T code): Was it an accidental poisoning, an attempted suicide or an assault?

Adverse Effects Code condition (ventricular fibrillation) first. Find drug in table, find drug Digoxin, Adverse Effects or Therapeutic Use column. Code in that order: (ICD-9 427.41, then E942.1. ICD-10 I49.01, then T46.0x5). Coding Adverse Effects: If the drug was prescribed by a physician and: The correct drug was taken, in the correct dosage, at the right time Via the right route of administration (i.e., orally, IV, IM, etc.) And had an adverse reaction Do NOT include a poisoning code; only code the effect and the E Code. Effect: What effect did the prescribed drug have on the patient (coma, nausea, rash, etc.)? Explanation (ICD-9 E code; ICD-10 T code): Identify this drug as being given for therapeutic use. FOR DETAILED INSTRUCTIONS, please REFER to the CDC s Official Guidelines for Coding (listed in the front of the ICD book) for specific coding rules.