ICD-9-CM for Hospitls Volumes 1, 2 & 3 2014 Professionl 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, 2014, Optum will provide these code chnges to you t no dditionl cost! Just check bck t www.optumcoding.com/productlerts to review the ltest informtion concerning ny new code chnges. Codes Vlid October 1, 2013, through September 30, 2014
415 420.91 Diseses of the Circultory System Tbulr List 415 420.91 Diseses of the Circultory System Diseses of Pulmonry Circultion (415-417) b 415 Acute pulmonry hert disese 415.0 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, 416.8-416.9, 459.89-459.9 c 415.1 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 (634-638 with.6, 639.6) ectopic or molr pregnncy (639.6) pregnncy, childbirth, or the puerperium (673.0-673.8) 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, 25 11 415.11 Itrogenic pulmonry embolism nd infrction Use dditionl code for ssocited septic pulmonry embolism, if pplicble, 415.12 CC Excl: 415.11-415.19, 416.2, 444.01-444.09, 459.89-459.9 AHA: 4Q, 95, 58 TIP: Do not report code 997.39 Other respirtory complictions, with code 415.11. 415.12 Septic pulmonry embolism Septic embolism NOS Code first underlying infection, such s: septicemi (038.0-038.9) 2 septic rteril embolism (449) CC Excl: See code: 415.11 AHA: 4Q, 07, 84-86 11 415.13 Sddle embolus of pulmonry rtery CC Excl: See code 415.11 AHA: 4Q, 11, 107-108 11415.19 Other CC Excl: See code: 415.11 AHA: 3Q, 10, 10; 4Q, 09, 86 I26.99 Other pulmonry emb w/o cute cor pulmonle b 416 Chronic pulmonry hert disese 416.0 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: 278.03, 416.0, 416.8-416.9, 417.8-417.9, 459.89-459.9 I27.0 Primry pulmonry hypertension 416.1 Kyphoscoliotic hert disese A DEF: High blood pressure within the lungs s result of curvture of the spine. CC Excl: 278.03, 416.0-416.1, 416.8-416.9 416.2 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: 415.11-415.19, 416.2, 444.01-444.09, 459.89-459.9 AHA: 4Q, 09, 85, 86 416.8 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 416.9 Chronic pulmonry hert disese, unspecified Chronic crdiopulmonry disese Cor pulmonle (chronic) NOS b 417 Other diseses of pulmonry circultion 417.0 Arteriovenous fistul of pulmonry vessels A 2 congenitl rteriovenous fistul (747.32) DEF: Abnorml communiction between blood vessels within lung. CC Excl: 417.0-417.9 417.1 Aneurysm of pulmonry rtery A 2 congenitl neurysm (747.39) congenitl rteriovenous neurysm (747.32) CC Excl: See code: 417.0 417.8 Other specified diseses of pulmonry circultion Pulmonry: Pulmonry: rteritis Rupture Stricture endrteritis of pulmonry vessel 417.9 Unspecified disese of pulmonry circultion Other Forms of Hert Disese (420-429) 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. 420.0 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 (115.0-115.9 with fifth-digit 3) meningococcl infection (036.41) syphilitic (093.81) CC Excl: 391.0, 393, 420.0-420.99, 423.3-423.9, 459.89-459.9 c 420.9 Other nd unspecified cute pericrditis 420.90 Acute pericrditis, unspecified A Pericrditis (cute): Pericrditis (cute): NOS sicc infective NOS CC Excl: See code: 420.0 AHA: 2Q, 89, 12 420.91 Acute idiopthic pericrditis A Pericrditis, cute: Pericrditis, cute: benign virl nonspecific CC Excl: See code: 420.0 11 HAC when reported with procedure codes 00.85-00.87, 81.51, 81.52, 81.54 nd POA = N 8 Newborn Age: 0 9 Peditric Age: 0-17 x Mternity Age: 12-55 y Adult Age: 15-124 Mjor CC Condition A CC Condition 7 HIV Relted Dx 140 Volume 1 October 2012 2013 ICD-9-CM
Tbulr List Diseses of the Circultory System 420.99 423.2 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 420.99 Other A Pericrditis (cute): pneumococcl purulent stphylococcl streptococcl suppurtive Pneumopyopericrdium Pyopericrdium 2 pericrditis in diseses clssified elsewhere (420.0) CC Excl: See code: 420.0 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. 421.0 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, 421.0-421.9, 424.90-424.99, 459.89-459.9 AHA: 4Q, 08, 73; 1Q, 99, 12; 1Q, 91, 15 I33.0 Acute nd subcute infective endocrditis 421.1 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 (115.0-115.9 with fifth-digit 4) meningococcl infection (036.42) monilil (112.81) CC Excl: See code: 421.0 421.9 Acute endocrditis, unspecified 7 Endocrditis Myoendocrditis cute or subcute Periendocrditis 2 cute rheumtic endocrditis (391.1) CC Excl: See code: 421.0 b 422 Acute myocrditis 2 cute rheumtic myocrditis (391.2) DEF: Acute inflmmtion of the musculr wlls of the hert (myocrdium). 422.0 Acute myocrditis in diseses clssified elsewhere Code first underlying disese, s: myocrditis (cute): influenzl (487.8, 488.09, 488.19) 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, 422.0-422.99, 429.0, 429.71-429.79, 459.89-459.9 c 422.9 Other nd unspecified cute myocrditis 422.90 Acute myocrditis, unspecified 7 Acute or subcute (interstitil) myocrditis 422.91 Idiopthic myocrditis 7 Myocrditis (cute or subcute): Fiedler's gint cell isolted (diffuse) (grnulomtous) nonspecific grnulomtous 422.92 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 422.0 422.93 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. 422.99 Other 7 b 423 Other diseses of pericrdium 2 tht specified s rheumtic (393) 423.0 Hemopericrdium A DEF: Blood in the pericrdil sc (pericrdium). CC Excl: 423.0-423.9, 459.89-459.9 423.1 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: 423.0 423.2 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: 423.0 Diseses of the Circultory System 420.99 423.2 b c Additionl Digit Required Uncceptble PDx Mnifesttion Code Hospitl Acquired Condition wx Revised Text l New Code s Revised Code Title 2013 ICD-9-CM Volume 1 141
00.22 00.49 Procedures nd Interventions, Not Elsewhere Clssified Tbulr List 00.22 00.49 Procedures nd Interventions, Not Elsewhere Clssified 00.22 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) 00.23 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) 00.24 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, 8 00.25 Intrvsculr imging of renl vessels Intrvsculr ultrsound (IVUS), renl vessels Renl rtery 2 dignostic ultrsound (non-invsive) of urinry system (88.75) 00.28 Intrvsculr imging, other specified vessel(s) 00.29 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 (17.41-17.49) 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. 00.31 Computer ssisted surgery with CT/CTA AHA: 4Q, 04, 113 00.32 Computer ssisted surgery with MR/MRA AHA: 4Q, 04, 113 00.33 00.34 00.35 00.39 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 (00.40-00.43), nd the number of stents inserted (00.45-00.48). Code lso ny: ngioplsty (00.61-00.62, 00.66, 39.50) therectomy (17.53-17.56) endrterectomy (38.10-38.18) insertion of vsculr stent(s) (00.55, 00.63-00.65, 36.06-36.07, 39.90) other removl of coronry rtery obstruction (36.09) AHA: 4Q, 05, 101 00.40 Procedure on single vessel Number of vessels, unspecified 2 (orto)coronry bypss (36.10-36.19) intrvsculr imging of blood vessels AHA: w4q, 11, 166-167;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 00.41 Procedure on two vessels 2 (orto)coronry bypss (36.10-36.19) intrvsculr imging of blood vessels AHA: 4Q, 06, 119; 4Q, 05, 105 00.42 Procedure on three vessels 2 (orto)coronry bypss (36.10-36.19) intrvsculr imging of blood vessels 00.43 Procedure on four or more vessels 2 (orto)coronry bypss (36.10-36.19) intrvsculr imging of blood vessels 00.44 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, 119 00.45 Insertion of one vsculr stent Number of stents, unspecified AHA: w4q, 11, 167;x 4Q, 10, 113; 3Q, 09, 13; 4Q, 05, 71 00.46 Insertion of two vsculr stents AHA: 2Q, 09, 12; 4Q, 05, 105-106 00.47 Insertion of three vsculr stents AHA: 4Q, 06, 119 00.48 Insertion of four or more vsculr stents 00.49 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) (36.06-36.07) intrcoronry rtery thrombolytic infusion (36.04) number of vsculr stents inserted (00.45-00.48) number of vessels treted (00.40-00.43) 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, 162 5 Bilterl Procedure 4 Non-covered Procedure 3 Limited Coverge Procedure wx Revised Text l New Code s Revised Code Title 70 Volume 3 Februry 2012 2013 ICD-9-CM
Tbulr List Opertions on the Digestive System 46.1 46.80 b 46.1 Colostomy Code lso ny synchronous resection (45.49, 45.71-45.79, 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. 46.10 46.11 46.13 46.14 Colostomy, not otherwise specified Temporry colostomy Permnent colostomy Delyed opening of colostomy b 46.2 Ileostomy Code lso ny synchronous resection (45.34, 45.61-45.63) 2 loop ileostomy (46.01) DEF: Cretion of rtificil nus by bringing ileum through bdominl wll to body surfce. 46.20 46.21 46.22 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, 17 46.23 46.24 Other permnent ileostomy Delyed opening of ileostomy b 46.3 Other enterostomy Code lso ny synchronous resection (45.61-45.8) 46.31 Delyed opening of other enterostomy 46.32 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, 13 46.39 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. 46.40 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) 46.41 Revision of stom of smll intestine 2 excision of redundnt mucos (45.33) AHA: 2Q, '05, 11 46.42 Repir of pericolostomy herni 46.43 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, 45.61-45.8) 46.50 Closure of intestinl stom, not otherwise specified 46.51 Closure of stom of smll intestine 46.52 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 46.60 Fixtion of intestine, not otherwise specified Fixtion of intestine to bdominl wll 46.61 Fixtion of smll intestine to bdominl wll Ileopexy 46.62 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. 46.63 Fixtion of lrge intestine to bdominl wll Cecocoloplicopexy Sigmoidopexy (Moschowitz) 46.64 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) 46.71 46.72 46.73 Suture of lcertion of duodenum Closure of fistul of duodenum Suture of lcertion of smll intestine, except duodenum AHA: 1Q, 10, 11 46.74 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) 46.75 Suture of lcertion of lrge intestine 46.76 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 (70.72-70.73) vesicocolic fistul (57.83) vesicosigmoidovginl fistul (57.83) AHA: 3Q, 99, 8 46.79 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, 14 46.80 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 46.1 46.80 b Additionl Digit Required Vlid OR Procedure Non-OR Procedure Adjunct Code 2013 ICD-9-CM Volume 3 133
Officil ICD-9-CM Guidelines for Coding nd Reporting Effective October 1, 2011 Note: Since no officil ICD-9-CM ddendum to the guidelines ws relesed in 2012, the guidelines included in this book stnd s the officil guidelines effective October 1, 2012, through September 30, 2013. The Centers for Medicre nd Medicid Services (CMS) nd the Ntionl Center for Helth Sttistics (NCHS), two deprtments within the U.S. Federl Government s Deprtment of Helth nd Humn Services (DHHS) provide the following guidelines for coding nd reporting using the Interntionl Clssifiction of Diseses, 9th Revision, Clinicl Modifiction (ICD-9-CM). These guidelines should be used s compnion document to the officil version of the ICD-9-CM s published on CD-ROM by the U.S. Government Printing Office (GPO). These guidelines hve been pproved by the four orgniztions tht mke up the Cooperting Prties for the ICD-9-CM: the Americn Hospitl Assocition (AHA), the Americn Helth Informtion Mngement Assocition (AHIMA), CMS, nd NCHS. These guidelines re included on the officil government version of the ICD-9-CM, nd lso pper in Coding Clinic for ICD-9-CM published by the AHA. These guidelines re set of rules tht hve been developed to ccompny nd complement the officil conventions nd instructions provided within the ICD-9-CM itself. The instructions nd conventions of the clssifiction tke precedence over guidelines. These guidelines re bsed on the coding nd sequencing instructions in Volumes I, II nd III of ICD-9-CM, but provide dditionl instruction. Adherence to these guidelines when ssigning ICD-9-CM dignosis nd procedure codes is required under the Helth Insurnce Portbility nd Accountbility Act (HIPAA). The dignosis codes (Volumes 1-2) hve been dopted under HIPAA for ll helthcre settings. Volume 3 procedure codes hve been dopted for inptient procedures reported by hospitls. A joint effort between the helthcre provider nd the coder is essentil to chieve complete nd ccurte documenttion, code ssignment, nd reporting of dignoses nd procedures. These guidelines hve been developed to ssist both the helthcre provider nd the coder in identifying those dignoses nd procedures tht re to be reported. The importnce of consistent, complete documenttion in the medicl record cnnot be overemphsized. Without such documenttion ccurte coding cnnot be chieved. The entire record should be reviewed to determine the specific reson for the encounter nd the conditions treted. The term encounter is used for ll settings, including hospitl dmissions. In the context of these guidelines, the term provider is used throughout the guidelines to men physicin or ny qulified helth cre prctitioner who is leglly ccountble for estblishing the ptient s dignosis. Only this set of guidelines, pproved by the Cooperting Prties, is officil. The guidelines re orgnized into sections. Section I includes the structure nd conventions of the clssifiction nd generl guidelines tht pply to the entire clssifiction, nd chpter-specific guidelines tht correspond to the chpters s they re rrnged in the clssifiction. Section II includes guidelines for selection of principl dignosis for non-outptient settings. Section III includes guidelines for reporting dditionl dignoses in non-outptient settings. Section IV is for outptient coding nd reporting. Section I. Conventions, generl coding guidelines nd chpter specific guidelines A. Conventions for the ICD-9-CM 1. Formt: 2. Abbrevitions. Index bbrevitions b. Tbulr bbrevitions 3. Punctution 4. Includes nd Excludes Notes nd Inclusion terms 5. Other nd Unspecified codes. Other codes b. Unspecified codes 6. Etiology/mnifesttion convention ( code first, use dditionl code nd in diseses clssified elsewhere notes) 7. And 8. With 9. See nd See Also B. Generl Coding Guidelines 1. Use of Both Alphbetic Index nd Tbulr List 2. Locte ech term in the Alphbetic Index 3. Level of Detil in Coding 4. Code or codes from 001.0 through V91.99 5. Selection of codes 001.0 through 999.9 6. Signs nd symptoms 7. Conditions tht re n integrl prt of disese process 8. Conditions tht re not n integrl prt of disese process 9. Multiple coding for single condition 10. Acute nd Chronic Conditions 11. Combintion Code 12. Lte Effects 13. Impending or Thretened Condition 14. Reporting Sme Dignosis Code More thn Once 15. Admissions/Encounters for Rehbilittion 16. Documenttion for BMI nd Pressure Ulcer Stges 17. Syndromes 18. Documenttion of Complictions of Cre C. Chpter-Specific Coding Guidelines 1. Chpter 1: Infectious nd Prsitic Diseses (001-139). Humn Immunodeficiency Virus (HIV) Infections b. Septicemi, Systemic Inflmmtory Response Syndrome (SIRS), Sepsis, Severe Sepsis nd Septic Shock c. Methicillin Resistnt Stphylococcus ureus (MRSA) Conditions 2. Chpter 2: Neoplsms (140-239). Tretment directed t the mlignncy b. Tretment of secondry site c. Coding nd sequencing of complictions d. Primry mlignncy previously excised e. Admissions/Encounters involving chemotherpy, immunotherpy nd rdition therpy f. Admission/encounter to determine extent of mlignncy g. Symptoms, signs, nd ill-defined conditions listed in Chpter 16 ssocited with neoplsms h. Admission/encounter for pin control/mngement i. Mlignnt neoplsm ssocited with trnsplnted orgn 3. Chpter 3: Endocrine, Nutritionl, nd Metbolic Diseses nd Immunity Disorders (240-279). Dibetes mellitus 4. Chpter 4: Diseses of Blood nd Blood Forming Orgns (280-289). Anemi of chronic disese 5. Chpter 5: Mentl Disorders (290-319) Reserved for future guideline expnsion 6. Chpter 6: Diseses of Nervous System nd Sense Orgns (320-389). Pin - Ctegory 338 b. Glucom 7. Chpter 7: Diseses of Circultory System (390-459). Hypertension 2013 ICD-9-CM Coding Guidelines 1