CHAPTER 2

Copyright © 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1

CHAPTER 2AN OVERVIEW

OF ICD-9-CM


An Overview of the ICD-9-CM• Classification System

– Morbidity (illness) – Mortality (death)

• ICD = International Classification of Diseases• WHO’s ICD-9 used globally

– World Health Organization• ICD-9-CM = 9th Revision; CM, Clinical Modification

– Continuity of data

(Cont’d…)


Overview(…Cont’d)• 1977: US develops ICD-9-CM version• More code subsets define medical care• ICD-9-CM data comparable to global

data in ICD-9• Updated October 1 of each year• Must use new codes as of October 1• Also updates April 1 with no grace

period


Medicare

• Medicare Catastrophic Act of 1988– Required use of ICD-9-CM codes for

diagnosis• Act later repealed, but codes still used• Effective 2003, all claims must have

valid diagnosis– Excludes ambulance suppliers


Uses of ICD-9-CM

• Facilities track facility use through codes

• Fiscal entities track health care costs

(Cont’d…)


Uses of ICD-9-CM(…Cont’d)• Research

– Health care quality– Future needs

• Newer cancer center built if patient use warrants


Uses of ICD-9-CM

• Use and results evident every day– Newscaster reference to number of AIDS

cases– Newspaper article about measles epidemic


ICD-9-CM Principles/PracticesFour groups function together to

maintain ICD-9-CM• Centers for Medicare and Medicaid

Services (CMS), formerly known as Health Care Financing Administration (HCFA)

(Cont’d...)


ICD-9-CM Principles/Practices(...Cont’d)• National Center for Health Statistics

(NCHS)• American Health Information

Management Association (AHIMA)• American Hospital Association (AHA)


ICD-9-CM Documents Medical Necessity• Diagnoses establish medical necessity• Services and diagnoses must correlate• Correct diagnosis codes allow:

– Accurate reimbursement– Fewer rejected claims– Reduced risk of sanctions/fines from audit


CMS-1500 (08/05) in Blocks 21 and 24E (Outpatient)

Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.


UB04 in Blocks 66-74 (Inpatient)

Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.


Ethics

• Documentation must support diagnosis• Example:

– Services provided– Diagnosis justifies services

• If in doubt, check it out; don’t make assumptions


Your Job

• Translate documentation into ICD-9-CM codes– Legionnaires’ disease = 482.84

• Assign code to highest level specificity• Medical record must substantiate

diagnosis code assignment


Format of the ICD-9-CM

• Volume 1, Diseases, Tabular List (diagnosis) (17 chapters)

• Volume 2, Diseases, Alphabetic Index (diagnosis) (3 sections)

• Volume 3, Procedures, Tabular List and Alphabetic Index (inpatient)


Volume 1, Diseases, Tabular List

• Contains code numbers• 001.0-999.9 Diagnosis codes describe

condition• V and E codes = supplemental

information

(Cont’d…)


Volume 1, Diseases, Tabular List(...Cont’d)

Divided into:• Chapter

– Section• Category

– Subcategory» Subclassification


Volume 2, Diseases, Alphabetic Index

• Appears first in book (may vary with publishers)

• Terms and code numbers verified inVolume 1

• Never code directly from Index!• Read all notes and follow instructions

(e.g., see also)• Tables (e.g., Drugs/Chemicals,

Hypertension, Neoplasm)


Volume 3, Procedures, Tabular List and Alphabetic Index• Not used for physician services• Index and Tabular List used for

procedures and therapies• Inpatient settings only• Procedures and therapies• Maximum 4 digits

– 20.41 Simple mastoidectomy


Volume 1, Tabular List

• Two major divisions – Classification of Diseases and Injuries

(codes 001.0-999.9)– Supplementary Classification

(V codes and E codes)


V Codes (V01.0-______)

• Patient not ill but encounters health services – e.g., Vaccination

• Patient presents for treatment – e.g., Chemotherapy

• Some V codes are primary only (e.g., V58.11, encounter for chemotherapy)

V89.09

(Cont’d…)


V Codes (V01.0-V89.09)(…Cont’d)• Factors that influence patient’s health

status – e.g., Personal history of [PHO] malignant

tumor, organ transplant– Birth status and outcome of delivery


Classification of Diseases and Injuries• Main portion of ICD-9-CM• Codes from 001.0-999.9• Most chapters are organ systems

– Digestive System– Respiratory System


Divisions of Classification of Diseases and Injuries• Chapters: 1 through 17• Section: A group of related conditions


Volume 1, Diseases, Format

Figure: 2.5

Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.


Category Code

• Category: Represent single disease/condition (3 digits)

Figure: 2.6



Subcategory Code

• Subcategory: More specific (4th digit)

Figure: 2.7



Subclassification Code

• Subclassification: More specific (5th digit)

Referenced from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.


Specificity in ICD-9-CM Codes

• Each digit adds to the specificity (detail)

Figure: 2.9


Remember

• Assign to the highest level possible, based on documentation

• If 4-digit code exists, do not report 3-digit code

• If 5-digit code exists, do not report 4-digit code


Appendices in Volume 1

• There are five appendices in official ICD-9-CM

• Private publishers may have more


Appendix A, Morphologyof Neoplasms• Used in conjunction with codes from

Chapter 2, Neoplasm– Inpatient setting: Cancer registries and

claim forms – Not placed on a billing claim form

(M codes)

(Cont’d…)


Appendix A, Morphology of Neoplasms(…Cont’d)• Begins with M followed by 5 digits

– M8400/0, Sweat gland adenoma• First four digits: Histologic type of

neoplasm • Fifth digit: Behavior (e.g., 0 = benign)


Appendix B, Glossary of Mental Disorders• Deleted in 2004• Most psychiatric disorders are

classified using:– The Diagnostic and Statistical Manual of

Mental Disorders (DSM-IV)


Appendix C, Drugs

• American Hospital Formulary Service (AHFS) publishes list of all drugs

• Tracks drugs nationally; used by pharmacists

• Each drug coded with up to six-digit code (e.g., 84:04.04)

(Cont’d…)


Appendix C, Drugs(…Cont’d)• AHFS listing correlated to ICD-9-CM

Table of Drugs and Chemicals• New drugs not identified by name

– Rather listed under heading “Drug” in Table of Drugs and Chemicals

– Example: 84:04.04 antibiotics


Appendix D, Industrial Accidents

• Three-digit codes that identify occupational hazards

• Not placed on insurance or billing form• Used by state and federal organizations

(OSHA) Occupational Safety and Health Administration to summarize industrial accident data


Appendix E, Three-Digit Categories• Presented by chapter• Categories are labeled 1 through 17• Provides quick overview of ICD-9-CM

contents


Volume 2, Sections

• Section 1, Index to Diseases• Section 2, Table of Drugs and Chemicals• Section 3, Index to External Causes of

Injuries and Poisonings (E Codes)– Never primary diagnosis– Medicare does not accept for professional

billing


Section 1, Index to Diseases• Largest part of Volume 2—Index• First step in coding, locate main bold term in

the Index• Subterms indented 2 spaces to the right• May have more than one subterm• 3 digits = category codes• 4 digits = subcategory• 5 digits = subclassification codes


A Word of Caution About the Alphabetic Index (Section I, Vol. 2)

• Some words in Index do not appear in Tabular—saves space

• Exact word may not be in code Tabular description– But found in Alphabetic Index– That is why you must locate term in Index

and then locate Tabular (follow where Index directs)


Section 2, Table of Drugs and Chemicals

• Drug name placed alphabetically on left under heading “Substance”


(Cont’d…)


Table of Drugs and Chemicals(…Cont’d)

• First column: “Poisoning” code for substance involved, wrong substance given or taken

• First-listed before manifestation condition(Cont’d…)



Table of Drugs and Chemicals(…Cont’d)• E codes identify how poisoning occurred

– Example: If analgesics poisoning occurred by accident, E850.9

• Correct order poisoning– 3 codes required:

• Identify agent analgesic 965.9• Condition—coma 780.01• Accidental poison E850.9

• Correct order adverse effect– 2 codes required

• Condition—coma 780.01• Therapeutic E935.9


Table of Drugs and Chemicals: Headings• Accident: Unintentional• Therapeutic: Correct dosage, correctly

administered, with adverse effects (example, allergic reaction)

• Suicide attempt: (must be documented)• Assault: Intentionally inflicted by

another person• Undetermined: Unknown intent


E Codes (E000-E999)

• Supplementary Classification of External Causes of Injury and Poisoning

• Alpha-numerical designations for injuries and poisonings

(Cont’d…)


E Codes (E000-E999)(…Cont’d)• Provides additional information about

external causes• Never a principal (inpatient) diagnosis• Separate E code index

– Locate the E Code index in your ICD-9-CM now


Section 3, E Codes

• Alphabetic Index to External Causes of Injuries and Poisonings

• Provide additional information about the nature of injury/poisoning and locality

• Never a principal (inpatient) or first-listed (outpatient) diagnosis


Section 3, E Codes(…Cont’d)• Separate Index to External Causes• Alphabetical, main terms in bold• Subterms are indented 2 to right under main

term• Some words in Index not in Tabular—saves

space• That is why you must locate the term in the

Index, then locate in Tabular


Index to External Causes: Example

• Main terms are type of accident (Collision)• Subterms are circumstances of the

accident (motor vehicle)



Volume 2, Neoplasm• In Volume 2,

Index, locate Neoplasm Table under the alphabetic entry “N”

• Do not reference Neoplasm table when diagnostic statement states “mass” From Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3,

Professional Edition, St. Louis, 2011, Saunders.


Volume 2, Terms

• Main terms (bold typeface)– Subterms – Indented two spaces to right – Not bold

• Example Pain (Main term in bold) orbital region 379.91 (subterm

indented)


Volume 2, Alphabetic Index

• Nonessential modifiers enclosed in parentheses (does not have to be in diagnostic statement)

• Have no effect on code selection • Clarify diagnosis

– Example: Ileus (adynamic) (bowel)….


ICD-9-CM Conventions

• Punctuation: [ ] ( ) : } italicized and bold type [ ]

• Symbols: § • Abbreviations: NEC, NOS• Notations: Includes, Excludes, Use

Additional Code, And/With, Code if Applicable


Abbreviations

• NEC: Not elsewhere classifiable– No more specific code exists

• NOS: Not otherwise specified– Unspecified in documentation


[ ] Brackets

• Enclose synonyms, alternative wording, or explanatory phrases

• Used to identify manifestation codes • Helpful, additional information• Can affect code• Found only in Tabular List (001.0-999.9)


Volume 2, Etiology and Manifestation of Disease• Etiology = cause of disease• Manifestation = symptom• Etiology + Manifestation =

Combination codes


Combination Code



Slanted Brackets [ ]

• Enclose manifestations of underlying condition– “Code first underlying disease”

• Used in the Alphabetic Index-Volume 2


Multiple Coding

• No combination code, use individual code(s) in this order– 250.4x– 581.81



( ) Parentheses

• Contain non-essential modifiers– Take them or leave them– Informational descriptive terms

• Found in Tabular List and Index• Does not affect code selection


Colon and Brace

• : Colon: In Tabular List, completes a statement with one or more modifiers

• } Brace: In Tabular List, modifies statements to the right of the brace


Italicized and Bold Type

• Italicized– All Excludes notes– Codes not used as principal diagnosis

• Bold– Codes and code titles in Tabular List,

Volume 1


Lozenge and Section Mark

• Lozenge: Indicates codes unique to ICD-9-CM

• § Section: Can be footnote indicator


Includes, Excludes, and Use Additional Code• Includes notes: In chapter, section, or

category• Excludes notes: Conditions are coded

elsewhere• Use Additional Code: Assignment of

other code(s) is necessary


And/With

• And: Means and/or– Example: 237.0, Neoplasm of uncertain

behavior of pituitary gland and/or craniopharyngeal duct

• With: Means one condition with (in addition to) another condition– Example: 070.41, acute hepatitis C with

hepatic coma


Volume 2, Cross References

• Directs you: see, see also, see category • “see” directs you to specific term

– Example: Panotitis—“see” Otitis media• “see also” directs you to another term

for more information– Example: Perivaginitis (see also Vaginitis)

(Cont’d…)


Volume 2, Cross References(…Cont’d)• “see category” Volume 1, Tabular List,

specific information about use of code– Example: Mesencephalitis (see also

Encephalitis) 323.9; late effect—see category 326


Code, If Applicable, Any Causal Condition First• May be primary diagnosis if no causal

condition applicable or known or documented

• Instructional note in Tabular List

(Cont’d…)


Code, If Applicable, Any Causal Condition First(…Cont’d)• Example: 707.10, Ulcer of lower limb,

except decubitus; states:– Chronic venous hypertension with ulcer

(459.31)• If ulcer caused by chronic venous

hypertension:– First: 459.31 chronic venous hypertension– Second: 707.10 ulcer of lower limb


Volume 2, Notes

• Define terms• Give further coding instructions

– Example: Index: “Melanoma,” • Note: “Except where otherwise indicated….”

(Cont’d…)


Volume 2, Notes

• Mandatory fifth digits also appear as notes (one reason to never code from Index)

(…Cont’d)

Figure: 2.13

From Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.


Volume 2, Eponyms• Disease or syndrome named for person

– Example:• Arnold-Chiari (see also Spina bifida)• Sturge-Weber• Prader-Willi


Volume 3, Procedures

• 90% of codes refer to surgical procedures(Cont’d…)

Figure: 2.14

Volume 3, Surgical procedures. (Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.)


Volume 3, Procedures

• 10% refer to diagnostic and therapeutic procedures

(Cont’d…)

(…Cont’d) Figure: 2.15



Volume 3, Procedures(…Cont’d)• Procedures done in physician’s office

or outpatient ASC are coded using CPT codes– Surgeon uses CPT to report services to

inpatients• Volume 3, Procedure codes are used by

hospitals to code facility services provided to inpatients


• Chapter 0– Procedures and Interventions, Not Elsewhere

Classified• Chapters 1-15

– Operations on organ systems • Chapter 16

– Miscellaneous Diagnostic and Therapeutic Procedures

– Most nonsurgical codes

Volume 3, Table of Contents

(Cont’d…)


Volume 3, Table of Contents

(…Cont’d)

Figure: 2.16Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.



• Conventions in Volume 3 same as those in Volumes 1 and 2

• “Code also...” Volume 3– Additional information about coding

various components or special adjunctive services or procedures

– “…any synchronous” means occurring at the same time



• Contains terms that do not appear in Volume 3 Tabular List– Example: In Index, the entry Gastrostomy,

subterm Janeway, directs you to 43.19– Janeway not mentioned in Tabular List

(Cont’d…)


Volume 3, Alphabetic Index(…Cont’d)• Terms in bold• Subterms not in bold• Never code directly from Index• Index example follows• Includes non-essential modifiers, as in

Volume 1


ExampleFigure: 2.17




• Index alphabetical• Ignores single spaces and hyphens

– Example: Opening and open reduction– “Opening” appears before “open

reduction” because space between two words ignored

(Cont’d…)


Volume 3, Alphabetic Index(…Cont’d)

• Often necessary and permissible to code individual components of procedure– Example: During a procedure, a portion of

intestine was removed and reconstruction of urinary bladder was done

• Both reconstruction (57.87) and resection (45.51) are coded

(Cont’d…)


Volume 3, Alphabetic Index(…Cont’d)• Cross references of see, see also, and

see category appear as they did in Volume 1

• Many operations named for surgeon who developed procedure (eponyms)– These procedures located under person’s

name or name of operation



• Format same as Volume 1, Tabular List of Diseases, except Volume 3 codes have two digits before decimal

(Cont’d…)


Volume 3, Tabular List(…Cont’d)• Category,

subcategory, and subclassification

Figure: 2.18Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.


Bundling

• Included in all surgical procedures opening and closing of surgical site– Do not unbundle and code these

separately– If closure takes place during separate

surgical procedure, closure can be reported separately


ConclusionCHAPTER 2

AN OVERVIEW OF ICD-9-CM

CHAPTER 2

Documents

p1the icd

overview of icd

appropriate icd

imprint of elsevier

required use of icd

clinical modification

health services

usage of health care