Medical Coding Chapter 2. CHAPTER 2 AN OVERVIEW OF ICD-9-CM.

Medical Coding Chapter 2

CHAPTER 2CHAPTER 2AN OVERVIEW

OF ICD-9-CM

An Overview of the ICD-9-CMAn 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

OverviewOverview

● 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

MedicareMedicare

● 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● Act later repealed, but codes still used● Effective 2003, all claims must have valid diagnosis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-CMUses of ICD-9-CM

● Facilities track facility use through codes● Fiscal entities track health care costs


● Research– Health care quality– Future needs

Newer cancer center built if patient use warrants


● Use and results evident every day– Newscaster reference to number of AIDS cases– Newspaper article about measles epidemic

ICD-9-CM Principles/PracticesICD-9-CM Principles/Practices

Four groups function together to maintain ICD-9-CM● Centers for Medicare and Medicaid Services (CMS),

formerly known as Health Care Financing Administration (HCFA)

ICD-9-CM Principles/PracticesICD-9-CM Principles/Practices

● National Center for Health Statistics (NCHS)● American Health Information Management Association

(AHIMA)● American Hospital Association (AHA)

ICD-9-CM Documents Medical Necessity

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)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)UB04 in Blocks 66-74 (Inpatient)

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

EthicsEthics

● Documentation must support diagnosis● Example:

– Services provided– Diagnosis justifies services

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

Your JobYour 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-CMFormat 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 ListVolume 1, Diseases, Tabular List

● Contains code numbers● 001.0-999.9 Diagnosis codes describe condition● V and E codes = supplemental information

Volume 1, Diseases, Tabular ListVolume 1, Diseases, Tabular List

(...Cont’d)

Divided into:● Chapter

– Section Category

– Subcategory

» Subclassification

Volume 2, Diseases, Alphabetic Index

Volume 2, Diseases, Alphabetic Index

● Appears first in book (may vary with publishers)● Terms and code numbers verified in

Volume 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

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 ListVolume 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-______)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)

V89.09V89.09

V Codes (V01.0-V89.09)V Codes (V01.0-V89.09)

● 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 InjuriesClassification 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

Divisions of Classification of Diseases and Injuries

● Chapters: 1 through 17● Section: A group of related conditions

Volume 1, Diseases, FormatVolume 1, Diseases, Format

Figure: 2.5Figure: 2.5

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

Category CodeCategory Code

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



Subcategory CodeSubcategory Code

● Subcategory: More specific (4th digit)



Subclassification CodeSubclassification 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 CodesSpecificity in ICD-9-CM Codes

● Each digit adds to the specificity (detail)


RememberRemember

● 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 1Appendices in Volume 1

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

● Private publishers may have more

Appendix A, Morphologyof Neoplasms

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)

Appendix A, Morphology of Neoplasms

Appendix A, Morphology of Neoplasms

● 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

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, DrugsAppendix 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)

Appendix C, DrugsAppendix C, Drugs

● 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 AccidentsAppendix 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 CategoriesAppendix E, Three-Digit Categories

● Presented by chapter● Categories are labeled 1 through 17● Provides quick overview of ICD-9-CM contents

Volume 2, SectionsVolume 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 DiseasesSection 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)

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

Section 2, Table of Drugs and Chemicals

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

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

Table of Drugs and Chemicals


(…Cont(…Cont’’d)d)

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

● First-listed before manifestation condition




● 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

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)E Codes (E000-E999)

● Supplementary Classification of External Causes of Injury and Poisoning

● Alpha-numerical designations for injuries and poisonings

E Codes (E000-E999)E Codes (E000-E999)

● 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 CodesSection 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 CodesSection 3, E Codes

● 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: ExampleIndex to External Causes: Example

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

(motor vehicle)

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

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

Volume 2, TermsVolume 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 IndexVolume 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 ConventionsICD-9-CM Conventions

● Punctuation: [ ] ( ) : } italicized and bold type [ ] ● Symbols: § ● Abbreviations: NEC, NOS● Notations: Includes, Excludes, Use Additional Code,

And/With, Code if Applicable

AbbreviationsAbbreviations

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

● NOS: Not otherwise specified– Unspecified in documentation

[ ] Brackets[ ] 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

Volume 2, Etiology and Manifestation of Disease

● Etiology = cause of disease● Manifestation = symptom● Etiology + Manifestation =

Combination codes

Combination CodeCombination Code

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

Slanted Brackets [ ]Slanted Brackets [ ]

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

● Used in the Alphabetic Index-Volume 2

Multiple CodingMultiple Coding

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

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

( ) Parentheses( ) 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 BraceColon 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 TypeItalicized 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 MarkLozenge and Section Mark

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

● § Section: Can be footnote indicator

Includes, Excludes, and Use Additional Code

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/WithAnd/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 ReferencesVolume 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)

Volume 2, Cross ReferencesVolume 2, Cross References

● “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



● 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, NotesVolume 2, Notes

● Define terms● Give further coding instructions

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

Volume 2, NotesVolume 2, Notes

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



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

Volume 2, EponymsVolume 2, Eponyms

● Disease or syndrome named for person– Example:

Arnold-Chiari (see also Spina bifida) Sturge-Weber Prader-Willi

Volume 3, ProceduresVolume 3, Procedures

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


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


● 10% refer to diagnostic and therapeutic procedures

(Cont(Cont’’d…)d…)

(…Cont(…Cont’’d)d) Figure: 2.15Figure: 2.15

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


● 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 ContentsVolume 3, Table of Contents

……

Volume 3, Table of ContentsVolume 3, Table of Contents


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


● Terms in bold● Subterms not in bold● Never code directly from Index● Index example follows● Includes non-essential modifiers, as in Volume 1

ExampleExample




● Index alphabetical● Ignores single spaces and hyphens

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

between two words ignored


● 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


● 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


● Category, subcategory, and subclassification

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

BundlingBundling

● 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 2Conclusion

CHAPTER 2AN OVERVIEW

OF ICD-9-CM

Medical Coding Chapter 2. CHAPTER 2 AN OVERVIEW OF ICD-9-CM.

Documents

audit slide

neoplasm slide

overview of icd

health services

medical care icd

supplemental information

measles epidemic slide

outcome of delivery