Medical Coding Chapter 2

CHAPTER 2 AN OVERVIEW OF ICD-9-CM SXS11ierPPT-INTC02_P1

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 The International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) is designed for the classification of patient morbidity and mortality information for statistical purposes and for the indexing of health records by disease and operation for data storage and retrieval. SXS11ierPPT-INTC02_P1

1977: US develops ICD-9-CM version Overview 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 The ICD-9-CM classification system is totally compatible with its parent system, ICD-9, allowing morbidity and mortality statistics to be compared internationally. Why is it useful to compare disease data with other countries? (For statistical information) SXS11ierPPT-INTC02_P1

Medicare Catastrophic Act of 1988 Required use of ICD-9-CM codes for diagnosis Act later repealed, but codes still used Effective 2003, all claims must have valid diagnosis Excludes ambulance suppliers The Medicare Catastrophic Coverage Act of 1988 required the submission of the appropriate ICD-9-CM diagnosis codes, with charges billed to Medicare Part B (outpatient services). SXS11ierPPT-INTC02_P1

Facilities track facility use through codes Uses of ICD-9-CM Facilities track facility use through codes Fiscal entities track health care costs Codes facilitate payment for health services. The tracking of diagnosis codes used determines usage of health care which then leads to increase in health care costs. SXS11ierPPT-INTC02_P1

Uses of ICD-9-CM Research Health care quality Future needs Newer cancer center built if patient use warrants How does research help predict health care trends? (It helps to get an idea of increasing needs of patients. For example if in 2006, there was a jump in cancer patients in a particular area of the United States, this may deem the need to build more cancer centers.) SXS11ierPPT-INTC02_P1

Use and results evident every day Uses of ICD-9-CM Use and results evident every day Newscaster reference to number of AIDS cases Newspaper article about measles epidemic SXS11ierPPT-INTC02_P1

ICD-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) SXS11ierPPT-INTC02_P1

ICD-9-CM Principles/Practices National Center for Health Statistics (NCHS) American Health Information Management Association (AHIMA) American Hospital Association (AHA) SXS11ierPPT-INTC02_P1

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 Why is it important that medical services and diagnoses agree? (Disagreement causes problems with third-party payer and holds up payment.) SXS11ierPPT-INTC02_P1

CMS-1500 (08/05) in Blocks 21 and 24E (Outpatient) ICD-9-CM codes are reported on the CMS-1500 insurance claim form used in physician offices. Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services. SXS11ierPPT-INTC02_P1

UB04 in Blocks 66-74 (Inpatient) The ICD-9-CM codes are also reported on the UB-04 form used in hospitals. Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services. SXS11ierPPT-INTC02_P1

Documentation must support diagnosis Example: Ethics Documentation must support diagnosis Example: Services provided Diagnosis justifies services If in doubt, check it out; don’t make assumptions Coders need to have in-depth knowledge of medical terminology and to understand the guidelines, terminology, and conventions used. Why is ethical coding important? (Keeps health care costs under control; third-party payers do not pay for services not rendered.) SXS11ierPPT-INTC02_P1

Translate documentation into ICD-9-CM codes 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 Transforming verbal or narrative descriptions of diseases, injuries, conditions, and procedures into numeric designations is complex. As with the CPT codes a 5-digit number takes up less room than a long worded description of a procedure or diagnosis. SXS11ierPPT-INTC02_P1

Volume 1, Diseases, Tabular List (diagnosis) (17 chapters) 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) The ICD-9-CM manual is published as a three-volume set. Which Volume contains the Alphabetical Index of Diagnoses? (Volume 2) Note that the Volume order in the ICD-9 coding book does not follow the 1, 2, 3 order. Example: The first thing you come to when you open the ICD-9 coding book is Volume 2, the alphabetical index. Next is Volume 1, the tabular list of diseases. Lastly is volume 3, procedures. SXS11ierPPT-INTC02_P1

Volume 1, Diseases, Tabular List Contains code numbers 001.0-999.9 Diagnosis codes describe condition V and E codes = supplemental information Volume 1 contains the following: Disease and condition codes and code descriptions (nomenclature). Supplementary Classification of Factors Influencing Health Status and Contact with Health Services (V codes). External Causes of Injury and Poisoning (E codes). SXS11ierPPT-INTC02_P1

Volume 1, Diseases, Tabular List (...Cont’d) Divided into: Chapter Section Category Subcategory Subclassification SXS11ierPPT-INTC02_P1

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 2 is the Alphabetic Index for Volume 1. Volumes 1 and 2 are used in inpatient and outpatient settings to substantiate medical services (medical necessity) through assignment of diagnosis codes. Why shouldn’t coders code directly from the Index? (Coders need to code to the furthest extent for correct coding and not all of the information, such as digits, are given in the index.) SXS11ierPPT-INTC02_P1

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 3 contains codes for surgical, therapeutic, and diagnostic procedures. Who is the primary user of Volume 3 in the medical community? (Hospitals) SXS11ierPPT-INTC02_P1

Volume 1, Tabular List Two major divisions Classification of Diseases and Injuries (codes 001.0-999.9) Supplementary Classification (V codes and E codes) After referencing the Index (Volume 2), the coder locates the codes identified in the Tabular List. The Tabular List is the listing of all code numbers available for assignment, as well as their descriptions. All possible descriptive terms are not listed in the Tabular List to save space; coders should trust the code provided in the Alphabetic Index to be correct. SXS11ierPPT-INTC02_P1

Patient not ill but encounters health services V Codes (V01.0-______) V89.09 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) The V codes are contained in the Supplementary Classification in Volume 1. These are three- or four-digit codes preceded by the letter V. SXS11ierPPT-INTC02_P1

Factors that influence patient’s health status 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 Some examples of V codes show family history of disease, personal history of disease, birth status, and outcome of delivery. SXS11ierPPT-INTC02_P1

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 Some chapters are based on the cause or type of disease or neoplasm. The main portion of CPT starts with Chapter 1: Infectious and Parasitic Diseases and ends with Chapter 17: Injury and Poisoning. SXS11ierPPT-INTC02_P1

Divisions of Classification of Diseases and Injuries Chapters: 1 through 17 Section: A group of related conditions A chapter is the main division in the ICD-9-CM manual. A section is a group of three-digit categories that represent a group of conditions or related conditions. What does a three-digit category represent? (Code of a single condition or disease.) SXS11ierPPT-INTC02_P1

Volume 1, Diseases, Format Figure: 2.5 This illustrates the format of each chapter. Refer to p. 33 of the text. Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. SXS11ierPPT-INTC02_P1

Category: Represent single disease/condition (3 digits) Category Code Figure: 2.6 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. Category: Represent single disease/condition (3 digits) There are approximately 1,000 codes at the category level; most others require a fourth or fifth digit. SXS11ierPPT-INTC02_P1

Subcategory: More specific (4th digit) Subcategory Code Figure: 2.7 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. Subcategory: More specific (4th digit) A four-digit subcategory code provides greater specificity in terms of cause, site, or manifestation of the condition. SXS11ierPPT-INTC02_P1

Subclassification Code Referenced from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. Subclassification: More specific (5th digit) A five-digit subclassification code adds even greater specificity to a condition’s description. SXS11ierPPT-INTC02_P1

Specificity in ICD-9-CM Codes Figure: 2.9 Always code to the highest level of specificity according to the documentation in the medical record. You must assign the fifth digit if it is available. Each digit adds to the specificity (detail) SXS11ierPPT-INTC02_P1

Assign to the highest level possible, based on documentation 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 A diagnosis code has three digits before the decimal point. A procedure code has two digits before the decimal point. If it isn’t documented, it can’t be coded. Why does greater specificity in coding result in quicker payment to the medical practice? (It decreases the number of third-party payer returns for further clarification of the diagnosis codes.) SXS11ierPPT-INTC02_P1

There are five appendices in official ICD-9-CM Appendices in Volume 1 There are five appendices in official ICD-9-CM Private publishers may have more Appendices are included as a reference for the coder so that it is possible to do the following: Provide further information about the patient’s clinical picture. Further define a diagnostic statement. Aid in classifying new drugs. Reference three-digit categories. SXS11ierPPT-INTC02_P1

Appendix A, Morphology of 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) What is morphology? (Science of the form and structure of organisms) SXS11ierPPT-INTC02_P1

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) Examples of types of neoplasms include epithelial, papillary, basal cell, and adenoma. Examples of behaviors of neoplasms are benign, malignant, and carcinoma in situ. What does in situ mean? (Carcinoma has not spread or metastasized.) SXS11ierPPT-INTC02_P1

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) Most psychiatric disorders are classified in accordance with The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). SXS11ierPPT-INTC02_P1

American Hospital Formulary Service (AHFS) publishes list of all drugs 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) The drugs are in alphabetical order. All the codes are 6 digits. This appendix is used primarily by pharmacists to track drugs nationally. SXS11ierPPT-INTC02_P1

AHFS listing correlated to ICD-9-CM Table of Drugs and Chemicals Appendix 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 ICD-9-CM codes and AHFS poisoning codes mean the same thing. SXS11ierPPT-INTC02_P1

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 The subsection is divided into the following categories: machines; means of transporting and lifting equipment; other equipment; materials, substances, and radiations; working environment; other agencies, not elsewhere classified; agencies not classified for lack of sufficient data. Statisticians use these data to analyze the risks involved in various occupations. SXS11ierPPT-INTC02_P1

Appendix E, Three-Digit Categories Presented by chapter Categories are labeled 1 through 17 Provides quick overview of ICD-9-CM contents Appendix E contains a listing of all 3-digit categories. Using Appendix E is a good way to get a quick overview of all the categories in the ICD-9 manual. SXS11ierPPT-INTC02_P1

Section 1, Index to Diseases Section 2, Table of Drugs and Chemicals 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 All three sections make up Volume 2. Not only does Volume 2 contain the Alphabetical index to Diseases it also includes the Table of Drugs and Chemicals that directly follow the alpha index, and after that falls the Index to External Causes of Injuries and Poisonings. All Indexes in Volume 2 are listed in alphabetical order. Never code directly from any of these indexes. SXS11ierPPT-INTC02_P1

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 Section 1 contains terms referring to diseases and injuries in alphabetic order. Each term is followed by the code or codes that apply to the term. What does the Alphabetic Index include? (Most diagnostic terms currently in use) SXS11ierPPT-INTC02_P1

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) Why do publishers try to save space in the Tabular List by not including some words? (To make the list less cumbersome to use) SXS11ierPPT-INTC02_P1

Section 2, Table of Drugs and Chemicals Section 2 includes codes for poisonings and external causes of injury by drugs or chemicals. If you cannot find the drug you are looking for in the table of drugs and chemicals you may need to reference a PDR or nursing drug handbook to find another name for that drug. Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. Drug name placed alphabetically on left under heading “Substance” SXS11ierPPT-INTC02_P1

Table of Drugs and Chemicals (…Cont’d) Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. First column: “Poisoning” code for substance involved, wrong substance given or taken First-listed before manifestation condition When does poisoning occur? (When a substance has been incorrectly taken) The poisoning can be accidental, adverse reaction from a therapeutic use, an intentional suicide attempt, assault, or at times it may be undetermined as what truly happened. SXS11ierPPT-INTC02_P1

Table of Drugs and Chemicals 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 Therapeutic E935.9 E codes are never reported as the principal diagnosis. Why? (They indicate an external cause for the poisoning, how it occurred.) Which external cause area would you code from if the patient developed a rash when she took her prescribed dose of medication? (Therapeutic Use) Which external cause area would you code from if the patient told the physician that she took here pills twice because she forgot that she had already taken them earlier? (Accident) SXS11ierPPT-INTC02_P1

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 When does an adverse effect occur? (When a substance is taken correctly, but there is a negative response to the substance) An adverse effect can be something as simple as a rash or as complicated as respiratory arrest. You should never assume what happened to the patient. If you were to code a suicide attempt and that is not what truly occurred this could affect many aspects of this patient’s life and also could affect how or even if the insurance company will cover the expenses incurred. SXS11ierPPT-INTC02_P1

Alpha-numerical designations for injuries and poisonings E Codes (E000-E999) Supplementary Classification of External Causes of Injury and Poisoning Alpha-numerical designations for injuries and poisonings The E codes are alphanumeric designations of external causes of injuries, poisonings, and adverse effects. SXS11ierPPT-INTC02_P1

Provides additional information about external causes 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 E codes permit the classification of environmental events, circumstances, and conditions as the cause of illness or injury. An E code is used in addition to a code from the Tabular List. Most groups of E codes have Includes or Excludes notes. Where is the separate E Code Index located? (Volume 2, Section III) Some states have made the assignment of E codes mandatory. SXS11ierPPT-INTC02_P1

Alphabetic Index to External Causes of Injuries and Poisonings 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 What do E codes describe? (External circumstances under which an accident, injury, or act of violence occurred) This is mainly statistical information. SXS11ierPPT-INTC02_P1

Separate Index to External Causes Alphabetical, main terms in bold Section 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 Code to the furthest level of specificity just as you would for diagnosis codes. Be as specific as possible. If a patient was in a MVC with another vehicle do not code an E code for a non-collision motor vehicle accident. SXS11ierPPT-INTC02_P1

Index to External Causes: Example Main terms are type of accident (Collision) Subterms are circumstances of the accident (motor vehicle) Example: If a patient fell skateboarding, use code E885.2 not E884.9 (Fall from one level to another) because it specifically states in the documentation that he fell from his skateboard. Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. SXS11ierPPT-INTC02_P1

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” • What are neoplasms? (Tumors) • What two steps are needed to locate the neoplasm code in the Alphabetic Index? (Locate neoplasm by its name or its morphology, i.e., form and structure; locate Neoplasm Table in the Alphabetic Index under the “Ns.”) • For each site, six possible code numbers may be assigned. How is the proper code determined? (If malignant, specify primary, secondary, or in situ; if benign, specify uncertain behavior or unspecified nature.) • Morphology codes are used to supplement the neoplasm code; these codes are optional and vary according to the facility’s policy. From Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. SXS11ierPPT-INTC02_P1

Main terms (bold typeface) 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) A main term may also be followed by a list of subterms that have an effect on the selection of an appropriate code for a given diagnosis. These subterms are indented under the main term and offer additional specificity. SXS11ierPPT-INTC02_P1

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)…. Coders reference Volume 2, the Alphabetic Index, first and then locate the diagnosis code identified in the Index in the Tabular List, Volume 1. A main term in the Index may be followed by a series of terms in parentheses. The presence or absence of parenthetic terms has no effect on the selection of the code listed for the main term; these are called non-essential modifiers. SXS11ierPPT-INTC02_P1

Punctuation: [ ] ( ) : } italicized and bold type [ ] Symbols: §  ICD-9-CM Conventions Punctuation: [ ] ( ) : } italicized and bold type [ ] Symbols: §  Abbreviations: NEC, NOS Notations: Includes, Excludes, Use Additional Code, And/With, Code if Applicable Definitions of the conventions are usually provided in the front portion of the manual. Each publisher has its own conventions that it adds to the standard conventions. Why would standard conventions make use of the manual more efficient? (Greater accuracy) SXS11ierPPT-INTC02_P1

NEC: Not elsewhere classifiable NOS: Not otherwise specified Abbreviations NEC: Not elsewhere classifiable No more specific code exists NOS: Not otherwise specified Unspecified in documentation NEC is listed in Volumes 1 and 2; NOS is listed only in Volume 1. NOS is used when the information available does not permit a more specific code assignment. If a coder runs into an NOS code, what should the coder do? (Ask the physician for more specific information so that the proper code can be assigned.) SXS11ierPPT-INTC02_P1

Enclose synonyms, alternative wording, or explanatory phrases [ ] 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) Brackets are found in Volume 1 of the Tabular List. This is very helpful, additional information. Example: Look up code 253.6 in the tabular section of your ICD-9 book. This is “Other disorders of neurohypophysis”. This is not very familiar to many people. Under this though it states “Syndrome of inappropriate secretion of antidiuretic hormone [ADH]”. Many people are very familiar with ADH. SXS11ierPPT-INTC02_P1

Volume 2, Etiology and Manifestation of Disease Etiology = cause of disease Manifestation = symptom Etiology + Manifestation = Combination codes For certain conditions, it is important to record both the etiology and the manifestation of the disease. In many cases, the etiology and manifestation of a disease can be coded by assigning a single five-digit code, which is called a combination code. What is the cause of disease called? (Etiology) An example is staphylococcal pneumonia (482.40). The etiology is staphylococcal and the manifestation is pneumonia. SXS11ierPPT-INTC02_P1

Combination Code Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. Combination codes give you the etiology (cause of disease) and the manifestation (symptom). Only one code is needed to describe the diagnosis. SXS11ierPPT-INTC02_P1

Enclose manifestations of underlying condition Slanted Brackets [ ] Enclose manifestations of underlying condition “Code first underlying disease” Used in the Alphabetic Index-Volume 2 Slanted brackets are used in the Alphabetic Index, Volume 2. An example would be “Diabetes, with, gangrene 250.7,” and following this in slanted brackets is the code 785.4. You would first code the diabetes and the number two diagnosis would be 785.4. SXS11ierPPT-INTC02_P1

No combination code, use individual code(s) in this order Multiple Coding Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. No combination code, use individual code(s) in this order 250.4x 581.81 For some conditions, it is not possible to provide specific fifth-digit subclassifications that indicate both etiology and manifestations. What can coders do in these cases? (Multiple coding is required to report the two facets of the disease.) It is important to record the multiple codes on the insurance form in the same sequence used in the Alphabetic Index. SXS11ierPPT-INTC02_P1

Contain non-essential modifiers ( ) Parentheses Contain non-essential modifiers Take them or leave them Informational descriptive terms Found in Tabular List and Index Does not affect code selection Parentheses are used to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number. These are found in both the tabular list and in the index. In the index they are typically used after the main term that you are looking up. For example: “Corn (infected) 700”. In the Tabular List they are used in many areas. One example is with the excludes that list what the code excludes, and after the wording of the diagnosis, they give the code in parentheses. SXS11ierPPT-INTC02_P1

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 Colons are used after an incomplete term that needs one or more of the modifiers that follow in order to make it assignable to a given category. A brace is used to enclose a series of terms, each of which modifies the statement appearing at the left of the brace. SXS11ierPPT-INTC02_P1

Italicized and Bold Type All Excludes notes Codes not used as principal diagnosis Bold Codes and code titles in Tabular List, Volume 1 Italicized type is used for all exclusion notes and to identify codes that are not usually sequenced as the principal diagnosis. Italicized codes always follow another code. What information in the Tabular List uses bold type? (All codes and titles) SXS11ierPPT-INTC02_P1

Lozenge and Section Mark  Lozenge: Indicates codes unique to ICD-9-CM § Section: Can be footnote indicator These conventions are used in some version of the ICD-9-CM. The lozenge is printed in the left margin preceding the disease code to denote a four-digit number unique to the ICD-9-CM manual (different from the ICD-9); it is used only in Volume 1, the Tabular List. What does a section mark in the Tabular List indicate? (Footnote located at the bottom of the page) SXS11ierPPT-INTC02_P1

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 Includes and Excludes notes appear in the Tabular List, Volume 1. Includes notes further define or provide examples and can apply to the chapter, section, or category. What are the three reasons for using Excludes notes? (The condition may have to be coded elsewhere; the code cannot be assigned if the associated condition is present; additional codes may be required to fully explain the condition.) SXS11ierPPT-INTC02_P1

With: Means one condition with (in addition to) another condition 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 “With” indicates that two conditions are included in the code. What else does it indicate? (That both conditions must be present) What does “and” mean? (it means either “and” or “or”) SXS11ierPPT-INTC02_P1

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) What do cross-references provide to the coder? (Possible modifiers for a term or its synonyms) There are three types of cross-references. When is “see” used? (An explicit direction to look elsewhere; used for anatomic sites and for many general adjective modifiers not normally used in the Alphabetic Index; also used to reference appropriate main term under which all information concerning a specific disease is found.) SXS11ierPPT-INTC02_P1

Volume 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 The “see category” cross reference to see other conditions. It is necessary for proper coding to reference the other term that is given. It directs you to Volume 1, Tabular list. SXS11ierPPT-INTC02_P1

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 Define “principal diagnosis.” (Used in the inpatient setting to identify reason for admission) SXS11ierPPT-INTC02_P1

Code, If Applicable, Any Causal Condition First 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 Coding for the underlying condition that is causing the problem. Both diagnoses would be coded. SXS11ierPPT-INTC02_P1

Give further coding instructions Volume 2, Notes Define terms Give further coding instructions Example: Index: “Melanoma,” Note: “Except where otherwise indicated….” Notes are used to define main terms and provide specific coding instructions. These are a must follow for correct coding. SXS11ierPPT-INTC02_P1

Volume 2, Notes (…Cont’d) Figure: 2.13 Notes are used to list fifth-digit subclassifications for subcategories. Only the four-digit code is given for the individual entry, and the coder must refer to the note following the main term to locate the correct fifth-digit subclassification. From Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. Mandatory fifth digits also appear as notes (one reason to never code from Index) SXS11ierPPT-INTC02_P1

Disease or syndrome named for person Volume 2, Eponyms Disease or syndrome named for person Example: Arnold-Chiari (see also Spina bifida) Sturge-Weber Prader-Willi Eponyms are listed both as main terms in their appropriate alphabetic sequence and under the main term “Disease” or “Syndrome.” Where do descriptions go? (Usually included in parentheses following the eponym) SXS11ierPPT-INTC02_P1

90% of codes refer to surgical procedures Volume 3, Procedures Figure: 2.14 Procedure codes are located in Volume 3. Where are procedure codes used? (In hospital settings) The codes are four-digit codes (34.28). Volume 3, Surgical procedures. (Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.) 90% of codes refer to surgical procedures (Cont’d…) SXS11ierPPT-INTC02_P1

10% refer to diagnostic and therapeutic procedures Volume 3, Procedures (…Cont’d) Figure: 2.15 This shows the format of Volume 3 on p. 62 of the text. Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. 10% refer to diagnostic and therapeutic procedures (Cont’d…) SXS11ierPPT-INTC02_P1

Volume 3, Procedures 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 Volume 3 is not used in physicians’ offices. Facility services include operating room, room and board, nurses, and supplies. SXS11ierPPT-INTC02_P1

Chapter 0 Chapters 1-15 Chapter 16 Volume 3, Table of Contents 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 All chapters are based on body systems except for Chapters 13 and 16. … SXS11ierPPT-INTC02_P1

Volume 3, Table of Contents (…Cont’d) This illustration is printed on p. 63 of the text. Figure: 2.16 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. SXS11ierPPT-INTC02_P1

Conventions in Volume 3 same as those in Volumes 1 and 2 Volume 3, Tabular List 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 Conventions, for example “see also” apply here too. Code to the furthest extent. For example, don’t use the code 27 (other operations of the mouth and face) for the incision of the palate (27.1) SXS11ierPPT-INTC02_P1

Volume 3, Alphabetic Index 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 When the exact word is not found in the Tabular List of Procedures but is found in the Index to Procedures, the code given in the Index is correct. SXS11ierPPT-INTC02_P1

Volume 3, Alphabetic Index Terms in bold Subterms not in bold Never code directly from Index Index example follows Includes non-essential modifiers, as in Volume 1 The Index to Procedures is arranged primarily by procedures. What are procedure codes? (Numbers only, no alphabetic characters) SXS11ierPPT-INTC02_P1

Example Figure: 2.17 Main terms are printed in bold type. A main term may be followed by a list of subterms (modifiers) that affect code selection. Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. SXS11ierPPT-INTC02_P1

Volume 3, Alphabetic Index Index alphabetical Ignores single spaces and hyphens Example: Opening and open reduction “Opening” appears before “open reduction” because space between two words ignored In the Alphabetic index spaces and hyphens are not counted in the alphabetizing. SXS11ierPPT-INTC02_P1

Volume 3, Alphabetic Index 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 What other sorts of procedures would require coding of individual components? (Bacterial smear, immunization, osteolysis) SXS11ierPPT-INTC02_P1

Volume 3, Alphabetic Index 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 Remember: “See” is an explicit direction to look elsewhere. “See also” directs the coder to look under another main term for more information. “See category” directs the coder to the Tabular List of Procedures for further information or specific site references. SXS11ierPPT-INTC02_P1

Volume 3, Tabular List Format same as Volume 1, Tabular List of Diseases, except Volume 3 codes have two digits before decimal Procedure codes comprise two digits, with two additional digits when necessary for greater specificity. SXS11ierPPT-INTC02_P1

Category, subcategory, and subclassification Volume 3, Tabular List Category, subcategory, and subclassification Refer to Fig. 2–18 on p. 66. Figure: 2.18 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders. SXS11ierPPT-INTC02_P1

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 Opening and closing of the surgical site are included in all surgical procedure codes. SXS11ierPPT-INTC02_P1

Conclusion CHAPTER 2 AN OVERVIEW OF ICD-9-CM SXS11ierPPT-INTC02_P1