Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 9 ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 Section IV. Diagnostic Coding Physician’s office Hospital-based outpatient services Part of Official Guidelines for Coding and Reporting, Section IV

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Section IV. Diagnostic Coding Guidelines do not address specific sequencing or diseases as inpatient do Though not stated, if there is no outpatient guideline, follow inpatient guidelines

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 Diagnostic Coding Guideline A Term first-listed diagnosis, rather than principal diagnosis Outpatient Surgery: Reason for surgery –Even if surgery is canceled due to contraindication

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 Diagnostic Coding Guideline A Observation Stay: Medical condition that occasioned admission –Assign a code from medical condition Observation Stay: Complications from outpatient surgery lead to observation report: Reason for surgery as first reported diagnosis Codes for complications necessitating observation

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 Selection of First-Listed Diagnosis Condition for encounter –Why patient presented, not necessarily most serious condition noted Documented Chiefly responsible for services provided Also list co-existing conditions

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 Diagnosis and Services Diagnosis and procedure MUST correlate Medical necessity must be established through documentation No correlation = No reimbursement

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 Symptoms, Signs, and Ill- Defined Conditions Can be the first-listed diagnosis if no more specific diagnosis available Diagnoses often are not established at the time of the initial encounter/visit

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 Diagnostic Coding Guideline B Use codes through V91.99 to code: –Diagnosis –Symptoms –Conditions –Problems –Complaints –Or other reason(s) for visit

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 Diagnostic Guideline C Documentation should describe patient's condition, using terminology that includes: –Specific diagnoses –Symptoms –Problems –Reasons for encounter

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 Diagnostic Guideline D Selection of codes through (Chapters 1-17) frequently used to describe reason for encounter

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 Diagnostic Guideline E Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when –An established diagnosis has NOT been determined by physician

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 Diagnostic Guideline F V codes deal with encounters for circumstances other than disease or injury –Example: Well-baby checkup See Section I.C.18. for information on V codes

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service V01-V91 –Assigned as first-listed diagnosis for: Admissions for evaluation Following an accident that would ordinarily result in health problem, BUT there is none –Car accident, driver hits head, no apparent injury, admit to R/O head trauma –Never a secondary diagnosis

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 V Codes Located after in Tabular Two digits before decimal (e.g., V10.1X) Index for V codes is Alphabetic Index to Diseases Main terms: –Contraception –Counseling –Dialysis –Status –Examination

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 Uses of V Codes Not sick BUT receives health care (e.g., vaccination) Services for known/resolving disease/injury (e.g., chemotherapy) Codes for “aftercare” (e.g., surgery or fracture) Indicate birth status/outcome of delivery (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 Uses of V Codes (…Cont’d) A circumstance/problem that influences patient’s health BUT NOT current illness/injury –Example: Organ transplant status –Example: Birth status and outcome of delivery (newborn) Section I.C.18.e. of Guidelines contains the V Code Table –Identifies if V code can be listed as first, first/additional, additional only

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 History V Code Categories in Tabular V10 Personal history of malignant neoplasm V11 Personal history of mental illness V12 Personal history of certain other diseases V13 Personal history of other diseases V14 Personal history of allergy to medicinal agents V15 Other personal history presenting hazards to health V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V18 Family history of certain other specific diseases V19 Family history of other conditions Condition no longer present or treated

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 Diagnostic Guideline G Codes have either 3, 4, or 5 digits 4 and/or 5 digit codes provide greater specificity (detail) (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 Diagnostic Guideline G (…Cont’d) 3-digit code used ONLY if no 4 or 5 digit Where 4 and/or 5 digits provided, must be assigned Diagnoses NOT coded to full digits available invalid Claims bounce!

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Diagnostic Guideline H List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided List additional codes that describe any coexisting conditions Assign V72.5 and V72.6X for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 Diagnostic Guideline I Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 Diagnostic Guideline J Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 Diagnostic Guideline K Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management Do NOT code conditions previously treated, no longer existing (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 Diagnostic Guideline K (…Cont’d) “History of” codes (V10-V19) may be used as secondary codes if: –Impacts current care or treatment

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 Special Note About “History of” Index to Disease, MAIN term “History” Entries between “family” and “visual loss V19.0” = “family history of” (FHO) Entries before “family” and after “visual loss” = “personal history of” (PHO) Personal history = V10-V15 Family history = V16-V19

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 Diagnostic Guidelines L and M For patients receiving diagnostic services ONLY Sequence first –Diagnosis –Condition –Problem OR –Other reason shown in medical record to be chiefly responsible for encounter (…Cont’d)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 Diagnostic Guidelines L and M (…Cont’d) Codes for other diagnoses (e.g., chronic conditions) –May be sequenced as secondary diagnoses Exception: Therapeutic Services –Patients receiving chemotherapy (V58.11), radiation therapy (V58.0), or rehabilitation (V57.0-V57.9) –V code first diagnosis and problem for which service being performed second

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 Diagnostic Guideline N For patients receiving preoperative evaluations ONLY –Code from category V72.8 (Other specified examinations) –Assign secondary code for reason for surgery –Code also any findings related to preoperative evaluation

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 Diagnostic Guideline O, Ambulatory Surgery Code diagnosis which required ambulatory surgery Pre- and post-op diagnosis different –Code the post-op diagnosis

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 Diagnostic Guideline P Code routine prenatal visits with no complications: –V22.0 (Supervision of normal first pregnancy) –V22.1(Supervision of other normal pregnancy) –DO NOT use these codes with pregnancy complication codes (Chapter 11, ICD-9-CM)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 V91 Multiple Gestation Placenta Status New in 2011 Identifies number of placentas and amniotic sacs for twins, triplets, quadruplets, other multiples

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 Conclusion CHAPTER 9 ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES