1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 12 CHAPTER-SPECIFIC GUIDELINES (ICD-9-CM CHAPTERS 9-17)

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 9 Diseases of Digestive System –Mouth to anus and accessory organs –Extensive subcategories 574 Cholelithiasis (10 subcategories) Each has fifth digit subclassification –Presence of hemorrhage associated with diseases in this chapter Query provider if documentation is not clear

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 10 Diseases of Genitourinary System Commonly used codes –Urinary tract infection (_____) –Inflammation of prostate (___.X) –Disorders of menstruation (626-627) & breast (610- 612) Use additional code to identify ________ Use additional codes to identify lower urinary tract symptom 599.0 601 organism

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 11, Complications of Pregnancy, Childbirth, and the Puerperium Extensive multiple coding with many fifth digit assignments and notes Chapter 11 codes take __________ over codes from other chapters Admission for pregnancy, complication –Obstetric complication = first-listed diagnosis precedence

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11. Complications of Pregnancy, Childbirth, and Puerperium Chapter 11 codes _______ medical record (600 series codes) Not on newborn medical record (Newborn, ___ series codes) Mother’s 700 (Cont’d…)

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11. Complications of Pregnancy, Childbirth, and Puerperium (…Cont’d) Mother’s record –Outcome of delivery code (V27.0-V27.9) when ________ delivered

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.a. General Rules for Obstetric Cases Not all encounters are pregnancy related –Example, pregnant woman, broken ankle Broken ankle _____ Pregnant state incidental, must be documented in medical record as treated condition not affecting pregnancy V22.2

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.a.4. Fifth Digit All categories EXCEPT 650 (Normal delivery) Requires ___ digit for: –Antepartum –Postpartum –Delivery fifth

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Codes 640-676.9 Share Fifth- Digit Subclassification Denotes current episode of care –0 __________ as to episode of care or not applicable –1 Delivered, ___ or ______ mention of antepartum condition –2 Delivered, ____ mention of postpartum complication –3 __________ condition or complication –4 __________ condition or complication Unspecified with without with Antepartum Postpartum

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.b. Selection of Principal Diagnosis—Obstetric No delivery: Principal diagnosis = principal __________ >1 complication, sequence any ___ complication first (Cont’d…)

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.b. Selection of Primary Diagnosis (…Cont’d) Routine prenatal visits no complications: –_____, Supervision, normal first pregnancy or –_____, Supervision, other normal pregnancy –Always primary diagnosis Prenatal outpatient visits for high-risk pregnancies: –___, Supervision of high-risk pregnancy (V23.X) V22.0 V22.1 V23

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.c.1. Fetal Conditions Affect Mother Codes from Categories 655 and 656 Assign only if known or suspected fetal or placenta problems affects management of the mother Requires additional diagnostic studies, observation, special care or termination of the pregnancy The existence of a fetal condition alone does not justify reporting these codes

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.c.2. In Utero Surgery When surgery is performed on the fetus, report a code from Category 655 identifying the fetal condition No code from Chapter 15, perinatal codes, should be used on the mother’s record to identify fetal conditions Surgery performed in utero on the fetus is still coded as an obstetric encounter

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.d. HIV Infection in Pregnancy, Childbirth, Puerperium Patient admitted during this period because of an HIV-related illness should receive –a principal code of 647.6x –followed by 042 Patient admitted with asymptomatic HIV status should be reported –647.6x –V08

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.e. Current Conditions Complicating Pregnancy Assign a code from Category 648.X for patient with current condition that affects management of the pregnancy, childbirth or the puerperium Use additional secondary code from other chapters to identify conditions

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.f. Diabetes Mellitus in Pregnancy Significant complicating factor in pregnancy Diabetic pregnant patients should be assigned code 648.0X AND A secondary code from Category 250 to identify type of diabetes Code V58.67, Long-term (current) use of insulin should also be reported if appropriate

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.g. Gestational Diabetes Occurs in second and third trimester in women who were not diabetic prior to pregnancy Can cause complications in pregnancy similar to those of pre-existing diabetes Puts women at greater risk of developing diabetes after the pregnancy (Cont’d…)

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.g. Gestational Diabetes (…Cont’d) Report 648.8X NEVER report codes 648.0X and 648.8X together Code V58.67, Long-term (current) use of insulin should also be reported if gestational diabetes is being treated with insulin

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.h. Normal Delivery, 650 No ___________, principal diagnosis = 650 With complications = NOT 650 V27.0 (_____ liveborn) –____ outcome for 650 (Normal Delivery) Normal delivery with resolved antepartum condition = 650 complications Single Only

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.i.1. Postpartum and Peripartum Periods After delivery and continues for _ weeks Peripartum period –Last month of pregnancy to five months postpartum 6

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.i.2.,3.,4. Postpartum Complications Any complication occurring within the 6-week period Complications occurring after the 6-week period may be reported with Chapter 11 codes, if the provider documents they are pregnancy related Complications occurring during the same admission as delivery are reported with fifth digit “2”; subsequent admissions/encounters with fifth digit “4”

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.i.5. Care following delivery outside hospital If delivered ____ to admission –In ambulance –At home –In ED DO NOT CODE ______ Code any _________ care prior delivery postpartum

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.j. Late Effect of Complication of Pregnancy Category 677 Reported when an initial complication of pregnancy requires care or treatment at a future date Category reported any time after initial postpartum period Like all late effects, code is sequenced following the complicating condition code

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.k. Abortions Codes 634-637 require fifth digits: –0: __________ –1: _________ (POC, product of conception) NOT expelled –2: ________, all (POC) expelled prior to care Unspecified Incomplete Complete

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.k.1. Fifth-Digits Appropriate fifth-digits listed under each code 640.0, _________ abortion –0: __________ episode –1: ________ with or without complication –3: _________ condition or complication Note that NOT all fifth-digits may be assigned (2 and 4) Threatened Unspecified Delivered Antepartum

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.k.4. Abortion with Liveborn Fetus Attempted abortion results in liveborn fetus: –______ (Early onset of delivery) appropriately Use ___ (Outcome of delivery) Attempted abortion procedure code also assigned 644.21 V27

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.11.k.5. Retained Products of Conception Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are reported with code from: –634 Spontaneous abortion –635 Legally induced abortion –With fifth digit “1” (incomplete) –Appropriate even if patient previously discharged with diagnosis of “complete”

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 12, Diseases of the Skin and Subcutaneous Tissue SKIN Epidermis Dermis Subcutaneous tissue Infectious Skin/Subcutaneous Tissue Scar tissue ACCESSORY ORGANS Sweat glands Sebaceous glands Nails Hair and hair follicles Other (Cont’ d…)

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 12 (…Cont’d) Multiple codes often necessary –Example: Cellulitis due to Staph –Cellulitis 682.9 –Staph 041.1X

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 13, Diseases of Musculoskeletal System and Connective Tissue Bone Bursa Cartilage Fascia Ligaments Muscle Synovia Tendons

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 13 Sections Arthropathies (joint disease) and Related Disorders ___________ (curvature of spine) Rheumatism, Excluding back Osteopathies, Chondropathies, and Acquired Musculoskeletal Deformities Newly Diagnosed Pathologic Fractures Extensive notes and fifth digits Dorsopathies

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 13, Diseases of Musculoskeletal System and Connective Tissue Refer to the note at the beginning of the chapter regarding fifth-digit sub- classifications Details located there are not repeated in the categories Used for Categories 711-712, 715-716, 718-719, and 730

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapters 14 and 15 _________ Anomalies (abnormality at birth) (740-759) Conditions Originating in Perinatal Period –Perinatal period through ___ day following birth –Codes can be used after 28 th day if documented that condition originated during _______ period Congenital 28 th perinatal

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.b. Use of Codes V30-V39 V30-V39 _______ infant(s) Example: –V30, Single liveborn –V31, Liveborn twins Inpatient: Principal diagnosis Note: V30 ONLY used ____, hospital where baby delivered liveborn once

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.d. Use of Category V29 Assign code when healthy newborn/infant is evaluated for suspected condition not found Do not use when patient has signs/symptoms of a suspected problem, code the signs/symptoms V29 is used secondary to V30

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.f. Maternal Causes of Perinatal Morbidity Codes from Categories 760-763 are assigned only when the maternal condition actually affected the fetus/newborn The fact that the mother has a medical condition or experiences a complication does not justify routine reporting of these categories

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.h. Coding Additional Perinatal Diagnoses Code newborn conditions that require: –Treatment –Further investigation –Additional resource –Prolonged ___________ (LOS) –Implications for future care length of stay (Cont’d…)

38. Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.h. Coding Additional Perinatal Diagnoses (…Cont’d) Insignificant newborn conditions, signs, symptoms –Resolve with no treatment –Need no code EVEN IF documented

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.i. Prematurity and Fetal Growth Retardation Codes for newborns from categories –___ (Slow fetal growth and fetal malnutrition) and –___ (Disorders relating to short gestation and low birthweight) 764 765 (Cont’d…)

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.i. Prematurity and Fetal Growth Retardation (…Cont’d) Not assigned solely on birthweight or gestational age of newborn –Use ______ assessment instead Use physician’s assessment of maturity Use additional code for number of _____ of gestation (765.0 and 765.1) clinical weeks

41. Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.15.j. Newborn Sepsis Code 771.81 should be assigned a secondary code from category 041 to identify the organism Do not report category 038 Do not assign 995.91, Sepsis, assign 771.81

42. Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 16, Symptoms, Signs, and Ill-Defined Conditions Do NOT code a sign or symptom if: –Definitive diagnosis made (symptoms are part of disease) Only used if no ______ diagnosis stated Signs/symptoms are transient or cause not determined Patient fails to return and provisional diagnosis is all that is documented specific (Cont’d …)

43. Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 16, Symptoms, Signs, and Ill-Defined Conditions (…Cont’d) More precise diagnosis not available for any other reason Certain symptoms that may represent important problems in medical care exist and might be desirable to classify them in addition to the known cause

44. Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 17, Injury and Poisoning, Section Examples Fractures Dislocations Sprains and Strains Intracranial Injury Internal Injury Crushing Injury Foreign Body Burns Late Effects Poisoning

45. Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.c. Burns Sequence ______ degree burn first Current burns (940-948) classified by –_____ (severity) –______ (% body surface) –____ –And if necessary, agent highest Depth Extent Site (Cont’d …)

46. Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.c. Burns (…Cont’d) Depth of burn is classified as –First degree: Erythema –Second degree: Blistering –Third degree: ___-thickness involvement Full

47. Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.c. Burns Classified According to extent body surface involved Burn site NOT specified –Additional data required Burns of different degrees/same local site –Report highest degree only Non-healing burns are reported as acute burns Report 958.3 as additional code for infected burn site

48. Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.c.6. Category 948 _____ digits = % total body surface involved ____ digits = % body surface involved in third-degree burns Rule of Nines applies (Cont’d…) Fourth Fifth

49. Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. (…Cont’d) Rule of Nines Figure: 12.6

50. Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.d. Debridement of Wounds, Infection, or Burn ________ debridement (86.22) –Cut away –Performed by physician ___________ procedure (86.28) –Shaved or scraped (includes water scalpel [jet]) –Performed by physician or –Nonphysician Excisional Nonexcisional

51. Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17. Injury and Poisoning (800-999) Separate code for each injury ________ injury first Superficial injuries not reported if in same location as more serious injury Wounds –Without mention of complication –Complicated Documented delayed healing/treatment, foreign body, primary infection –With tendon involvement Most serious

52. Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.a.2. Vessel and Nerve Damage Code ______ injury first –Use additional code if nerve/vessel damage minor Primary injury = nerve/vessel damage Code nerve/vessel damage first primary

53. Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section 1.C.17.b.1. Acute Fracture vs. Aftercare Active treatment of fracture (800-829) may be: –Physician evaluation –ER encounter –Surgical treatment –Closed treatment After active treatment completed, use aftercare codes –Aftercare involving internal fixation (V54.X) –Aftercare for healing traumatic fracture (V54.1X) –Other orthopedic aftercare (V54.8X) –Unspecified orthopedic aftercare (V54.9)

54. Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.b.2. Multiple Fractures Same coding principles as multiple injuries Code multiple fractures, by ___ Sequenced by _______ Codes describe accidents, injury, open wounds, etc. site severity (Cont’d …)

55. Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Fractures (…Cont’d) Not indicated as closed or open = _____ Same bone fractured AND dislocated –Code ______ ONLY (highest level of injury) closed fracture

56. Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.e. Adverse Effects, Poisoning, and Toxic Effects Properties of some drugs, medicinal, and biological substances, or combinations may cause toxic reactions Classify as Adverse Effect when drug was correctly prescribed/administered –Code effect first –E-code from therapeutic column for drug (Cont’d…)

57. Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.e. Adverse Effects, Poisoning, and Toxic Effects Poisoning occurs when drugs/chemical substances are not taken as directed Wrong dosage given in error Medication given to wrong person Medication taken by wrong person Medication overdose has occurred Medications (prescription or over-the-counter) taken in combination with alcohol and/or recreational drugs Over-the-counter taken in combination with prescription drugs without provider approval (…Cont’d) (Cont’d…)

58. Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.17.e. Adverse Effects, Poisoning, and Toxic Effects Sequencing of Poisoning: Poisoning code from Table of Drugs & Chemicals first Manifestation(s) of the poisoning second Corresponding E code from the Table of Drugs and Chemicals last –If intent unknown or questionable, report intent as undetermined (E980-E989) (…Cont’d)

59. Slide 59 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. E Codes Provides supplemental information Never ________ diagnosis Identify: –_____ of an injury or poisoning, –_____ (unintentional or intentional), and –_____ it occurred first-listed Cause Intent Place

60. Slide 60 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. General E Code Guidelines Use with any code in Vol. 1 ____ encounter –Use E code __________ encounter –Use late effects E codes Initial Subsequent

61. Slide 61 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Intent Unknown Unspecified Questionable Code As Undetermined* *(E980-E989)

62. Slide 62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.19.c. Table of Drugs and Chemicals Alphabetic listing with codes Do NOT code directly from Table Always reference Tabular

63. Slide 63 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.19.c. Two or More Substances Involved If two or more substances involved code: –Each unless __________ code exists Code substance more closely related to principal diagnosis, and –Include one code from each category (cause, _____, place) Interaction of a drug(s) and alcohol –Using ________ and E codes for both combination intent poisoning

64. Slide 64 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.19.e. Unknown or Suspected Intent Unknown Unspecified Questionable Undetermined E980-E989

65. Slide 65 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.19.f. Undetermined Cause Intent known, cause unknown, use –E928.9, Unspecified accident –E958.9, Suicide and self-inflicted injury by unspecified means –E968.9, Assault by unspecified means

66. Slide 66 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Section I.C.19.g. Late Effects of External Cause Should be used with late effect of a previous injury/poisoning Should NOT be used with related current injury code

67. Slide 67 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 12 CHAPTER-SPECIFIC GUIDELINES (ICD-9-CM CHAPTERS 9-17)