1. Medical Coding
Chapter 4

2. Using ICD-9-CM General Guidelines
Chapter 1, Infectious and Parasitic Diseases
Chapter 2, Neoplasms
Chapter 3, Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders
Chapter 4, Diseases of Blood and Blood- Forming Organs
Chapter 5, Mental Disorders
Chapter 6, Diseases of Nervous System and Sense Organs
Chapter 7, Diseases of Circulatory System
Chapter 8, Diseases of Respiratory System
Chapter 9, Diseases of Digestive System
Chapter 10, Diseases of Genitourinary System
Chapter 11, Complications of Pregnancy, Childbirth, and the Puerperium
Chapter 12, Diseases of Skin and Subcutaneous Tissue
Chapter 13, Diseases of Musculoskeletal System and Connective Tissue
Chapters Congenital Anomalies; 14 and 15, Certain Conditions Originating in Perinatal Period
Chapter 16, Symptoms, Signs, and Ill-Defined Conditions
Chapter 17, Injury and Poisoning and E Codes
Basic Coding Guidelines
ICD-10-CM
The ICD-9-CM includes 17 chapters.
Section I presents the ICD-9-CM conventions, general coding guidelines, and chapter-specific guidelines.
Sections II and III outline the selection of diagnoses for inpatient records.
Section IV contains the diagnosis guidelines for outpatient services.
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3. Using ICD-9-CM Guidelines developed by cooperating parties
AHA (American Hospital Association)
AHIMA (American Health Information Management Association)
CMS (Centers for Medicare and Medicaid Services)
NCHS (National Center for Health Statistics)
As cooperating parties for ICD-9-CM, these entities developed and approved the guidelines for coding and reporting.
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4. General Guidelines Appendix A of text contains official Guidelines
Inpatient coders use Sections I-III of Guidelines
Outpatient coders primarily use Sections I and IV, however…
• In the text, Official Guidelines for Coding and Reporting that apply to only one setting are identified as “inpatient” or “outpatient.”
• From which section do inpatient coders code? (Sections I-III)
• From which section do outpatient coders code? (Primarily Sections I and IV.)
(Cont’d…)
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5. General Guidelines Basic coding guidelines do NOT cover all situations
(…Cont’d)
Basic coding guidelines do NOT cover all situations
Outpatient coders also use many inpatient guidelines
The number that appears to the left of the guideline in the text is the number of the guideline as listed in the Official Guidelines for Coding and Reporting.
These are only basic coding guidelines and are not for all situations.
When we are going through these slides, they will be marked with either an (I) for inpatient or (O) for outpatient depending on what they pertain to.
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6. Steps to Accurate Coding
Identify MAIN term(s) in diagnosis
Locate MAIN term(s) in Index
Review subterms
Follow cross-reference instructions
(e.g., see, see also)
Verify code(s) in Tabular
If you begin coding by using these steps, you will develop good coding habits.
What is the first step in correct coding of diagnoses? (Identify the main term(s) of the diagnosis you are going to code.)
What is the second step in correct coding of diagnoses? (Locate the main term(s) in the index)
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7. Remember Read Tabular notes Code to highest specificity (detail)
NEVER CODE FROM INDEX!
Also, code the diagnosis until all elements are completely identified.
Remember, just as in CPT coding, you never code from the Index of the ICD-9-CM. Always check the cross references and instructions and verify your code in the Tabular.
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8. Guideline Section I.B.3. Level of Detail in Coding
Assign diagnosis to highest level of specificity
Do NOT use three-digit code if there is fourth
Do NOT use four-digit code if there is fifth
If not specific, claims bounce!
Diagnosis and procedure codes are to be used at the highest number of digits available, according to documentation in the medical record.
Diagnosis codes with three digits are included in the ICD-9-CM as the heading of a category of codes that may be further subdivided.
A code is invalid if it has not been coded to the full number of digits available for that code.
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9. Guideline Section I.B.7. Conditions integral to disease
Signs and symptoms that are associated routinely with a disease process should not be reported separately, unless otherwise instructed in the classification
Example:
Fever and shortness of breath due to pneumonia
Report only Pneumonia 486
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10. Guideline Section I.B.8. Conditions NOT integral to disease
Additional signs and symptoms not routinely associated with disease process should be reported
Example:
Dehydration due to pneumonia
Report
Pneumonia and
dehydration
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11. Section I.B.9. Multiple coding for a single condition
Etiology (cause)
Manifestation (symptom)
Slanted brackets [ ]
Example: Retinopathy, diabetic [362.01]
Code as shown
250.5X
362.01
The etiology/manifestation convention requires two codes to fully describe a single condition that affects multiple body systems.
Other instances (single conditions) may require more than one code to fully describe the condition.
“Use additional code” indicates that a secondary code should be added.
“Code first” notes may be found under certain codes that refer to conditions that may be due to an underlying condition; the underlying condition is sequenced first.
“Code, if applicable, any causal condition first” notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable.
(Cont’d…)
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12. Section I.B.9. Multiple coding for a single condition
(…Cont’d)
Must check Tabular notes to assign correct fifth digit for diabetes
Tabular: 362.0, Diabetic retinopathy, instructs to “Code first diabetes 250.5”
250.5X Cause is diabetes
Manifestation is retinopathy
Report 250.5X,
X = required additional digit
There are conditions for which you need two codes to represent one diagnosis.
What would the two codes be that you would need to represent one diagnosis? (Possibly, the disease and the underlying cause of the disease—a wound infection due to a bacteria. A disease like diabetes and an effect the diabetes has on the eyes, retinopathy)
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13. Section I.B.10. Acute and Chronic Conditions
Exists alone or together
May be separate or combo codes
Reporting both codes, code acute first
(Cont’d…)
What is the difference between acute and chronic? (Acute: having a short and relatively severe course. Chronic: persisting over a long time)
If the same condition is described as both acute (or subacute) and chronic and separate subentries with the same indentation level exist in the Alphabetic Index, both should be coded.
Sequence the acute or subacute code first.
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14. Section I.B.10. Acute and Chronic Conditions
(…Cont’d)
Example, acute and chronic pancreatitis
When two separate codes exist, code:
Acute pancreatitis 577.0
Chronic pancreatitis 577.1
Place acute first and chronic second
577.0, 577.1
When acute and chronic conditions both exist and the index contains separate entries for both, use both codes.
Always sequence the acute code first.
(Cont’d…)
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15. Section I.B.10. Acute and Chronic Conditions
(…Cont’d)
Combination code: Both acute and chronic condition
Diarrhea (acute) (chronic)
Acute and subacute bacterial endocarditis 421.0
Otitis acute and subacute 382.9
There are codes that also represent both an acute and chronic condition in one code.
What is this type of code called? (A combination code)
Notice that the code definition will tell you what the code entails.
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16. Section I.B.11. Combination Code
Always use combination code if one exists
Example, encephalomyelitis (manifestation) due to rubella (etiology),
Assign only when code fully identifies condition
A combination code is:
A single code used to classify two diagnoses
A diagnosis with an associated secondary manifestation
A diagnosis with an associated complication
Combination codes are identified by referring to subterm entries in the Alphabetic Index and by reading Inclusion and Exclusion notes in the Tabular List.
Multiple coding should not be used when the classification provides a combination code that clearly identifies all elements documented in the diagnosis.
If the combination code lacks necessary specificity in describing the manifestation or complication, then an additional code may be reported as a secondary code.
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17. Section I.B.12. Late Effects
Ex., followed by code 906.6
Late effect is a residual of (remaining from) previous illness/injury
e.g., Scar produced by previous burn
Residual coded first (scar)
Late effect cause (burn) coded second 906.6
No time limit
Generally requires 2 codes
Late effects codes are not in a separate chapter in the Tabular List. Instead, the coder must identify a case as a late effect.
Sometimes, an acute illness or injury leaves a patient with a problem that remains after the illness or injury has resolved.
The code for the current injury or illness cannot be coded at the same time as the code for the late effect, except in the case of cerebrovascular disease.
(Cont’d…)
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18. Late Effects Late effect codes not in separate chapter
(…Cont’d)
Late effect codes not in separate chapter
Rather throughout Tabular
Reference the term “Late” in the Index
There is no time limit on developing a residual
There may be more than one residual
Example: Patient had a stroke and has residual paralysis on dominant side (hemiparesis, ) and aphasia,
Late effect means the original injury has healed and you are dealing with a “residual” condition
In the index, reference the term “Late” to locate these codes.
When coding “late effects of stroke,” you need to know the effect of the stroke on the patient.
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19. Section I.C.7.d. Late Effects of Cerebrovascular Disease
438 indicates conditions classified to as causes of Late Effects
Code V12.54
Assigned for TIA and cerebral infarction without residual deficits
Do not report from category 438

20. Conclusion CHAPTER 4
USING ICD-9-CM
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