Chapter 6

1. Chapter 6 ICD-9-CM Coding

2. ICD-9-CM Coding • International Classification of Diseases (ICD) • Used to code and classify mortality (death) data from death certificates

3. ICD-9-CM Coding • International Classification of Diseases, Clinical Modification (ICD-9-CM) • Used to code and classify morbidity (disease) data from inpatient and outpatient records

4. Overview of ICD-9-CM • ICD-9-CM is organized into three volumes: • Volume 1 • Tabular List • Volume 2 • Index to Diseases • Volume 3 • Index to Procedures and Tabular List

5. Mandatory Reporting of ICD-9-CM Codes • Medicare Catastrophic Coverage Act of 1988 • Mandated reporting of ICD-9-CM diagnosis codes on Medicare claims

6. Mandatory Reporting of ICD-9-CM Codes • Medical necessity: • Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury

7. ICD-9-CM Annual Updates • CMS enforces regulations pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) • Requires all code sets reported on claims be valid at the time services are provided

8. ICD-9-CM Annual Updates • Compliance means: • Traditional mid-year (April 1) and end-of-year (October 1) coding updates • Must be immediately implemented so that accurate codes are reported on submitted claims

9. ICD-9-CM Annual Updates • If outdated codes are submitted on claims: • Providers and health care facilities will incur administrative costs associated with resubmitting corrected claims and delayed reimbursement for services provided

10. Outpatient Coding Guidelines • Diagnostic Coding and Reporting Guidelines for Outpatient Services: Hospital-Based and Physician Office • Developed by the federal government for use in reporting diagnoses for claims submission

11. Outpatient Coding Guidelines • Developed and approved by: • American Hospital Association (AHA) • American Health Information Management Association (AHIMA) • Centers for Medicare and Medicaid Services (CMS, formerly HCFA) • National Center for Health Statistics (NCHS)

12. Outpatient Coding Guidelines • Although the guidelines were originally developed for use in submitting government claims, insurance companies have also adopted them.

13. Coding Tip Most critical rule involves beginning the search for the correct code assignment using the Index to Diseases/of Diseases.

14. Selection of First-Listed Condition • In the outpatient setting: • Term first-listed diagnosis is used • Determined in accordance with ICD-9-CM’s coding conventions as well as general and disease-specific coding guidelines

15. Selection of First-Listed Condition • Outpatient treated in one of four settings: • Ambulatory Surgery Center (ASC) • Patient is released prior to a 24-hour stay • Health care provider’s office

16. Selection of First-Listed Condition • Outpatient treated in one of four settings: 3. Hospital clinic, emergency or outpatient department, or same-day surgery unit 4. Hospital observation setting • Patient’s length of stay is 23 hours, 59 minutes, and 59 seconds or less

17. Coding Tip • Outpatient surgery: • Code reason for surgery as the first-listed diagnosis (reason for the encounter) • Even if surgery is not performed due to a contradiction

18. Coding Tip • Observation stay: • When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis

19. Coding Tip • Outpatient surgery requires longer stay: • A patient presents for outpatient surgery and develops complications requiring admission to observation. • Code the reason for the surgery as the first reported diagnosis, followed by codes for the complications as secondary diagnoses.

20. Coding Tip An inpatient is a person admitted to a hospital or long term care facility for treatment with an expected stay of 24 hours or more.

21. Coding Tip • In medical literature, you may see principal diagnosis referred to as first-listed diagnosis. • Remember! • The outpatient setting’s first-listed diagnosis is not the principal diagnosis

22. Coding Tip • Inpatient principal diagnosis: • Condition determined after study that resulted in the patient’s admission to the hospital. • UB-04 secondary diagnoses include co-morbidities and complications

23. ICD-9-CM Tabular List of Diseases (codes 001.0-V86.1) Must be used to identify diagnoses, symptoms, conditions, problems, complaints, or any other reason for the encounter/visit.

24. Accurate Reporting of ICD-9-CM Diagnosis Codes Documentation should describe patient’s condition using terminology that includes specific diagnoses as well as symptoms, problems, or reasons for the encounter.

25. ICD-9-CM Tabular List of Diseases (codes 001.0-V86.1) Must be used to identify diagnoses, symptoms, conditions, problems, complaints, or any other reason for the encounter/visit.

26. Reason for Encounter • Codes 001.0–999.9 • Frequently used to describe reason for encounter • Codes are from section of ICD-9-CM for the classification of diseases and injuries.

27. Signs and Symptoms Codes that describe signs and symptoms are acceptable for reporting purposes when the physician has not documented an established or confirmed diagnosis.

28. Factors Influencing Health Status and Contact with Health Services (V codes) Provides codes to deal with encounters for circumstances other than a disease or injury Codes V01.0-V86.1

29. Level of Detail in Coding • Codes contain 3, 4, or 5 digits • Codes with three digits: • Included in ICD-9-CM as the heading of a category of disease codes • May be further subdivided into four or five digits • Provide greater specificity

30. Level of Detail in Coding • Three-digit disease code is assigned only if it is not further subdivided • If fourth-digit subcategories or fifth-digit subclassifications are provided: • They must be assigned • If not the code is invalid

31. Sequencing ICD-9-CM Diagnosis First code for the diagnosis, condition, problem, or other reason for encounter shown in the medical record to be chiefly responsible for the services provided.

32. Sequencing ICD-9-CM Diagnosis Additional codes that describe coexisting conditions that were treated or medically managed during the encounter.

33. Qualified Diagnoses • Do not code diagnoses documented as: • Probable, suspected, questionable, rule out, or working diagnosis, because these are considered qualified diagnoses • Instead code condition to highest degree of certainty for that encounter

34. Qualified Diagnoses • Qualified diagnosis: • Working diagnosis that is not yet proven or established • Example: • Suspected pneumonia • Code the sign or symptom: • Wheezing, shortness of breath, etc.

35. Chronic Diseases • If treated on an ongoing basis: • May be coded and reported as many times as the patient receives treatment and care for the condition

36. Code all Documented Conditions that Coexist Code all that coexist at the time of the encounter, and require or affect patient care, treatment or management.

37. Code all Documented Conditions that Coexist • Do not code conditions that were previously treated and no longer exist. • However, history codes (V10-V19) may be reported as secondary codes.

38. Encounter for Diagnostic Services First, report the diagnosis, condition, problem, or reason for encounter that is documented in the patient record as being chiefly responsible for the outpatient services provided during the encounter.

39. Encounter for Therapeutic Services Sequence first the diagnosis, condition, problem, or other reason for the encounter shown in the medical record to be chiefly responsible for the outpatient services provided.

40. Encounter for Preoperative Evaluation Assign appropriate sub classification code located under subcategory V72.8.

41. ICD-9-CM Coding System • ICD-9-CM has three volumes: • Tabular List • Index to Diseases • Index to Procedures and Tabular List

42. ICD-9-CM Coding System • Tabular and Index to Diseases • Used in provider and health facilities to code diagnoses • Index to Procedures and Tabular List • Used in hospitals to code inpatient procedures

43. ICD-9-CM Coding System • Publishers make coding easier by placing the Index to Diseases in front of the Tabular List

44. Supplementary Classifications:V Codes and E Codes • V codes are assigned when a circumstance other than a disease or injury is present. • Examples: • Removal of cast applied by another physician (V54.89) • Exposure to tuberculosis (V10.3)

45. V Codes and E Codes • Like V codes, E codes are located in the Tabular List: • E codes describe external causes of injury, like poisoning, accidents, or other adverse reactions affecting a patient’s health

46. Appendices • Appendices serve in coding neoplasms, adverse effects of chemicals and drugs, and external causes of disease and injury. • In addition, the disease category codes are listed as an appendix.

47. Appendices • Morphology of Neoplasms (M codes) contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology.

48. Appendices • Morphology • Indicates tissue type of a neoplasm • Benign • Not cancerous • Malignant • Cancerous

49. Appendices • Classification of Drugs by AHFS list contains the American Hospital Formulary Services list number and its ICD-9-CM code number • Organized in numerical order according to AHSF list number

50. Appendices • Classification of industrial accidents according to agency based on employment injury statistics • Adopted by the International Conference of Labor Statisticians • Difficult to locate the E code entry in the ICD-9-CM Index to External Causes