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Reporting Additional Diagnoses for Inpatient Services

Reporting Additional Diagnoses for Inpatient, Short-Term, Acute Care and Long- Term Care Hospital Records

For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation, or therapeutic treatment, or diagnostic procedures, or extended length of hospital stay, or increased nursing care and/or monitoring.

The following guidelines are to be applied in designating “other diagnoses” when neither the Alphabetic Index nor the Tabular List in ICD-9-CM provides direction.   The listing of the diagnoses in the patient record is the responsibility of the attending physician.

Previous Conditions:

If the physician has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded.  However, history codes (V10 – V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Abnormal Findings:

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their critical significance.

Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a physician.

Uncertain Diagnosis:

If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, code the condition as if it existed or was established.  The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Diagnostic Coding and Reporting for Inpatient Services

Selection  of  Principal  Diagnosis(es) for  Inpatient,  Short-Term,  Acute Care, and Long-Term Care Hospital Records

The circumstances of inpatient admission always govern the selection of principal diagnosis.  The principal diagnosis is  defined in  the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”The UHDDS definitions are used by acute care short-term hospitals to report inpatient data elements in a standardized manner.  These data elements and their definitions can be found in the July 31,1985 Federal Register (Vol. 50, No. 147), pp. 31038-40.

In determining principal diagnosis the coding conventions in the ICD-9-CM, Volumes I and II take precedence over these official guidelines.The importance of consistent, complete documentation in the medical record cannot be overemphasized.  Without such documentation the application of all coding guidelines is a difficult, if not impossible, task.

  1. Code for symptoms, signs and ill-defined conditions.  Codes, symptoms, signs and ill- defined conditions from chapter 16, are not to be used as principal diagnosis when a related definitive diagnosis has been established.
  2. Two or more interrelated conditions, each potentially meeting the definition for  principal diagnosis. When there are two or more interrelated conditions potentially  meeting the definition  of  principal  diagnosis,  either  condition  may  be  sequenced  first,  unless  the circumstances of the admission, the therapy provided, the Tabular List, or the  Alphabetic Index indicate otherwise.
  3. Two or more diagnoses that equally meet the definition for principal diagnosis.  In the unusual  instance  when  two  or  more  diagnoses  equally  meet  the  criteria  for  principal diagnosis  as  determined  by  the  circumstances  of  admission,  diagnostic  workup  and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction, any one of the diagnoses may be sequenced first.
  4. Two or more comparative or contrasting conditions. In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or”, they are coded as if the diagnosis was confirmed and the diagnoses are sequenced according to the circumstances of the admission.   If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.
  5. When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first. All the contrasting/comparative diagnoses should be coded as additional diagnoses.
  6. Sequence as  the  principal  diagnosis  the  condition,  which  after  study  occasioned  the admission to the hospital, even though treatment my not have been carried out due to unforeseen circumstances.
  7. When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis.  If the complication is classified to the 996–999 series, an additional code for the specific complication may be assigned.
  8. If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, code the condition as if it existed or was  established.    The  basis  for  these  guidelines are  the  diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Diagnostic Coding and Reporting for Outpatient Services

Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.

Selection In the outpatient setting, the term “first-listed diagnosis” is used in lieu of principal diagnosis. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

Code Range The appropriate code(s) from 001.0   – V83.89 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reasons for the encounter/visit.

Accurate Reporting For  accurate  reporting  of  ICD-9-CM  diagnosis  codes,  the  documentation should  describe  the patient’s condition, using the terminology, which includes specific diagnoses as well as symptoms, problems or reasons for the encounter. There are ICD-9-CM codes to describe all of these.

Code Selection The selection of codes 001.0 – 999.9 will frequently be used to describe the reason for the encounter. These codes are from the section of ICD-9-CM for the classification of diseases and injuries (e.g., infectious & parasitic diseases; neoplasms; symptoms, signs and ill-defined conditions, etc.)

Symptoms, and Signs Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the physician.

Circumstances Other Than Disease or Injury The Supplementary Classification of Factors Influencing Health Status and Contact With Health Services (V01.0 –V83.89) is provided to deal with occasions when circumstances other than disease or injury are recorded as diagnoses or problems.

Code Specificity ICD-9-CM is composed of codes with either 3, 4, or 5 digits. Codes with 3 digits are included in the heading of a category of codes that may be further subdivided by the use of fourth or fifth digits, which provide greater specificity. A code is invalid if it has not been coded to the full number of digits required for that code.

Code Sequence List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.

Uncertain Diagnosis Do  not  code  diagnoses documented as  “probable,” “suspected,” “questionable,” “rule  out”,  or “working diagnosis.”    Rather,  code  the  condition(s) to  the  highest  level  of  certainty  for  that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Please Note: This differs from the coding practices used by hospital medical record departments for coding the diagnosis of acute care, short-term hospital inpatients.

Chronic Disease Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).

Coexisting Conditions Code all documented conditions that exist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. History codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Diagnostic and Therapeutic Services For  patients  receiving  diagnostic  services  only  during  an  encounter/visit,  sequence  first  the diagnosis, condition, problem, or other reason for the encounter/visit in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.  Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For outpatient encounters for diagnosis tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

Note:  This differs from the coding practice in the hospital setting regarding abnormal findings on test results. For  patients  receiving  therapeutic  services  only  during  an  encounter/visit,  sequence  first  the diagnosis, condition, problem or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.  Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.

The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

Preoperative Evaluations For patients receiving preoperative evaluations only, sequence a code from category V72.8, Other Specified Examinations, to describe the preoperative consultations.  Assign a code for the condition to describe the reason for the surgery as an additional diagnosis.  Code also any findings related to the preoperative evaluation.

Ambulatory Surgery For  ambulatory  surgery,  code  the  diagnosis  for  which  the  surgery  was  performed.    If  the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

Prenatal Visits For routine outpatient prenatal visits when no complications are present, codes V22.0, supervision of normal first pregnancy, and V22.1, supervision of other normal pregnancy, should be used as principal  diagnoses.    These  codes  should  not  be  used  in  conjunction with  Chapter  11  codes (Complications of Pregnancy, Childbirth, and the Puerperium (630-677).

10 Steps to Correct coding

10 Steps To Correct Coding

To code accurately, it is necessary to have a working knowledge of medical terminology and to understand the characteristics, terminology, and conventions of ICD-9. Providers should follow the steps below to ensure correct coding.

Step 1: Identify the reason for the visit (e.g., sign, symptom, diagnosis, condition to be coded).

Physicians  describe  the  patient’s  condition  using  the  terminology  that  includes  specific diagnoses as well as symptoms, problems or reasons for the encounter. If symptoms are present but a definitive diagnosis has not been determined, code the symptom. Do not code conditions that are referred to as “rule out,” “suspected,” “probable” or “questionable.”

Step 2: Always consult the Alphabetic Index, Volume 2, before turning to the tabular list.

The most critical rule is to begin a code search in the alphabetic index (volume 2). Never initially turn to the Tabular List (Volume 1), as this will lead to coding errors and less specificity in code assignments. To prevent coding errors, use both the Alphabetic Index and the tabular list when locating and assigning a code.

Step 3: Locate the main entry term

The  Alphabetic  Index  is  arranged  by  condition.  Conditions  may  be  expressed  as  nouns, adjectives and eponyms. Some conditions have multiple entries under their synonyms. Main terms are identified using boldface type.

Step 4: Read and interpret any notes listed with the main term.

Notes are identified using italicized type.

Step 5: Review entries for modifiers.

Nonessential modifiers are in parentheses. These parenthetical terms are supplementary words or explanatory information that may either be present or absent in the diagnostic statement and do not affect code assignment.

Step 6: Interpret abbreviations, cross-references, symbols and brackets.

Cross-references used are  “see,” “see category” or  “see also.” The abbreviation NEC (not elsewhere classified) may follow main terms or sub-terms. NEC indicates that there is nospecific code for the condition even though the medical documentation may be very specific. The  3 5th box indicates the code requires a fifth digit. If the appropriate fifth digits are not found in the index, in a box beneath the main term, you MUST refer to the Tabular List.  Italicized Brackets []   are used to enclose a second code number that must be used with the code immediately preceding it and in that sequence.

Step 7: Choose a tentative code and locate it in the tabular list.

Be guided by any inclusion or exclusion terms, notes or other instructions, such as “code first” and “use additional code” that would direct the use of a different or additional code from that selected in the index for a particular diagnosis, condition or disease.

Step 8: Determine whether the code is at the highest level of specificity.

Assign three-digit codes (category codes) if  there are  no  four-digit codes within the  code category. Assign four-digit codes (subcategory codes) if there are no five-digit codes for that category. Assign five-digit codes for those categories where they are available.

Step 9: Consult the color-coding and reimbursement prompts, including the age, sex and Medicare as secondary payer edits.

Consult the official ICD-9-CM guidelines for coding and reporting, and refer to the AHA’s “Coding Clinic for ICD-9-CM” for coding guidelines governing the use of specific codes.

Step 10: Assign the code.

ICD 9 Introduction

History and Overview of ICD-9-CM

Background

The International Classification of Diseases, Ninth Revision, (ICD-9-CM) is a classification system developed by the World Health Organization (WHO) for classifying morbidity and mortality information for statistical purposes, for indexing hospital records by diseases and operations, and for storing and retrieving data.

In 1979, the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9- CM) was issued in the United States.  Physicians have been required by law to submit diagnosis codes for Medicare reimbursement since the passage of the Medicare Catastrophic Coverage Act of This act requires physician offices to include the appropriate diagnosis codes when billing for services provided to Medicare beneficiaries on or after April 1, 1989. The Centers for Medicare and Medicaid Services (CMS) designated ICD-9-CM as the coding system physicians must use.

Characteristics of ICD-9-CM

ICD-9-CM is comprised of a three-volume set of codes.  Volumes 1 and 2 are used primarily for physician billing and contain diagnosis codes and symptoms.  Volume 3 is used for skilled nursing facility and hospital billing.  Volume 3 also contains codes for surgical and non-surgical procedures.

  • Volume 1   Diseases – Tabular or Numerical Codes (including V and E Codes)
  • Volume 2      Diseases  – Alphabetic Index to Diseases, Table of Drugs & Chemicals, and Alphabetic Index to Causes of Injury & Poisoning.
  • Volume 3  Index to Procedures, Tabular List, Pharmacological Listings, Diagnosis Code/MDC/DRG List, and Complication & Cormorbidity (CC) List. ICD-10 International Classification of Diseases.

Volume 1 (Tabular-Numeric)

  • Chapter headings appear in BOLD CAPITALIZED letters and include the three digit category codes included in the chapter.
  • Subheadings appear in BOLD CAPITALIZED letters and break out the specific conditions or diagnoses within a chapter. Subheadings contain the three digit category codes.

Categories are three-digit diagnoses codes.

Sub-categories are four-digit and five-digit assigned codes.

Fifth digits can appear in a variety of places:

Beginning of a chapter

Beginning of a section

Beginning of a three digit category

Within a four digit sub-category

The Tabular List of Diseases (Volume 1) arranges the ICD-9-CM codes and descriptors numerically (001–999.9).  Tabs divide this section into chapters, identified by the code range on the tab. The Tabular List includes two supplementary classifications:

  • V Codes – Supplementary Classifications of Factors Influencing Health Status and Contact with Health Services (V01-V84).
  • E Codes – Supplementary Classification of External Causes of Injury and Poisoning (E800- E999).

ICD-9-CM includes four official appendixes: Appendix A – Morphology of Neoplasms Appendix B – Deleted Effective October 1, 2004

Appendix C – Classification of Drugs by AHFS List

Appendix D – Classification of Industrial Accidents According to Agency

Appendix E – List of Three-Digit Categories

Volume 2 (Alphabetic Index)

The Alphabetic Index contains three sections.

Section 1: An alphabetic index of diseases and injuries

Section 2: Alphabetic Index to Poisoning and External Causes of Adverse Effects of Drugs and Other Chemical Substances (Table of Drugs and Chemicals)

Section 3: Alphabetic Index to External Causes of Injury and Poisoning (E Codes)

The Alphabetic Index has been placed before the Tabular List in both the disease and procedure classifications.   This allows the user to locate the correct codes in a logical natural manner by locating the term in the index, then confirming the accuracy of the code in the tabular list.  Reliance on only the Alphabetic Index or the Tabular List leads to errors in code assignments and less specificity in code selection.

When two codes are required to indicate etiology (cause) and manifestation, the Alphabetic Index (Volume 2) will indicate the required coding order.  The second code will be italicized and listed in slanted brackets.   The coder should assign the two codes in the same order as they appear in Volume.

Volume 3 (Procedures – Tabular & Alphabetic Index)

Volume 3, which is updated annually by CMS, is used for hospital and skilled nursing facility billing.Volume 3 begins with an Alphabetical Index to Procedures.  The index is followed by the Tabular List of procedure descriptors (i.e., thoracentesis (34.91), laporatomy (54.1)) and corresponding 3 or 4-digit numerical codes).

Chapters 1-15 contain surgical procedures and are organized anatomically.   Chapter 16 contains miscellaneous diagnostic and therapeutic procedures.

Listed below are the exclusive resources found ONLY in the ICD-9-CM Expert for Hospitals, Volume 1, 2, and 3 books.

Pharmacological Listings  The most common generic and brand name of drugs are linked with the disease processes to assist in the identification of complications and cormorbidities (CC) thereby improving Diagnosis Related Groups (DRG) assignment practices.

Diagnosis Code/Major Diagnostic Categories (MDC) Diagnosis Related Groups (DRG) List

Provides the complete list of principal diagnosis codes and the MDC and the DRG to which they belong, with the exception of a combination of principal and secondary diagnoses.

Complication & Cormorbidity (CC) Code List

A complete list of all codes considered Complication and Cormorbidities (CC) that will affect

DRG assignment. This is an essential auditing tool for assigning the most appropriate DRG. Valid Three-digit ICD-9-CM Codes

ICD-9-CM is composed of codes with either 3, 4, or 5 digits.  A code is invalid if it has not been coded to the full number of digits required for that code.  There are a certain number of codes that are valid for reporting as three-digit codes.  A list of the valid three-digit codes is included as a convenient reference when auditing claims.

The following table is an index listing the chapter, chapter heading, and procedure codes within Volume 3.

Volume 3 Procedures – Tabular and Alphabetic Index
Chapter Chapter Heading Codes
1 Operations on the Nervous System 01-05
2 Operations on the Endocrine System 06-07
3 Operations on the Eye 08-16
4 Operations on the Ear 18-20
5 Operations on the Nose, Mouth, and Pharynx 21-29
6 Operations on the Respiratory System 30-34
7 Operations on the Cardiovascular System 35-39
8 Operations on the Hemic and Lymphatic System 40-41
9 Operations on the Digestive System 42-54
10 Operations on the Urinary System 55-59
11 Operations on the Male Genital Organs 60-64
12 Operations on the Female Genital Organs 65-71
13 Obstetrical Procedures 72-75
14 Operations on the Musculoskeletal System 76-84
15 Operations on the Integumentary System 85-86
16 Miscellaneous Diagnostic and Therapeutic Procedures 87-99

Operative Note Practice Scenario – 10

An esophagogastroduodenoscopy was performed with balloon dilation to open an esophageal stricture. After three attempts, the balloon dilation was unsuccessful. Jumbo biopsy forceps were then used to remove a section of the scarred stricture to create a wedge and prevent the stricture from constricting the esophageal lumen.

Codes:

Operative Note Practice Scenario – 8

The patient was brought in for surgical intervention of a mature, symptomatic cataract in the left eye and high intraocular pressures despite medical therapy. Procedures performed were an external trabeculectomy and phacoemulsification with posterior chamber intraocular lens placement.

Discharge diagnoses: (1) Advanced primary open-angle glaucoma, severe stage, (2) cataract, left eye.

Codes:

Operative Note Practice Scenario – 7

Preoperative diagnoses: Rhegm atogenous retinal detachment and nuclear sclerotic cataract, both to the right eye.

Name of Procedures: A 25-gauge pars plana vitrectomy, retinal detachment repair, air fluid exchange, air gas exchange with SF6 24%, indirect ophthalmoscope-delivered laser, all to the right eye.

Description of Procedure: The patient was seen in the pre-operative holding area and all questions about the procedure answered. Right eye was identified as the correct operative site and informed consent was confirmed. The patient was rolled in the supine position to the operative suite where appropriate cardiac and pulmonary monitoring devices were applied per anesthesia. The patient was placed under general anesthesia without complication. Right eye was prepped and draped in normal sterile fashion. Sterile lid speculum was placed. A standard 3-port 25-guage vitrectomy unit was used after placing the infusion cannula 4 mm posterior to the infratemporal limbus. Correct position was visualized before turning it on. Additional 2 ports were placed without complication. Initial vitrectomy was performed and carried out into the periphery with the aid of scleral depression. A posterior vitreous detachment was already present. The retinal detachment extended from 12 o’clock temporally down to 6:30 o’clock. Directly temporally there was an old demarcation line with a small horseshoe retinal tear in the middle near the aura. This was trimmed free from vitreous. A drainage retinotomy was then created along the superior temporal arcade with electric diathermy. Air fluid exchange was then performed with drainage of subretinal fluid using a 25-guage backflush cannula. The retina was seen to lay flat. Plugs were placed and indirect ophthalmoscope was used to place laser retinopexy around the retinotomy site, the previously marked retinal hole and in a 360 degree retinopexy fashion. Drainage was performed one more time before placing SF6 24% into the posterior segment. Sclerotomy ports were removed in sequential fashion. All wounds were found to be airtight. The patient was given subconjunctival injections of Ancef and Decadron. A sterile led speculum was removed. A light pressure patch was placed. The patient was taken to recovery room in stable condition after being awakened form general anesthesia in stable condition. He was to remain face down overnight and follow up tomorrow for post-operative exam and instructions.

Codes: