Volume 2 Coding Tables
Three main tables are presented in the Alphabetic Index as tables. The Hypertension and Neoplasm tables are found in their proper alphabetical place in the Index, but the Table of Drugs and Chemicals follows the alphabetic listing.
Hypertension Table The hypertension table is found under the main heading “Hypertension/hypertensive” This table contains the complications, etiology (cause) and clinical manifestations of hypertension. There are three subcategories for each listing in this category.
|Malignant hypertension is usually defined as very high blood pressure withswelling of the optic nerve behind the eye, called papilledema. Malignant hypertension is usually accompanied by other organ damage like heart failure, kidney failure, and hypertensive encephalopathy. Malignant hypertension is a medical emergency.
||In a benign (nonmalignant) hypertension, in which hypertensive neuroretinopathy is absent, a hypertensive crisis mayoccur based on the development of concomitant acute end-organ dysfunction.
||This form indicates that the type of hypertension has not yet been determined by the physician.
Hypertension, Essential, or NOS: Assign hypertension arterial (essential)(primary)(systems)(NOS) to category code 401 with the appropriate fourth digit to indicate malignant (0.0), benign (0.1), or unspecified (0.9). Do not use either malignant (0.0) or benign (0.1) unless medical record documentation supports such a designation.
Hypertension with Heart Disease: Heart conditions (425.8., 429.0-429.3, 429.8,429.9) are assigned to a code from category 402 when a causal relationship is stated (due to hypertension) or implied (hypertensive). The same heart conditions with hypertension, but without a stated casual relationship are coded separately.
Hypertensive Renal Disease with Chronic Renal Failure: Assign category code 403, hypertensive renal disease, when conditions classified to categories (585-587) are present. Unlike hypertension with heart disease, ICD-9-CM presumes a cause-and-effect relationship and classifies renal failure with hypertension as hypertensive renal disease.
Hypertensive Heart and Renal Disease: Assign codes from combination category 404 when both hypertensive heart and hypertensive renal disease are stated in the diagnosis.
Hypertensive Cerebrovascular Disease: First assign category codes from 430-438 (cerebrovascular disease) and then the appropriate hypertension code from categories (401-405).
- Hypertensive Retinopathy: Two codes are necessary to identify the condition. First assign the code from the subcategory 362.11 (hypertensive retinopathy), then the appropriate code from categories 401-405 to indicate the type of hypertension.
Hypertension, Secondary:Two codes are required: One to identify the underlying etiology and one from category 405 to identify the hypertension.
Hypertension, Transient or Elevated Blood Pressure: Assign code 796.2, elevated blood pressure reading without diagnosis of hypertension. Use codes 642.3X for transient hypertension of pregnancy.
Hypertension, Controlled/Uncontrolled: Assign appropriate code from categories (401-405). Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to the current therapeutic regimen.
The neoplasm table is found under the main term Neoplasm, neoplastic. The table gives the code numbers for neoplasm by anatomical site. For each site, there are six possible code numbers according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior or of unspecified nature. The description of the neoplasm will often indicate which of the six columns is appropriate.
The word neoplasm simply means new growth. Neoplasm may remain benign (non-cancerous), become cancerous (malignant), spread to other areas (metastasis) or, remain in one designated area (ca in situ). It should be noted, the term mass is not synonymous with neoplasm, as it is often used to describe cysts and thickenings such as those occurring with hematoma or infection.
To properly code a neoplasm it is necessary to determine from the record if the neoplasm is benign, in-situ, malignant, or of uncertain histologic behavior. If malignant, any secondary (metastatic) sites should also be determined.
The neoplasm table in the Alphabetic Index should be referenced first. If the histological term is documented, that term should be referenced first, rather than going immediately to the Neoplasm Table, in order to determine which column in the Neoplasm Table is appropriate. For example, if the documentation indicates “adenoma”, refer to the term in the Alphabetic Index to review the entries under this term and the instructional note to “see also neoplasm, by site, benign.” The table provides the proper code based on the type of neoplasm and the site. It is important to select the proper column in the table that corresponds to the type of neoplasm. The tabular list should then be referenced to verify that the correct code has been selected from the table and that a more specific site code does not exist.
- If the treatment is directed at the malignancy, designate the malignancy as the principal diagnosis.
- When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
- Coding and sequencing of complications associated with the malignant neoplasm or with the therapy thereof are subject to the following guidelines;
o When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the anemia is designated as the principal diagnosis and is followed by the appropriate code(s) for the malignancy.
o When the admission/encounter is for management of an anemia associated with chemotherapy or radiotherapy and the only treatment is for the anemia, the anemia is sequenced first followed by the appropriate code(s) for the malignancy.
o When the admission/encounter is for management of dehydration due to the malignancy or the therapy, or a combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
o When the admission/encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of an intestinal malignancy, designate the complication as the principal or first-listed diagnosis if treatment is directed at resolving the complication.
- When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.
- Admissions/Encounters involving chemotherapy and radiation therapy:
o When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by chemotherapy or radiation treatment, the neoplasm code should be assigned as principal or first-listed diagnosis. When an episode of inpatient care involves surgical removal of a primary or secondary site malignancy followed by adjunct chemotherapy or radiotherapy, code the malignancy as the principal or first- listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-
o If a patient admission/encounter is solely for the administration of chemotherapy or radiation therapy code V58.0, Encounter for radiation therapy, this should be the first-listed or principal diagnosis. If a patient receives both chemotherapy and radiation therapy, both codes should be listed, in either order of sequence.
o When a patient is admitted for the purpose of radiotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is V58.0, Encounter for radiotherapy, or V58.1, Encounter for chemotherapy.
- When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
“V” Codes Associated with Neoplasms
||Personal history of malignant neoplasm
||Family history of malignant neoplasm
||Observation and evaluation for suspected conditions not found
||Special screening for malignant neoplasms
Table of Drugs and Chemicals
The Table of Drugs and Chemicals contains an extensive list of drugs, and other chemical substances to identify poisoning states and other external causes of adverse effects set in a six- column format. The first column is used to code the substance involved in the poisoning situation. The next five columns are grouped under the heading “External Cause (E Code)” and identify the circumstances involved.
The E codes in the five columns in this table are defined as:
Accidental Poisoning Codes (E850-E869) identify accidental overdose of drug, wrong substance given or taken inadvertently, accidents in the usage of drugs and biologicals in medical and surgical procedures, and to show external causes of poisoning classifiable to 980 – 989. Therapeutic Uses
Codes (E930-E949) indicates a correct substance properly administered in therapeutic or prophylactic dosage as the external cause of adverse effects.
Suicide Attempt Codes (E950-E952) identify instances in which self-inflicted injuries or poisonings are involved.
Assault Codes (E961-E962) indicate injury or poisoning inflicted by another person with the intent to injure or kill.
Undetermined Codes (E980-E982) are to be used when the intent of the poisoning or injury cannot be determined (i.e., whether it was intentional or accidental).