ICD-9-CMGeneral Guidelines

Term first-listed diagnosis, rather than principal diagnosis

Outpatient Surgery: Reason for surgery◦ Even if surgery is cancelled due to

contraindication

Diagnostic Coding Guideline A

Observation Stay: Medical condition that occasioned admission◦ Assign a code from medical condition

Observation Stay: Complications from outpatient surgery lead to observation report:

Reason for surgery as first reported diagnosis Codes for complications necessitating observation

Diagnostic Coding Guideline A

Condition for encounter◦ Why patient presented, not necessarily most

serious condition noted Documented Chiefly responsible for services provided Also list co-existing conditions

Selection of First-Listed Diagnosis

Diagnosis and procedure MUST correlate

Medical necessity must be established through documentation

No correlation = No reimbursement

Diagnosis and Services

Can be the first-listed diagnosis if no more specific diagnosis available

Diagnoses often are not established at the time of the initial encounter/visit

Symptoms, Signs, and Ill-Defined Conditions

Use codes 001.0 through V89.09 to code:

◦ Diagnosis◦ Symptoms◦ Conditions◦ Problems◦ Complaints◦ Or other reason(s) for visit

Diagnostic Coding Guideline B

Documentation should describe patient's condition, using terminology that includes:

◦ Specific diagnoses ◦ Symptoms◦ Problems◦ Reasons for encounter

Diagnostic Guideline C

Selection of codes 001.0 through 999.9 (Chapters 1-17) frequently used to describe reason for encounter

Diagnostic Guideline D

Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when ◦ An established diagnosis has NOT been

determined by physician

Diagnostic Guideline E

V codes deal with encounters for circumstances other than disease or injury◦ Example: Well-baby checkup

See Section I.C.18 for information onV codes

Diagnostic Guideline F

Located after 999.9 in Tabular Two digits before decimal (e.g., V10.1X) Index for V codes is Alphabetic Index

to Diseases Main terms:

◦ Contraception◦ Counseling◦ Dialysis◦ Status◦ Examination

V Codes

Not sick BUT receives health care (e.g., vaccination)

Services for known/resolving disease/injury (e.g., chemotherapy)

Codes for “aftercare” (e.g., surgery or fracture)

Indicate birth status/outcome of delivery

(Cont’d…)

Uses of V Codes

(…Cont’d)

A circumstance/problem that influences patient’s health BUT NOT current illness/injury ◦ Example: Organ transplant status◦ Example: Birth status and outcome of delivery

(newborn) Section I.18.e. of Guidelines contains the V

Code Table◦ Identifies if V code can be listed as first,

first/additional, additional only

Uses of V Codes

V10 Personal history of malignant neoplasm V12 Personal history of certain other diseases V13 Personal history of other diseases V14 Personal history of allergy to medicinal agents V15 Other personal history presenting hazards to health V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V18 Family history of certain other specific diseases V19 Family history of other conditionsCondition no longer present or treated

History V Code Categories in Tabular

Codes have either 3, 4, or 5 digits

4 and/or 5 digit codes provide greater specificity (detail)

(Cont’d…)

Diagnostic Guideline G

(…Cont’d) 3-digit code used ONLY if no 4 or 5 digit Where 4 and/or 5 digits provided, must be

assigned Diagnoses NOT coded to full digits available

invalid Claims bounce!

Diagnostic Guideline G

List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided

List additional codes that describe any coexisting conditions

Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis

Diagnostic Guideline H

Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses

Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit

Diagnostic Guideline I

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

Diagnostic Guideline J

Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management

Do NOT code conditions previously treated, no longer existing

(Cont’d…)

Diagnostic Guideline K

(…Cont’d) “History of” codes (V10-V19) may be used

as secondary codes if:◦ Impacts current care or treatment

Diagnostic Guideline K

For patients receiving diagnostic services ONLY

Sequence first◦ Diagnosis ◦ Condition ◦ Problem OR◦ Other reason shown in medical record to be

chiefly responsible for encounter (…Cont’d)

Diagnostic Guidelines L and M

(…Cont’d) Codes for other diagnoses

(e.g., chronic conditions) ◦ May be sequenced as secondary diagnoses

Exception: Therapeutic Services◦ Patients receiving chemotherapy (V58.11),

radiation therapy (V58.0), or rehabilitation (V57.0-V57.9)

◦ V code first diagnosis and problem for which service being performed second

Diagnostic Guidelines L and M

For patients receiving preoperative evaluations ONLY

◦ Code from category V72.8 (Other specified examinations)

◦ Assign secondary code for reason for surgery◦ Code also any findings related to preoperative

evaluation

Diagnostic Guideline N

Code diagnosis which required ambulatory surgery

Pre- and post-op diagnosis different◦ Code the post-op diagnosis

Diagnostic Guideline O, Ambulatory Surgery

Code routine prenatal visits with no complications: ◦ V22.0 (Supervision of normal first pregnancy) ◦ V22.1 (Supervision of other normal pregnancy) ◦ DO NOT use these codes with pregnancy

complication codes (Chapter 11, ICD-9-CM)

Diagnostic Guideline P

ICD-9-CM CODINGConclusion – General Guidelines