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U. S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL FORT SAM HOUSTON, TEXAS 78234

MD0753

MEDICAL RECORDS ADMINISTRATION BRANCH I (BOOK 2 OF 2)

CENTER AND SCHOOL FORT SAM HOUSTON, TEXAS 78234 MD0753 MEDICAL RECORDS ADMINISTRATION BRANCH I (BOOK 2

EDITION 101

TABLE OF CONTENTS

 

Page

APPENDIX A - Coding Principles

A-1

APPENDIX B - Excerpts from Volume 1

B-1

APPENDIX C - Excerpts from Volume 2

C-1

APPENDIX D - Excerpts from Volume 3

D-1

APPENDIX E - Excerpts from External Cause of Injury Codes

E-1

APPENDIX F - Excerpts from Military Occupational Specialty Codes

F-1

APPENDIX A - CODING PRINCIPLES

EXPLANATION

There are specific guidelines for coding diagnoses and surgical procedures. This appendix contains excerpts of coding principles (modified for instructional purposes) from the Individual Patient Data System (IPDS) User's Manual published by the U.S. Army Patient Administration Systems and Biostatistics Activity (PAS&BA). These excerpts provide coding principles for diagnostic and operative coding using the ICD-9-CM. The IPDS User's Manual includes additional principles that are not provided in this appendix. The numbers for each of the principles in this appendix are the same as the corresponding principle in the IPDS User's Manual so you will be able to identify the principles that are not covered in this subcourse.

In previous lessons, you have reviewed the preliminary coding guidelines that, for the most part, are applicable generically; i.e., they apply to all coding processes. To provide more specific guidance, this appendix includes 18 principles in short, narrative form. However, each coder should have his/her own copy of the Triservice Disease and Procedure Coding Guidelines ICD-9-CM , which became effective 1 January 1991.

Principle I. SUSPECTED CONDITIONS

1. Qualifying adjectives used in the final diagnostic statement imply that a final

judgment has not been made. When words such as "suspected," "probable," "questionable," "likely," etc., are used in the diagnosis, code the condition as if it were a confirmed diagnosis.

2. The code assigned to the questionable condition may be used as the principal

diagnosis if it was proven to be the condition, after study, that occasioned this admission.

3. Qualifying adjectives such as "Rule Out," "R/O," and "Ruled Out" present special

problems for which the following coding rules have been developed.

a. Rule Out and R/O. When these words appear in the final diagnostic statement,

they have the same meaning as "suspected" and are to be coded as if the condition were confirmed.

b. When "Ruled Out," "Not Proven," "Not Confirmed," and "No Evidence Of" appear

as part of the diagnosis or the diagnosis is stated in terms which indicate the absence of the condition under investigation, the appropriate code from the Supplementary Classification (V71 category) will be used. The medical record documentation must support the investigation of the suspected condition. Admissions following head trauma where there is no visible evidence of injury and which after observation show no evidence of after effects are coded to V71.4--Ø, the code extender for Observation, head injury, ruled out. (V713-V716 categories require STANAG Cause of Injury Code and Trauma code.) Note that codes from the V71 category may only be used as a principal diagnosis.

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4.

Acute and Chronic. When a specific disease is stated as both acute and chronic

and the Alphabetic Index provides separate codes for each condition, both will be coded. If the condition described as both acute and chronic was listed as the cause of admission, the acute condition will be indicated as the principal diagnosis.

5. Subacute. If the condition is stated as subacute and the Alphabetic Index does not

provide a specific code for the subacute stage, then the code provided for the acute stage of the condition will be used.

6. Acute Upper Respiratory Infection (URI).

Occasionally, this diagnosis is written

as Acute Respiratory Disease (ARD). Either of the terms used with conditions that are clearly Acute Upper Respiratory Infection should be coded to 465 category.

1. Suspected Conditions.

APPLICATION

When the final diagnosis is qualified as possible,

suspected, probable, etc., it is coded as a confirmed diagnosis.

EXAMPLE:

DIAGNOSIS: Suspected pneumococcal pneumonia

481

2. Rule Out, R/O. These terms indicate a suspected condition and are coded as

confirmed diagnoses.

EXAMPLE:

DIAGNOSIS: Rule Out Sepsis.

Ø38.9

3. Ruled Out. Conditions stated as ruled out, not proven, no evidence of, or other

terms indicating the absence of a condition are coded to the Supplementary Classifications Category V71 (observation and evaluation for suspected condition), with the exception of head trauma.

EXAMPLES:

a. DIAGNOSIS: Pulmonary emboli, ruled out.

V71.8

b. DIAGNOSIS: Questionable concussion, ruled out.

V71.4--Ø

4. Acute/Subacute and Chronic. If a disease is stated as both acute/subacute and

chronic and the Alphabetic Index provides a separate code for each condition, use both codes.

EXAMPLE:

DIAGNOSIS: Acute and chronic gonococcal salpingitis

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Ø98.17 Ø98.37

5.

Acute Upper Respiratory Infection (URI).

Frequently this diagnosis is written :

Acute Respiratory Disease or simply ARD.

EXAMPLES:

a. DIAGNOSIS: ARD Viral

465.9

b. DIAGNOSIS: Acute Upper Respiratory Infection URI

465.9

PRINCIPLE II. MULTIPLE CODING

1. Multiple coding as used throughout these coding guidelines is defined as the

assignment of more than one code to fully identify all the component parts of a diagnostic/procedure statement. In the diagnostic classification multiple coding was developed to increase specificity by identifying associated conditions or those which have a cause and effect relationship. Some instances where multiple coding will be used are late effects (cause of) with residuals, etiology (underlying cause) with manifestations and/or complications, adverse effects of medications with drugs (E Codes), and pregnancy related complications (see principle IX). In the procedure, classification multiple coding was developed to identify any additional components of a procedure (if performed) and to identify any synchronous (performed at the same time) procedures.

WHEN MULTIPLE CODING IS USED

a. Written Instructions:

(1) Code also

(a)

Further instruction in the Tabular List, Volume 1, to code the underlying "

It is an instruction to code "first";

cause (etiology) is indicated by "Code also

therefore, the etiology code is sequenced first. Italicized codes in slanted brackets are used to identify the manifestations.

" to

identify adjunct or synchronous procedures done, i.e., those performed or occurring at the same time. "Code also" has a different significance in procedure coding from that in diagnostic coding; there is no implication of sequencing or mandatory multiple coding attached to it.

(b) Multiple coding of procedures is indicated by the term "Code also

(2) Use additional code

.The user should add further information to give a

more complete description of the diagnosis or procedure.

(3) Note coding instructions.

.Some main terms are followed by notes that define terms and give

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b. Without Written Instructions:

(1) Late effects (cause of) with residual. The residual code is sequenced before the late effect code.

(2) Etiology (underlying cause) with manifestations/ complications. Code first the underlying cause, then the manifestation/complication.

(3) Adverse effects of medication with drugs (E Codes). This mandates that both codes be used and sequenced with the reaction first followed by the E code.

(4) Any other conditions in the main classification that can be more completely identified by the use of multiple coding.

NUMBER OF CODES REQUIRED

2. The number of codes to be used depends upon the needs of the user. Avoid

indiscriminate coding of all signs and symptoms with their accompanying definitive diagnoses, laboratory test results, social factors and other personal, nonmedical data mentioned in the record. Code only those conditions that require treatment or management during the current episode of hospitalization. DO NOT CODE conditions stated as "history of," "status post," etc., not treated or managed during current hospitalization.

EXCEPTION: Personal history of malignant neoplasm V10.00-V10.9 for a previously treated malignant neoplasm with no evidence of recurrence in the primary site. (See principle VIII (Neoplasms.)*

3. Diseases/conditions that are treated in one facility before transfer to another are not

coded by the receiving facility unless that disease/condition is still present and being treated.

EXCEPTION: When coding underlying cause of death/separation, the receiving facility will code the actual disease/condition that caused the death/separation, even if not treated by that facility.

1. Written Instruction:

a. Code also

APPLICATION

DIAGNOSIS: Acute myocarditis, secondary to tuberculosis.

Code also underlying disease as:

myocarditis (acute):

influenza (487.8) tuberculosis (017.9)

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EXAMPLES

DIAGNOSIS: Acute myocarditis secondary to tuberculosis

DIAGNOSIS: Phagolytic glaucoma with hypermature cataract

DIAGNOSIS: Temporary colostomy with cecectomy

b. Use additional code

Ø17.9Ø 422.Ø

366.18 365.51

46.11 45.72

The words "if desired" as appears in above should be deleted where found throughout the coding books. All Army MTFs will use additional codes.

EXAMPLE:

Use additional code, to identify infectious organism.

DIAGNOSIS: Acute Pharyngitis, staphylococcal.

c. Note

462 Ø41.1

The term "Note" is found in both Diseases and Procedures Indexes and Tabulars. In the Procedures Tabular "Note" may appear at the two- or three-digit level ; and in the Disease Tabular at the category level. Guidance on use of fifth-digit subclassification codes is a "Note" instruction without the actual term.

EXAMPLE:

DIAGNOSIS: Third degree burn to trunk comprising 20 percent body surface.

NOTE: This category is to be used when the site of the burn is unspecified or with categories 940-947 when the site is specified.

Third-degree burn to trunk, 20 percent body surface

942.3Ø 948.22

2. Without Written Instructions:

a. Late effect (cause of) with residual.

If both the residuals and the cause of the late effect are provided, sequence the code for the residuals first. If the cause of the late effect is specified but not the residuals, code the cause of the late effect.

DIAGNOSIS: Hemiplegia secondary to poliomyelitis 12 years ago. (See principle XV for definitions of late effect.)

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EXAMPLE:

Hemiplegia; Late effect of Poliomyelitis

b. Etiology with manifestation(s).

EXAMPLE:

DIAGNOSIS: Cataract, Diabetic.

Diabetes

Cataract

c. Adverse effects of medications.

342.9 138

25Ø.5Ø[36641]

Sequence first the code which identifies the manifestation or the nature of the adverse reaction. An additional code must be used to identify the drug causing the adverse reaction.

DIAGNOSIS: Gastritis, secondary to prescribed dosage of aspirin.

EXAMPLE:

Gastritis, secondary to aspirin

535.4 E935.3

3. Use the multiple coding principle for any other conditions in the main classification

that can be more completely identified by the use of more than one code.

EXAMPLE:

DIAGNOSIS: Postoperative thrombophlebitis femoral vein, following hysterectomy

Thrombophlebitis

during or resulting from a procedure NEC

femoral

451.11

997.2 451.11

997.2

PRINCIPLE III. COMBINATIONS AND DOD CODE EXTENDERS

1. Two conditions or a specific diagnosis with an associated secondary process or

complication are frequently assigned to the same code. This is referred to as a combination code. Where the coding books provide a single code to fully identify all the conditions described in the diagnostic statement, the one code is sufficient.

2. The combination code may not be so stated in the RUBRIC (Category) title, but may

have its own fourth-digit (subcategory) title to identify both disease conditions.

EXCEPTION: Where specific instructions in this user's manual direct other -wise; for example, see principle XII (Drug and Alcohol).

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3.

There have been a number of codes in the ICD-9-CM code books "modified" to

meet the needs of the services. Numeric characters have been added at the seventh- digit level of a coding field. These codes are referred to as DOD Code Extenders.

4. The DOD Code Extenders are found in Appendix A of the Triservice Disease and

Procedure Coding Guidelines ICD-9-CM . To ensure that these codes are used when appropriate, all military MTF users of ICD-9-CM code books are responsible for posting all DOD Code Extenders to their books.

APPLICATION

1. Combination Codes. Two or more conditions or a specific disease condition with

an associated secondary process or complication is frequently assigned one code, a combination code.

EXAMPLE:

DIAGNOSIS: Acute appendicitis with perforation and peritonitis.

2. DOD Code Extenders. A number of codes in ICD-9-CM have been modified to

meet the needs of the Uniformed Services.

54Ø.Ø

EXAMPLE:

DIAGNOSIS: Lyme Disease

Ø88.81

PRINCIPLE IV. V CODES

1. The purpose of the V codes is to identify encounters with the health care settings for

reasons other than an illness or injury classified to categories ØØ1 -999. The majority of the V codes are oriented toward ambulatory care. Although certain categories of V codes will be used quite frequently for inpatient care, coders should exercise care regarding the extent to which these codes are used on inpatient records.

2. The V code is primarily for use as a supplemental code with the primary code being

the current condition which requires hospitalization. However, it may be used as a solo code for inpatients without disease or current injury; for example, a patient who is admitted for surgical or orthopedic aftercare, as an organ or tissue donor, newborn, etc. In these cases, the V code will be the principal diagnosis.

3. The diagnostic statements requiring a V code appear in a variety of terms. The

Alphabetic Index does not provide an exhaustive list of terms, but it does provide some key works under which the appropriate V code may be found. Some of the key words are: Admission, Examination, History, Observation, Problem, Status, etc.

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4.

Subcategories and Subclassifications V1Ø.Ø-V1Ø.9 are to be used only as

additional codes in classifying the primary site of a previously excised or eradicated malignant neoplasm with no evidence of recurrence of the primary site. Subcategory codes V1Ø.6Ø-V1Ø.79 are also used only as additional codes for classifying leukemia and other lymphatic and hematopoietic neoplasms in remission (see principle VIII, Neoplasms).

5. Subcategory code V15.Ø (allergy, other than to medicinal agents) may be used as

principal diagnosis, solo code, or it may be used as an additional code as appropriate. For example, it will be used to denote hypersensitivity to insect sting (bite) where that condition results in disability separation/failure to meet medical procurement standards.

6. Subclassification code V15.81 should be used when indicated for patients who do

not comply with prescribed medical treatment. This will be used only as an additional code.

7. Subcategory V22.2 (Pregnant State, Incidental) will be used only as an additional

code; for example, when the cause of admission is not the pregnancy but an unrelated condition (fractured femur, patient is 3 months pregnant).

8. Subcategory V24.0 (Postpartum Care and Examination Immediately After Delivery)

will be used only when patient is admitted immediately following delivery for routine care. Should be used only as principal diagnosis.

9. Subcategory V25.2 (Sterilization). This code is to be used for elective sterilization

procedures of both males and females. It is to be used only when the sterilization procedure was performed for the major purpose of contraception rather than for treatment of a disease where sterilization is an incidental result, using the following guidelines:

a. If the primary reason for admission is for elective sterilization for contraceptive

purposes, use code V25.2 as the cause of admission. If the sterilization is purely elective, code V25.2 will suffice as a solo code for the diagnosis.

b. If the sterilization procedure was performed for contraceptive purposes during a

current admission for obstetrical delivery, use code V25.2 as an additional code. However, if the sterilization was an end result of a hysterectomy performed because of injury or damage to the uterus during delivery, do not use code V25.2.

c. Do not use code V25.2 when the major purpose of the procedure performed was

not for contraception; for example, when a hysterectomy is performed for cancer of the uterus.

10. Category V27 (Outcome of Delivery) will be used on the mother's record to denote

whether the delivery process resulted in a live -born, stillborn, multiple birth or any combination thereof. The proper use of the V27 category is explained further in Principle IX (OB-GYN Conditions).

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11.

Categories V3Ø-V37 (Live-Born Infants According to Type of Birth) will be used for

coding of live-born infants. The appropriate fourth digit ".Ø" (Born in Hospital) and ".1" (Born Before Admission to Hospital) will separate hospital births from those born en route or shortly before admission. For inpatient care " .2" (Born Outside Hospital and Not Hospitalized) will not be used on inpatient records. V39 (Unspecified Live Birth) will not be used for inpatient care. (For further details and application of the V30 -V37 categories, see Principle X ( Perinatal Morbidity and Mortality.)

12. Category V42 (Organ or Tissue Replaced by Transplant) may be used, as

appropriate, for inpatient care. The subcategory codes are status codes to indicate the presence of a transplanted organ/tissue. These codes will never be used as the cause of admission or principal diagnosis. (For further details and application of this category, see Principle XVI.)

13. Category V44 (Artificial Opening Status) and V45 (Other Post -Surgical Status) are

appropriate for inpatient coding to describe a post -surgical status that affects patient care management, for example, V45.1 (Renal dialysis status). These codes will never be used as the cause of admission.

14. Categories V5Ø-V59 (Persons Encountering Health Service for Specific

Procedures and Aftercare) will have inpatient utilization as follows:

a. Subcategory V5Ø.1 (Other Plastic Surgery for Unacceptable Cosmetic

Appearance) will be used as the diagnostic code to support surgery done for purely cosmetic reasons as distinguished from therapeutic indications. A few surgical procedures that can be done for therapeutic reasons but are often done for purely cosmetic purposes are mammary augmentation, facial rhytidectomy (face lift), blepharoplasty, rhinoplasty, and otoplasty. Use of this diagnostic code excludes plastic surgery following healed injury or operation. Category code V51 will be used to support plastic surgery done following previous surgery or injury.

b. Categories V51-V58 are for use in indicating a reason for care of patients who

have already been treated for some disease or injury not now present.

c. Subcategories V54.Ø and V54.8 (Other Orthopedic Aftercare) would be used

when a patient is admitted for routine removal of device following "healed fracture" or similar condition. Either code can be a sole diagnostic code used as the cause of admission.

d. Subcategories V55.Ø-V55.3 (Attention to Artificial Openings) may be used to

classify admission without mention of complication but for the purpose of closing or revising the ostomy site.

e. Category V59 (Donors) provides a classification for donor of tissues or organs.

(For further details and application of this category, see Principle XVI.)

15. Subcategory V63.2 (Person Awaiting Admission to Adequate Facility Elsewhere) is

a possible code for use in those instances where the patient is being held in the hospital pending transfer to another institution. It is to be used as an additional code only.

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16.

Subcategories V64.1-V64.3 provide a classification for those patients admitted for a

scheduled procedure but discharged with surgery cancelled shortly after admission. These codes will not be used as the cause of admission.

17. Subcategory V65.2 (Person Feigning Illness (Malingerer)) should be used only after

the record has been reviewed by either a department chief, the chief of professional services, or a medical care evaluation committee because of the legal implications (Manual of Courts-Martial, 1969, para 194).

18. Category V67 (Follow-up Examination) will be used to include surveillance only

following treatment, and will be used for follow-up exams for patients with previously treated neoplasms.

19. V7Ø category will be used for examination and screening for specified

circumstances. Code V7Ø.8 will be used for examination of potential organ or tissue donors. (See Principle XVI.)

20. Category V71 will be used for inpatients to classify observations and evaluation for

suspected conditions which show no need for further treatment or medical care. Codes from this category can only be used as the principal diagnosis.

APPLICATION

1. V Codes are primarily for use as a supplemental code with the primary code being

the current condition which requires hospitalization. However, it may be used as a solo code for inpatients without disease or current injury. It may be used as the principal diagnostic code to support surgery done for purely cosmetic purposes.

EXAMPLE:

DIAGNOSIS: Protruding ears. (Eight-year old is admitted for Otoplasty.)V50.1 744.29

2. A V code denotes hypersensitivity to insect sting (bite) where that condition results

in disability separation/failure to meet medical procurement standards.

EXAMPLE:

DIAGNOSIS: Hypersensitivity to bee sting. (Patient is being separated from the Service.)

V15.Ø

3. Sterilization. If the primary reason for admission was for elective sterilization, use

code V25.2. Also, use this V code as an additional code if the sterilization procedure was performed for contraceptive purposes during a current obstetrical delivery admission. Do not use this V code when the major purpose of the procedure performed was not for elective sterilization, but to remedy a disease process.

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EXAMPLE:

DIAGNOSIS: Admitted for a Laparoscopy with Tubal Ligation. (Patient has five children.)

V25.2

4. Category V44 and V45. Appropriate for inpatient coding to describe a postsurgical

status that affects patient care management.

EXAMPLE:

DIAGNOSIS: Acute Pharyngitis: Patient has a temporary Tracheostomy

462 V44.Ø

5. Subcategories V64.1-V64.3 provide a classification for those patients admitted for a

scheduled procedure but discharged with surgery cancelled shortly after admission.

EXAMPLE:

DIAGNOSIS: Chronic Tonsillitis : Patient admitted for Tonsillectomy May 3 1979: Surgery cancelled. Patient is running temperature.

474.Ø 78Ø.6 V64.1

6. Category V71 will be used for inpatients to classify observations and evaluation for

suspected conditions which show no need for further treatment or medical care.

EXAMPLE:

DIAGNOSIS: Observation following auto accident, no injury found.

V71.4--9

PRINCIPLE V. SURGERY AND PROCEDURES

1. The ICD-9-CM procedure classification is contained in a separate volume 3 which

includes the Tabular List and Alphabetic Index. The procedure classification has 16 chapters of which 15 are assigned to anatomical sites (body systems). All surgical procedures on a single body system appear together as follows:

CHAPTER

CODES

1 Operations on the Nervous System

Ø1-Ø5

2 Operations on the Endocrine System

Ø6-Ø7

3 Operations on the Eye

Ø8-16

4 Operations on the Ear

18-2Ø

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5

Operations on the Nose, Mouth, and Pharynx

21-29

6 Operations on the Respiratory System

3Ø-34

7 Operations on the Cardiovascular System

35-39

8 Operations on the Hemic and Lymphatic System

4Ø-41

9 Operations on the Digestive System

42-54

10 Operations on the Urinary System

55-59

11 Operations on the Male Genital System

6Ø-64

12 Operations on the Female Genital System

65-71

13 Obstetrical Procedures

72-75

14 Operations on the Musculoskeletal System

76-84

15 Operations on the Integumentary System

85-86

Chapter sixteen is devoted to miscellaneous diagnostic, therapeutic, and prophylactic nonsurgical procedures on all body systems and include the following:

(1) Diagnostic Radiology by anatomical site, distinguishing between Tomography, Contrast Radiology, and Flat X-ray.

(2) Diagnostic Ultrasound and Thermography.

(3) Nuclear Medicine, both diagnostic and therapeutic.

(4) Physical Therapy, Respiratory Therapy, Rehabilitation, and related procedures.

(5) Prophylactic vaccination and innoculation.

2. Alphabetic Index

a. The Alphabetic Index is organized by "main terms" printed in bold typeface

which usually identify the type of procedure performed. The "main terms" represent:

Procedures -- Aortogram, audiometry Operations -- Appendectomy, cholecystectomy Nouns -- Operation, procedure Verbs -- Shortening, repair

b. Eponyms (procedures named after people) are listed in the Alphabetic Index

both as main term entries in alphabetical sequence and under the main term "operation." A description of the procedure or anatomic site usually follows the eponym.

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EXAMPLES:

Baldy-Webster operation (uterine suspension) 69.22 Emmet operation (cervix) 67.61

c. A main term may be followed by a series of words (modifiers) in parenthesis.

The presence or absence of these modifiers in the procedure do not affect the selection of the code.

EXAMPLE:

Decortication Lung (Partial) (Total ) 34.51

d. A main term may be followed by individual indented line entries ( subterms)

which describe a difference in site, surgical technique, approaches, and the extent of the procedure. The presence of these entries do affect the selection of the code.

Excision lesion (local) skin 86.3 breast 85.21 nose 21.32 radical (wide)

3. Tabular List

EXAMPLE:

86.4

The procedure code structure is as follows:

a. Two digit section codes which provide a section heading by site and general

description of the procedure.

EXAMPLE:

32 Excision of lung and bronchus.

b. Three digit category codes which specify the procedure.

EXAMPLE:

32.0 Local excision or destruction of lesion or tissue of bronchus.

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c.

Four digit subcategory codes which provide greater specificity in identifying

anatomical sites and defining selected procedures, techniques, or the surgical approach. When a three-digit code is followed by a four-digit code, the four-digit code must be used. The four-digit codes are also used to differentiate between unilateral and bilateral, and between types of conditions such as direct and indirect hernia.

EXAMPLE:

32.2 Local excision or destruction of lesion or tissue

of lung

32.21 Plication of emphysematous bleb

32.29 Other local excision or destruction of

lesion or tissue of lung

4. The two instructions unique to Volume 3 are:

a. Omit code.

b. Code also any synchronous procedure.

5. The following guidelines are to be used for coding procedures:

a. The surgical approach and closure as part of the operation do not require

additional codes. Procedures such as laparotomy are not coded if used as an approach for a surgical procedure such as excision or repair.

b. When a biopsy is performed as part of a more extensive surgical procedure,

code both the biopsy and surgical procedure.

c. If a procedure is started and not completed, the approach (incision) is coded.

6. Instructions for Coding Procedures/Use of Alphabetic Index Volume 3

a. Use the Alphabetic Index to locate the main term (procedure): excision, incision,

graft, control, etc.

b. Read and be guided by any note that appears under the main term such as

"see" and "see also."

c. Read any terms enclosed in parentheses (modifiers) following the main entry as

well as subterms indented under the main entry for selection of the appropriate code.

d. Follow any cross-reference instructions.

e. Do not code from the Alphabetic Index, important instructions appear in the

Tabular List. Verify the code number in the Tabular List.

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7.

Instructions for Coding Procedures/Use of Tabular List

a. Refer to the Tabular List to verify that the code selected is in accordance with

the desired classification of the procedure.

b. Read and be guided by the inclusion or exclusion notes that may appear not

only under the particular code but also under the category code or section title for that particular code.

c. Use as many codes as necessary to adequately classify a surgical procedure,

unless instructed otherwise by the term "omit code."

8. Sequencing Guidelines

a. Report all significant procedures. A significant procedure is one which carries

an operative or anesthetic risk, or requires highly trained personnel, and requires special facilities or equipment. Verify procedures were performed and not just scheduled. To increase accuracy and specificity of coding, examine the discharge summary, operative reports, x-rays, pathology reports, notes, and orders for additional procedures not listed on the Inpatient Treatment Record Coversheet (ITRCS) by the physician.

b. The principal procedure is listed as the first procedure statement on the ITRCS.

The principal procedure is that procedure most related to the principal diagnosis. A principal procedure is one which was performed for definitive treatment (therapeutic) rather than one performed for diagnostic or exploratory purposes.

c. When a diagnostic procedure is relat ed to the principal diagnosis and a

therapeutic procedure is related to a secondary diagnosis, then the principal procedure is the therapeutic procedure.

d. When two or more therapeutic procedures are performed and all or none are

related to the principal diagnosis, then the procedure during which tissue was removed or the procedure which subjected the patient to the greatest risk is selected as the principal procedure.

e. If diagnostic procedures are performed and all or none of them relate to the

principal diagnosis, select the procedure which impacts most dramatically on resource usage.

f. An incidental appendectomy (47.1) should not be coded as a principal procedure.

g. If there is a disagreement between the ITRCS and the operation/tissue report,

refer the record back to the supervisor and/or physician for clarification.

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9. Conventions and Instructional Terms

Conventions, abbreviations, and instructional terms used in the procedure classification are similar to those in the diagnostic classification.

Includes: Inclusions are separate terms entered under a two or three digit code. These inclusion terms represent only the most frequently used terms and serve as a guide to examples of the procedures included in the code and title. Other terms also classified to that code and title are found in the Index. The location of the term "includes" indicates which codes are included. "Includes" at section level applies to all codes in that section.

85 Operation on the Breast

Includes: Operations on skin of:

Breast Previous Mastectomy Site

Female or

Male

}

"Includes" at category level applies to all codes in that category.

09.4 Manipulation of lacrimal passage

Includes: removal of calculus that will dilation

Excludes:

Exclusions are italicized terms prefaced by a box, indicating that the code and title do not include these terms. The position of the exclusion terms is the same as the inclusions and have the same significance as the inclusion terms with the same application. When both inclusion and exclusion terms appear together, the inclusion terms are listed first.

Note:

Notes appear in the Index and Tabular List.

See:

This instruction tells the coder to look elsewhere for the code.

Excision

fallopian tube - see salpingectomy

See Also:

This instruction is a suggestion to look further if the main term or subterm(s) for that entry is insufficient for coding the procedure.

Angioplasty - see also repair, blood vessel coronary 36.0

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See Category:

code numbers rather than one code.

This term is infrequently used. It refers the coder to a section of

Lysis Adhesions Bone - see category 78.9

§ The section mark symbol preceding a code denotes the placement of a footnote at the bottom of the page which is applicable to all subdivision in the code.

Code also: This instruction in the Tabular List is a guide to determining the number of codes necessary. It is a reminder to code the individual components of

a

procedure when they are accomplished at the same time. "Code also"

is

also used as an instruction to code the use of special adjunctive

procedures or equipment. "Code also" often includes the word "synchronous" (performed at the same time).

46.1 Colostomy

Code also any synchronous resection (45.49, 45.71-45.79, 45.8)

The instruction "Code also" may appear under two-digit, three-digit, or four-digit codes.

Omit Code: The surgical approach and closure are a part of the operation and do not require codes in addition to the code for the operation unless they are unusual or required by the statement "code also." Procedures such as laparotomy are not coded if used as an approach for a surgical procedure such as excision or repair. The surgical approach code is used when there is no further operative procedure, e.g., exploratory laparotomy with biopsy. Both the laparotomy and the biopsy are coded. Exception: If a procedure is started and not completed, the approach (incision) is coded. The instruction "omit code" is the guide in both the Tabular List and Alphabetic Index.

APPLICATION

1. When an endoscopy is performed and the endoscope is passed through more than one cavity, the code for the endoscopy will identify the farthest site.

Esophagoscopy NEC Esophagogastroscopy NEC (Other gastroscopy) Duodenoscopy (Other endoscopy of small intestine) Esophagogastroduodenoscopy

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44.13

42.23

45.13

45.13

2.

There are some codes in the classification which identify endoscopic biopsies.

Bronchoscopy with biopsy (Endoscopic bronchial biopsy)

33.24

3. If there is no code which includes both procedures, code each procedure

separately.

Laryngoscopy with biopsy (Laryngoscopy) (Biopsy of Larynx)

31.42

31.43

4. If an endoscopy is performed and another procedure such as excision of lesion is

performed, code both the endoscopy and the other procedure- unless instructed otherwise in the Alphabetic Index or the Tabular List.

PROCEDURE: Cystoscopy with transurethral resection of prostate

Cystoscopy (transurethral)

57.32

Resection prostate -- see also Prostatectomy transurethral (punch)

60.2

Transurethral resection of prostate

60.2

5. A principal procedure is one which was performed for definitive (therapeutic)

treatment rather than one performed for diagnostic purposes.

DIAGNOSIS: Torn medial meniscus

836.Ø

PROCEDURE: Arthroscopy with meniscectomy

8Ø.6 8Ø.26

The meniscectomy is the principal procedure for it was performed for therapeutic treatment, the arthroscopy is a diagnostic procedure.

6. When a diagnostic procedure is related to the principal diagnosis and a therapeutic

procedure is related to a secondary diagnosis, then the principal procedure is the therapeutic procedure.

PRINCIPAL DIAGNOSIS : Gastritis SECONDARY DIAGNOSIS : Left indirect inguinal hernia

PROCEDURES: Gastroscopy (diagnostic) Left inguinal herniorrhaphy (therapeutic)

The herniorrhaphy is the principal procedure.

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PRINCIPLE VI. SYMPTOMS, INCONCLUSIVE DIAGNOSES, COPD

1. Signs and symptoms that point rather definitely to a particular diagnosis are

assigned to the appropriate chapter of ICD-9-CM rather than chapter 16; for example, hematuria is assigned to the chapter for Genitourinary System (Code 5997). Chapter 16 includes ill-defined conditions and symptoms that could be the result of two or more conditions, or may involve two or more systems of the body, and are used in cases where the necessary studies to determine a definitive diagnosis were not completed prior to disposition; for example, transfer and death cases without an autopsy.

2. Chapter 16 includes Category Codes 780-799. The paragraph on page 707 of

Volume 1, ICD-9-CM should be reviewed carefully prior to assigning codes from this chapter.

3. Diagnostic statements that may require use of codes from chapter 16 are:

a. When a specific diagnosis cannot be made at time of disposition.

b. Transient signs and symptoms whose etiology could not be determined.

c. Provisional diagnosis made for dispositioned patients (e.g., patients that are

transferred).

d. A more precise diagnosis cannot be made for other reasons.

e. Certain signs and symptoms are important in rendering appropriate medical

care; therefore, the appropriate code from chapter 16 will be used as an additional code when the etiology is known.

4. The signs and symptoms found in Chapter 16 (Categories 780-799) of ICD-9-CM

may be used as the principal diagnosis only when:

a. No definite cause is identified.

b. The signs and symptoms are followed by comparative contrasting diagnoses.

c. The signs and symptoms are a residual of late effect.

d. The signs and symptoms are the result of an adverse reaction to medication.

5. Comparative/Contrasting Diagnoses:

a. If the differential diseases/conditions have a symptom(s) stated, the symptom

may be used as the principal diagnosis.

b. If the differential diseases/conditions have no symptom stated, assign codes for

the stated conditions and assign the first listed as the principal diagnosis.

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6.

Chronic Obstructive Pulmonary Disease (COPD) Category Code 496. This code is

to be used only when COPD is reported without mention of a more specific chronic obstructive pulmonary disease. COPD with other diagnoses (such as emphysema, chronic bronchitis, allergic alveolitis, asthma, and bronchiectasis) is classified to the specific condition rather than category 496.

APPLICATION

1. Diagnostic statement that requires assigning codes from chapter 16.

EXAMPLE:

DIAGNOSIS: Dysuria, etiology undetermined

7881

2. COPD is coded to category 496. This category will be used only when there is no

mention of a specific chronic obstructive pulmonary disease. Also, assign the symptom(s) code as additional codes.

EXAMPLE:

DIAGNOSIS: Pneumothorax, spontaneous, left. Chronic Obstructive Pulmonary Disease.

5128 496Ø

DIAGNOSIS: Chronic Obstructive Pulmonary Disease Emphysema, Compensatory`

5182

PRINCIPLE VII. COMPLICATIONS OF CARE

1. Surgical and Postoperative Complications.

a. Accurate coding of complications as a result of surgical procedures is very

important. In some hospitals, the Quality Assurance personnel rely on correct coding of complications to alert them of a potential problem. To code a surgical complication proceed as follows in the stated order until the appropriate code is located.

(1) Look up an entry for the complication (such as infection) and the indented modifier "postoperative."

(2) Look up "Complication" and an indented modified to describe the complication.

(3) Look up "Complication, surgical procedure" and identify the body system to which the complication is assigned.

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b. Postoperative complications affecting a specific anatomical site or body system

are classified to categories 001-799 in the main classification. Complications affecting more than one site or body system are classified to categories 996-999 of the chapter on injury and poisoning. Of particular significance are the last three lines of the exclusion note which state: "any condition classified elsewhere in the Alphabetic Index when described as due to a procedure." An additional code, when possible, will be used to specifically identify the anatomical site or the manifestation of the postoperative complication. When multiple coding is used, sequencing of codes is important. A postoperative complication may be principal diagnosis if it is the cause for readmission. The codes from categories 996-999 take precedence in sequencing, when an additional code is used for specificity.

c. Subcategories/subclassifications codes 996.0-996.5 are specific for mechanical

complications resulting form various prosthetic devices or implants. They include mechanical breakdown or obstruction, leakage, displacement, perforation, or protrusion of the devices. Complications of a mechanical nature of internal prosthetic devices and implants are classified to 996.0-996.5. Complications involving implants and internal devices are classified to 996.7. The remaining codes in category 996 are for physiological complications; for example, complications or rejections following organ or tissue transplants with an accompanying code from category V42 to identify the specific organ or tissue involved. (See principle XVI (Organ and Tissue Transplants) for correct sequencing of codes.)

2. Medical Care Complications.

a. Subcategory codes 999.0 through 999.9 will be used when the diagnostic

statement specifies that condition as a complication resulting from medical care. Carefully read the inclusion and exclusion terms.

b. Subcategory code 999.9 may be used alone to indicate a complication of

medical care when the specific condition is not mentioned by the responsible physician. When possible, an additional code will be used for specificity to completely describe the condition.

3. Complications vs. Aftercare.

a. Coding personnel should thoroughly review the record to ascertain whether the

condition requiring hospitalization was in fact a complication or aftercare.

b. An admission for aftercare is usually scheduled, whereas an admission for

complication of surgical or medical care occurs at the time the complication develops.

APPLICATION

1. Read carefully the "excludes" note, Page 867 in Volume 1, ICD-9-CM.

EXAMPLE:

DIAGNOSIS: Infection of surgical wound (Cesarean section 3 weeks ago)

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674.34

2.

A condition specified as a complication of surgical care or postoperative, which does

not have a specific subentry in the Alphabetic Index will be multiple coded, when possible.

EXAMPLE:

DIAGNOSIS: Pneumothorax due to accidental puncture during cardiac catherization.

9982/5128

3. Category 996 provides codes at the fourth- and fifth-digit level to distinguish

between mechanical and physiological complications.

EXAMPLES:

DIAGNOSIS: Migration of breast prosthesis.

DIAGNOSIS: Infected breast implant following mastectomy.

99654

9966

4. Complications or rejection of organ or tissue transplant.

EXAMPLE:

DIAGNOSIS: Cadaveric renal transplant X3, rejection episode.

99681 V42Ø

PRINCIPLE VIII. NEOPLASMS

1. Instructions on how to use Chapter 2, Neoplasms (140-239) are provided on page

81, Volume 1 of ICD-9-CM. All neoplasms whether functionally active or not are classified to Chapter 2. If the neoplasm is functionally active, an additional code should be used to identify the functional activity.

a. Table of neoplasms.

(1) The Table of Neoplasms gives the code numbers for neoplasms by anatomical site. For each site, there are six possible code numbers according to whether the neoplasm in question is malignant, primary, secondary, benign, in situ, of uncertain behavior, or of unspecified nature.

(2) The description of the neoplasm will often indicate which of the six columns is appropriate; for example, malignant melanoma of skin, benign fibroadenoma of breast, or carcinoma in situ of cervix uteri. Where such descriptors are not present, the remainder of the index should be consulted.

(3) Sites marked with the sign "*"; for example, face NEC*, should be classified to malignant neoplasm of skin of these sites if the variety of neoplasm is a squamous-cell carcinoma or an epidermoid carcinoma and to benign neoplasm of skin of these sites if the variety of neoplasm is a papilloma (any type).

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(4) The term "cancer" when modified by an adjective or adjectival phrase indicating a morphological type should be coded in the same manner as "carcinoma" with that adjective or phrase. Thus, "squamous cell cancer" should be coded in the same manner as "squamous-cell carcinoma."

b. Morphology codes (Volume 1, pages 1055 -1076).

(1) ICD-9-CM provides an optional set of four-digit codes preceded by the letter "M" for identifying the morphology of neoplasms. An additional set of single digits is provided to identify the behavior of the neoplasm, such as "/3" for malignant, primary site. Morphology codes are not used in the inpatient record.

(2) The morphology codes may be located in the Alphabetical Index (Volume 2) in alphabetical sequence under the main term entry for the specific neoplasm.

(3) The word morphology is defined as the study of the form and structure of the cells and tissues from which the neoplasms arise.

(a) The properties of a particular neoplasm is determined by the tissue of

origin as opposed to the organ of origin.

(b) The type of cells that a malignant neoplasm is comprised of often

determines the rate of growth, degree of malignancy, and the particular type of treatment rendered.

(4) Metastatic neoplasms are identified at the metastatic site by their morphology, which is different from that of the normal tissue at the metastatic site and the same as the morphology of the tissue and cells at the primary site. This is important to remember when coding neoplasms and determining primary versus secondary sites.

(a) Classification of neoplasms by the tissue from which they arise are:

1. Epithelial tissue--adenoma, papilloma, carcinoma, and

adenocarcinoma.

2. Connective tissue--fibroma, leiomyoma, fibrosarcoma, and

leiomyosarcoma.

3. Nervous tissue--meningioma and glioma.

(b) Classifications of neoplasms by cells from which they arise are:

1. Clear cell adenoma.

2. Acinar cell adenoma.

3. Basal cell carcinoma.

4. Squamous cell carcinoma.

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c.

Personal History of Malignant Neoplasm.

In addition to the categories for

malignant neoplasm provided in chapter 2, ICD-9-CM contains codes in the supplementary classification for describing history of (primary) malignant neoplasm (codes V1Ø.ØØ-V1Ø.9), and for describing the purpose of an encounter as for radiotherapy (code V58.Ø) and for maintenance chemotherapy (code V58.1).

d. Categories 150 and 201 contain a departure from the usual princi ples of

classification in that the fourth-digit subdivisions in each case are not mutually exclusive. In each instance, the dual axis is provided to account for differing terminology encountered on source documents; for example, one surgeon may describe the location of an esophageal malignancy as cervical portion, while another may say upper third.

e. Neoplasms with Overlapping Site Boundaries.

Categories 140-195 are for

the classification of primary malignant neoplasms according to their point of origin. A primary malignant neoplasm whose point of origin cannot be determined but whose stated sites overlaps two or more subcategories within a three -digit category should be classified to the four-digit subcategory .8 (other). For certain malignant neoplasms whose point of origin cannot be determined but whose stated sites overlap two or more three-digit categories, codes for contiguous sites are provided. These codes are 149.8, 159.8, and 165.8. Overlapping malignant neoplasms that cannot be classified as indicated above should be assigned to the appropriate subdivision of category 195 (Malignant neoplasm of other and ill-defined sites).

2. Coding Principles.

a. Primary Site is Still Present (Solid Tumors).

For example, the hospital

admission during which the malignancy is diagnosed or during which the primary treatment took place. Code the primary site using codes from chapter 2 (codes 14Ø.Ø-195.9). If present, code also secondary sites which may be present using categories 196-199.

b. Primary Site Previously Treated (Solid Tumors).

The primary site was

previously excised or eradicated with no recurrence of original primary site. If a

neoplasm is eradicated on a previous admission, regardless of the length of time since eradication, the neoplasm should not be coded as being present unless there has been

a recurrence. An eradicated neoplasm is one that has been removed by surgical

procedure or otherwise destroyed through other treatment. To note the eradicated neoplasm in the present record, code a personal history of a malignant neoplasm.

(1) Code the primary site using codes from the supplementary classification (codes V1Ø.ØØ-V1Ø.9). These codes will never appear as the cause of admission diagnosis.

(2) If the patient has secondary sites present, code these using categories 196-199. Also code the previous primary site code (V1Ø.ØØ-V1Ø.9).

(3) If the patient has no secondary malignancy, and if the reason for admission

is follow-up of the malignancy, code to V67. Also code the previous primary site

(V1Ø.ØØ-V1Ø.9).

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c.

Primary Malignancy of Hematopoietic and Lymphatic Tissue.

(1) Malignancy of hematopoietic and lymphatic tissue is always coded to 2ØØ.Ø-2Ø8.9 series with appropriate fifth digit where required, unless it is st ated to be "in remission."

(2) For malignancy of hematopoietic and lymphatic tissue "in remission", a V67 with an additional code from categories V1Ø.6-V1Ø.7, as applicable, will be used.

d. Patient Admitted Solely and Specifically for Radiotherapy Session or for

Maintenance Chemotherapy.

(1) Patients admitted solely and specifically for radiotherapy and no other treatment, use code V58.Ø as principal diagnosis.

(2) Patients admitted solely for chemotherapy and no other treatment, use code V58.1 as principal diagnosis.

(3) The present primary and any secondary malignancies should be classified supplementally. If either or both neoplasms have been eradicated, the personal history of malignancy should be coded.

e. Metastatic Cancer.

(1) If the primary malignancy is no longer present, identify the previous primary site using the proper code within the V1Ø category. In such cases, do not assign the code for "primary site unknown."

EXAMPLE: Metastatic carcinoma to lung from breast. Bilateral radical mastectomy performed 6 months ago.

Code to: Secondary neoplasm of lung (197.Ø) and personal history of malignant neoplasm of breast (V1Ø.3).

(2) Cancer described as "metastatic from" a site should be interpreted as primary of that site.

EXAMPLE: Metastatic carcinoma from breast.

Code to: Primary malignant neoplasm of breast (174.9). Secondary neoplasm of unspecified site (199.1).

(3) Primary site unknown. When the primary site is unknown, code to the unspecified site for the morphological type involved; for example, carcinoma (199.1), melanoma (172.9), adenocarcinoma (199.1), osteosarcoma (17Ø.9), and fibrosarcoma

(171.9).

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(4) Cancer described as "metastatic to" a site should be interpreted as a secondary of that site. Also, assign the appropriate code for the primary malignant neoplasm of specified site if the primary site is identified or code to the unspecified site (as stated in e(3) above).

EXAMPLE: Metastatic carcinoma to lung.

Code to: Secondary neoplasm of lung (197.Ø) and primary malignant neoplasm of unspecified site (199.1).

EXAMPLE: Metastatic carcinoma from liver to lung.

Code to: Primary malignant neoplasm of liver (155.Ø) and secondary neoplasm of lung

(197.Ø).

(5) If two or more sites are stated in the diagnosis and all are qualified as metastatic code as for primary site unknown, code the stated sites as secondary neoplasm of those sites.

EXAMPLE: Metastatic melanoma of lung and liver.

Code to: Secondary neoplasm of lung (197.Ø) and liver (197.7) and primary malignant melanoma of unspecified site (172.9).

EXAMPLE: Metastatic carcinoma of brain and lung.

Code to: Secondary neoplasm of brain (198.3) and lung (197.Ø) and primary carcinoma of unspecified site (199.1).

(6) If only one site is stated in the diagnosis and this is qualified as metastatic, proceed as follows:

(a) Code as for primary site unknown; however, if this code is 199.Ø or

199.1, follow rule (6)(b) below.

(b) If the code arrived at in (6)(a) above is 199.Ø or 199.1, code instead as

for primary malignant neoplasm of the stated site except for the following sites, which should be coded to the secondary neoplasm of that site.

bone (198.5) brain (198.3) diaphragm (198.8) heart (198.8) liver (197.7) lymph nodes (196.9) mediastinum (197.1)

meninges (198.4) peritoneum (197.6) pleura (197.2) retroperitoneum (197.6) spinal cord (198.3) site classifiable to 195

(198.89)

Also assign the appropriate code for primary or secondary malignant neoplasm of specified or unspecified site, depending on the diagnostic statement being coded.

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EXAMPLE: Metastatic lung cancer.

Code to: Primary malignant neoplasm of lung (162.9), and secondary malignant neoplasm, unspecified site 199.1.

EXAMPLE: Metastatic cancer of brain.

Code to: Secondary neoplasm of brain (198.3) and primary malignant neoplasm of unspecified site (199.1).

(7) If no site is stated in the diagnosis, but the morphological type is qualified as "metastatic," code as primary site unknown.

EXAMPLE: Metastatic apocrine adenocarcinoma.

Code to: Primary malignant apocrine adenocarcinoma of unspecified site (173.9), and secondary malignant neoplasm, unspecified site 199.1.

f. When Neoplasm is the Underlying Cause of Death.

(1) Code to primary site when known or as "primary site unknown" when undetermined.

(2) Categories 196, 197, and 198 are not to be used for underlying cause of death coding. Secondary neoplasm of specified sites, of unspecified site, or without mention of primary site, will be coded as "primary site unknown."

EXAMPLE: Metastatic carcinoma to colon.

Code to: Morphological type involved (carcinoma - 199.1) for underlying cause of death.

3. Sequencing.

a. The patient is admitted with a suspected malignant neoplasm:

(1) If confirmed, the neoplasm is sequenced first.

(2) If not confirmed, list as admission for suspected neoplasm.

b. The patient is admitted with a confirmed malignant neoplasm:

(1) If the neoplasm is treated (e.g., surgically), the neoplasm is sequenced first.

(2) If only a condition caused by the neoplasm is treated, the condition (not the neoplasm) is sequenced first (e.g., dehydration). An exception to this is if the condition is coded in Chapter 16 of ICD-9-CM.

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(3) If the patient is admitted specifically for chemotherapy or radiotherapy, principal diagnosis is admission for chemotherapy or radiotherapy.

c. The patient is admitted for restaging:

(1) If a new neoplasm is found, the neoplasm is principal.

(2) If known neoplasm has grown, the neoplasm is principal.

(3) If nothing new is found, admission for follow-up examination is principal.

APPLICATION

1. The Table of Neoplasms give the code numbers for neoplasms by anatomical site.

For each site there are five possible code numbers according to whether the neoplasm in question is malignant, benign, in situ, of uncertain behavior, or of unspecified nature.

EXAMPLE:

DIAGNOSIS: Carcinoma in situ, rectum

23Ø.4

2. Primary site is still prese nt (solid tumors). Code the primary site using codes from

chapter 2 (codes 14Ø.ØØ-195.8). Code, also, any secondary sites which may be present, using codes 196.Ø-199.1.

EXAMPLE:

DIAGNOSIS: Adenocarcinoma of prostate gland metastatic cancer to urinary bladder.

185.Ø 198.1

3. Primary site previously treated (solid tumors). The primary site was previously

excised or eradicated with no recurrence of original primary site. (See coding principles in paragraphs 2a and 2b above.)

EXAMPLE:

DIAGNOSIS: Bladder tumor examination; surgery performed 6 months ago for malignancy of bladder. No evidence of recurrence.

V67.Ø V1Ø.51

4. A primarily malignant neoplasm that overlaps two or more subcategories within a

three-digit rubric and whose poi nt of origin cannot be determined should be classified to the subcategory ".8" (Other).

EXAMPLE:

DIAGNOSIS: Glioma of left parieto-occipital area.

191.8

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5.

Patients admitted solely for radiotherapy session or for maintenance chemotherapy,

code to proper V58 category.

EXAMPLE:

DIAGNOSIS: Carcinoma of cervix, hysterectomy 2 months ago. Admitted for maintenance chemotherapy.

V58.1 V1Ø.41

PRINCIPLE IX. OB-GYN CONDITIONS

1. Abortion Category Codes.

a. For DOD purposes, abortions will be classified by type, in the following

categories:

(1) Missed abortion, ectopic and molar pregnancy - 63Ø to 633.

(2) Spontaneous - 634.

(3) Legally induced (therapeutic, elective) - 635.

(4) Illegally induced - 636.

(5) Unspecified abortion - 637.

(6) Failed attempted abortion - 638.

(7) Complications following abortion and ectopic and molar pregnancies - 639.

b. The subcategory levels (fourth digits) identify the presence or absence of

complications. They identify complications resulting from the abortion, not the reasons for performing the abortion. Use of the fifth digit Ø, unspecified stage, is strongly discouraged and will be questioned.

c. Fifth digit codes listed at the bottom of pages 531, 532, and 533 are for use with

abortion categories 634 through 637 to indicate the stage of the abortion as complete, incomplete, or unspecified.

d. When abortion procedures are done for therapeutic reasons, or if the MTF is

allowed to perform elective abortions, the procedures frequently used are:

(1) Hysterotomy or hysterectomy to terminate pregnancy - 74.91.

(2) Amniotic or saline injection for termination of pregnancy - 75.Ø.

(3) Vacuum aspiration for termination of pregnancy - 69.51.

(4) D & C to terminate pregnancy - 69.Ø1.

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e. Legally induced abortion, Category 635, includes both elective and therapeutic

abortions. A therapeutic abortion is one induced for medical indications which would be life threatening to the mother if the pregnancy were carried to term. An elective abortion is one performed at the request of the patient. To distinguish between therapeutic and elective abortions, code extenders have been provided to meet DOD statistical requirements. The code extenders will be used in the seventh position of the diagnostic field. The use of 9 (unspecified) will be questioned. The code extenders are as listed below.

Elective

635.XX - Ø

Therapeutic

635.XX - 1

Unspecified

635.XX - 9

f. When a therapeutic abortion is performed, the reason (diagnosis) for this legally

induced abortion must also be coded. Codes from categories 640-648 will be used to reflect the complication(s) of pregnancy leading to the therapeutic abortion; the fifth digit Ø will indicate abortive outcome. The reason for the abortion will be selected from other ICD-9-CM categories and will be used as an additional code. Sequence the abortion code first.

g. An abortion resulting in a live-born fetus is coded as an abortion by type, with a

code from category V27 as appropriate.

h. Complications following abortion, ectopic, or molar pregnancy are classified to

category 639. This category is to be used as an additional code when there are immediate complications during the same admission as treatment for the ectopic or molar pregnancy. For example, Pelvic Peritonitis due to ruptured tubal pregnancy is coded to 633.1 and 639.Ø Codes 634-638 are never used in combination with category code 639 during the same admission. However, a code from 639 category is the principal diagnostic code for complications stemming from an abortion done during a previous episode of care.

i. The subcategory codes for 634, Spontaneous Abortions, identify the presence or

absence of any complications arising during the same admission or encounter as that for the abortion. For example, the diagnosis "incomplete spontaneous abortion with delayed hemorrhage" is coded 634.11. The use of this code indicates that the delayed hemorrhage occurred during the same admission as that for the spontaneous abortion. Another example is "Spontaneous abortion with urinary tract infection" which is coded to 634.7Ø. Additional codes specific for the complication are not required.

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APPLICATION

Abortion Codes

1. When coding a therapeutic abortion, code also the reason why the abortion was

performed.

EXAMPLE:

DIAGNOSIS: Therapeutic abortion, complete, due to severe maternal rheumatic

heart disease

648.6Ø 398.9Ø

D&C

69.Ø1

635.92 - 1

2. An admission for complication(s) after an abortion is coded to category 639.

EXAMPLE:

DIAGNOSIS: Excessive hemorrhage following elective abortion at Cypress Community Hospital

693.1

2. Pregnancy and Puerperium Category Codes.

a. Categories 64Ø-676 have fifth-digit codes to provide more specificity regarding

the outcome of current hospitalization. Specifically, the fifth digits have the following meanings: (See Volume 1, page 537).

Ø - Unspecified as to the episode of care or not applicable. (The fifth digit "Ø" will be used only to denote abortive outcome.)

1 - Delivery with or without mention of antepartum condition.

2 - Delivery with mention of postpartum complication during present episode of care.

3 - Antepartum condition or complication (undelivered).

4 - Postpartum condition or complication following delivery that occurred during previous episode of care or outside hospital with subsequent admission.

b. Puerperal complications are those occurring after delivery until 6 weeks

following termination of pregnancy. Fifth digits "2" and "4" will distinguish between immediate (during present episode of care) and delayed puerperal complications/conditions.

c. The ICD-9-CM index will often direct coder to the same fourth-digit code for

complications that are related to pregnancy, childbirth (delivery) and the puerperium. The fifth digits for these categories will indicate the specific status of patient at disposition.

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d.

Categories 647 and 648 are combination codes for nonobstetrical conditions in

obstetrical patients. These conditions are classified elsewhere but will be recorded as complication of pregnancy, childbirth, or the puerperium. When these codes are used, an additional code is required to denote the specific condition. With one exception,

code 648.8

will take precedence in sequencing.

does not require an additional code. The code from categories 647 or 648

e. Categories V22 (Normal Pregnancy) and V23 (Supervision of High Risk

Pregnancy) will be used most often for outpatient care. Codes in V22, Normal pregnancy, are not to accompany any codes in Chapter 11, Complications of Pregnancy, Childbirth, and the Puerperium. The use of V22.2, Pregnant state incidental, is used for a patient whose principal diagnosis is unrelated to and is not complicating the pregnancy. V23 subcategory codes will be used primarily for outpatient care to identify patients whose pregnancy is of a high risk status; for example, teenage pregnancies and pregnancies in women over 40 years old are considered to be high risk in nature and often require close monitoring, even on an inpatient basis.

APPLICATION

Pregnancy and Puerperium Codes

1. Use an additional code with categories 647 and 648 to further describe the

conditions complicating the pregnancy or the puerperium. Any conditions listed in 647 or 648 categories will require multiple coding, but 647 and 648 codes will be sequenced prior to the code for the specified condition. (Note exception to dual coding ( para 2d, above) 648.8 .

EXAMPLE:

DIAGNOSIS: Pregnancy complicated by Sickle-cell Anemia

648.23

282.6Ø

2. Use fifth digit "4" to identify a postpartum condition or complication following delivery

that occurred during previous episode of care or outside hospital with subsequent admission.

EXAMPLE:

DIAGNOSIS: Purulent Mastitis, 3 weeks following delivery

675.14

3. Use V22.2 (Pregnant state, incidental) when patient's cause of admission is not the

pregnancy.

EXAMPLE:

DIAGNOSIS: Meniere's Syndrome, Pregnancy, 16 weeks

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386.ØØ V22.2

3. Deliveries.

a. A large portion of the military services inpatient workload is comprised of

conditions relating to pregnancy, labor, delivery, and the puerperium. Coding personnel should be thoroughly familiar with the sections in chapter 11 used in classifying specific conditions associated with obstetrics; for example:

(1) Categories 64Ø-648 complications mainly related to pregnancy.

(2) Categories 65Ø-659 normal delivery, and other indications of care in pregnancy, labor and delivery.

(3) Categories 66Ø-669 complications occurring mainly in the course of labor and delivery.

(4) Categories 67Ø-676 complications of the puerperium.

b. Category 65Ø (Delivery in a completely normal case) includes only normal,

spontaneous delivery, cephalic (vertex) presentation, of a single full -term live-born infant. An episiotomy or amniotomy may be performed. This code excludes application of forceps or any manipulation to assist delivery. This code excludes stillbirth or multiple births. This code cannot be used in combination with other codes in chapter

11.

c. In assigning codes from the V27 category in conjunction with the 65Ø code,

V27.Ø is the only valid outcome of delivery code which can be used.

d. Subcategory 669.5 (Forceps or Ventouse Delivery without mention of indication)

includes normal delivery of a live fetus, cephalic presentation, with application of low or outlet forceps or vacuum extraction without mention of any complication of labor or delivery. 669.5 is used with mid or high forceps only if the complication necessitating the use of mid or high forceps is not stated.

e. Subcategory 656.4 (Intrauterine Death) includes delivery of a fetal death

(stillbirth) after completion of 20 weeks gestation. The key word in the Alphabetic Index is Intrauterine Death, not stillbirth.

f. Subcategory 644.2 (Early Onset of Delivery) includes premature delivery,

premature labor with onset of delivery and spontaneous delivery of premature infant.

g. Category 651 (Multiple Gestation Delivery).

multiple gestation, either during pregnancy or for delivery.

This code is for use in denoting

h. Outcome of Delivery. The V27 category is to be used to record the outcome of

delivery on the mother's cover sheet. In the Alphabetic Index look for "Outcome of Delivery," which will lead to the V27 category. This V27 category has subcategories to denote live-born and stillborn.

i. In the case of a stillbirth, the appropriate V27 code will be recorded on the

mother's cover sheet, and there will be no separate record made for the stillbirth.

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j. When a delivery is complicated, use as many codes as is necessary to completely describe the complications.

k. For a spontaneous delivery occurring in the hospital, in addition t o the diagnostic

code(s), a procedure (delivery) code will be used. Procedure code 73.59 (other manually assisted delivery) will only be assigned if no other delivery code from category 73-74 is used.

Delivery Codes

APPLICATION

1. Use subcategory 669.5 with mid or high forceps only if the complication

necessitating the mid or high forceps is not stated.

EXAMPLE:

DIAGNOSIS: Delivery, full-term: Live-born infant:

Vertex presentation: Low forceps.

669.51 V27.Ø

2. Use as many codes as necessary to completely describe a complicated delivery.

Record the outcome of delivery.

EXAMPLE:

DIAGNOSIS: Pregnancy, uterine, delivered,male infant, frank breech presentation:

first degree perineal laceration (with hematoma of vulva).

652.21 664.Ø1 664.51 V27.Ø

3. Category 651 will be used with deliveries of multiple births. If, during the same

episode of care, a complication of delivery or an antepartum condition occurs in addition to a postpartum complication, assign fifth digits 1 and 2 respectively, to the codes identifying the complications.

EXAMPLE:

DIAGNOSIS: Intrauterine pregnancy, full-term delivered twins, live -born male infants, postpartum phlebothrombosis, deep

651.Ø1 671.42 V27.2

PRINCIPLE X. PERINATAL MORBIDITY AND MORTALITY

1. The perinatal period is defined as that period occurring before, during, and up to 28

days following birth.

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2.

Conditions specifically classified to Chapter 15 when originating in the perinatal

period must be qualified by such terms as "neonatal" or "of newborn" or transitory in nature.

3. If the same condition occurs in a permanent state in the newborn, it will be coded to

the appropriate category in the main classification.

4. The conditions classified to Chapter 15 include:

a. Conditions in the newborn infant or in an infant in the perinatal period

b. Conditions in any age group that originated in the perinatal period.

5. Categories 76Ø-763 are used to identify maternal conditions that are found to be the

cause of morbidity or mortality in the newborn.

6. Although many of the category titles in Chapter 15 contain the term "maternal" and

appear to refer to the maternal conditions, all the codes in Chapter 15 pertain to the infant identifying the maternal conditions affecting the infant.

7. There are codes in this perinatal category to show gestational maturity. These

codes can be located under terms as immaturity, prematurity, post-term, light-for-dates, and heavy-for-dates.

8. Categories 765 and 766 are not to be used as underlying cause of death if any other

cause of perinatal mortality is reported.

9. Respiratory distress syndrome of newborn may be coded in one of two ways.

Respiratory distress syndrome which is referred to as mild and recovery occurs within 72 hours of birth is coded to 77Ø.6. If respiratory distress syndrome is more severe and recovery is not apparent within the first 72 hours of life, then code to 769.

APPLICATION

1. Use codes from categories 76Ø-763 to identify maternal conditions on the infant's

record that have caused morbidity or mortality in the newborn.

EXAMPLE

DIAGNOSIS: Single, full-term, live-born, male infant Congenital cataracts resulting from antenatal exposure to maternal rubella

V3Ø.Ø 76Ø.2 743.39

2. Conditions originating in the perinatal period qualified as "neonatal" or "of newborn"

are usually transitory and will be coded with the appropriate perinatal code. If the disease occurs in the permanent state in the newborn, code the condition from the main classification.

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EXAMPLE

DIAGNOSIS: Neonatal single, full-term, live-born female infant, transient diabetes mellitus.

V3Ø.Ø 775.1

PRINCIPLE XI. POISONING AND ADVERSE EFFECTS OF DRUGS AND E CODES

1. ICD-9-CM provides codes to differentiate between poisoning and an adverse

reaction to a correct substance properly prescribed and administered correctly. (See principle XIV for poisoning.)

2. The World Health Organization has proposed a definition of an adverse drug

reaction as any response to a drug "which is noxious and unintended and which occurs at doses used in man for prophylaxis, diagnosis, or therapy".

3. Terms frequently used in diagnostic statements to identify adverse drug reaction to

a correct substance properly administered are: accumulative effect, allergic reaction, idiosyncratic reaction, hypersensitivity, paradoxical reaction, and side effects, synergistic reaction and antagonistic drug interactions.

4. Categories E93Ø-E949 provide means to identify the drug responsible for a n

adverse reaction to a substance correctly administered. These E Code subcategories provide the same specificity in identifying the drug involved in causing the adverse reaction as do categories 96Ø-979 in identifying the drug involved in poisoning. Not e that codes 96Ø-979 cannot be used in combination with codes E93Ø-E949. One identifies a substance causing poison, and the other identifies a substance causing an adverse reaction in therapeutic use.

5. The adverse reaction to a correct substance properly administered is classified to

the manifestation or the nature of the adverse reaction, such as gastritis, lymphadenitis, urticaria, psychosis, etc.

6. Two codes are required to code an adverse reaction to a correct substance properly

administered. First code the adverse reaction using a code from ØØ1-799 categories; second, code the drug or substance which caused it, using an E code from the Therapeutic column of the Table of Drugs and Chemicals. If the reaction is unknown, use code 995.2 and the E code.

7. Codes E93Ø-E949 can never be used as a solo code. The adverse reaction code is

always sequenced first. The E code can never be the principal diagnosis.

8. Code 995.2 will be used for unspecified nature of allergic or idiosyncratic reactions

to a correct substance properly administered (drug allergy, NOS). It is provided for those cases in which a code from ØØ1-799 cannot be assigned because the nature of the reaction is not known/stated. In these cases 995.2 is sequenced first, and the E code is an additional code.

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9.

The code 9Ø9.9 entitled "Late effect of other and unspecified external causes" is

provided to code the late effects of a previous adverse reaction the nature of which is not stated. In essence 9Ø9.9 is used to code a late effect in a case which would have been coded to 995.2 if it had been described as a current effect.

10. Chronic effects and delayed effects of drugs.

drugs, such as the accumulative effect of digitalis, are coded as an adverse reaction to a correct substance properly administered. Delayed chronic effects of drugs that occur or are present a long time after the administration of the drug to which the patient developed a reaction are coded as late effects of either poisoning or adverse reaction to correct substance properly administered, depending on the circumstances.

11. Poisoning due to drugs, medicinal substances, and biologicals is defined as

conditions resulting from overdose of these substances or from the wrong substance given or taken in error. Prior to using the table of drugs and chemicals, all coding personnel should read the introduction in volume 2, page 763. Note also the table beginning on page 765. The military hospitals will use only the first column "Poisoning" and the third column "Therapeutic Use" in assigning codes from this table.

Long-term, chronic effects of

a. The column heading "Poisoning" provides codes 96Ø-979 for poisoning,

overdose, wrong drug given or taken, and wrong dosage given or taken, and codes 98Ø-989 for toxic effects of substances chiefly nonmedicinal as to source.

b. The adverse effect in "Therapeutic Use" column is intended to provide the

E Codes for external cause of adverse reactions to a correct substance (drugs, medicinal, and biological substances) properly administered.

12. Categories 96Ø-979 identify the drugs, medicinal substances, and biologicals

causing the poisoning. These codes are found in Volume 2 (Table of Drugs and Chemicals), pages 765-861.

13. If unable to locate the specific drug that caused the poisoning in the table, consult

the index of the American Hospital Formulary Service (AHFS). The numbers assigned the drugs by the AHFS correlate to the code numbers for poisoning in ICD-9-CM (see volume 2, pages 796-802).

14. Physicians use various terms when describing poisoning such as : overdose,

poisoning, toxic effect, wrong dosage given or taken, and wrong drug given or taken. Interactions between any drug and alcohol or between prescribed and over-the-counter drugs are classified as poisonings.

15. To code a poisoning, select a code from the poisoning column of the table of Drugs

and Chemicals. If known, code the reaction/manifestation as an additional code. If a secondary code is used, the code for the poisoning must be sequenced first. Unlike coding an adverse effect, there is no code for an unknown reaction to a poisoning.

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APPLICATION

1. Chronic or long-term effect of drug:

EXAMPLE:

DIAGNOSIS: Cardiac arrhythmia secondary to digitalis intoxication.

427.9 E942.1

2. Delayed or late effect of drug with previous manifestations specified:

EXAMPLE:

DIAGNOSIS: Brain damage secondary to cerebral anoxia 1 year ago, resulting from severe allergic reaction to penicillin.

348.1 E93Ø.Ø

3. Delayed or late effect of adverse reaction without specifying the previous adverse

reaction.

EXAMPLE:

DIAGNOSIS: Brain damage, due to allergic reaction to penicillin 1 year ago.

348.9 909.9 E93Ø.Ø

NOTE: Code 9Ø9.9 is used to denote the cause of the late effect of a previous adverse reaction to a drug only when the nature or manifestation of the previous allergic reaction is not specified.

4. Categories 96Ø-979 identify drugs, medicinal and biological substances causing the

poisoning.

EXAMPLE:

DIAGNOSIS: Overdose, seconal

967.Ø

PRINCIPLE XII. DRUG AND ALCOHOL

1. Definitions of Dependency and Abuse.

It is the responsibility of the physician to

clearly indicate in the diagnostic statement whether the individual is abusing or dependent on the specific substance. To assist coding personnel in determining the correct classification for specific diagnostic statements, the following definitions are provided:

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a. Alcohol dependence syndrome (Alcoholism).

A state, psychic and usually

also physical, resulting from taking alcohol, characterized by behavioral and other responses that always include a compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present.

b. Nondependent abuse of alcohol.

Includes individuals whose use of alcohol

has brought them to medical attention. Nondependent abuse of alcohol is applicable to individuals formerly diagnosed as simple drunkenness cases. It also applies to individuals not suffering from alcoholism whether or not they are intoxicated when seen by a physician, after being referred to him in connection with driving-while-intoxicated charges, altercations involving alcohol, AWOL or absences from work due to overuse of alcohol, or for similar reasons when these individuals may benefit from available rehabilitative services.

c. Drug dependence. A state, psychic and sometimes also physical, resulting

from taking a drug, characterized by behavioral and other responses that always include a compulsion to take a drug on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present. A person may be dependent on more than one drug.

d. Nondependent abuse of drugs.

Includes cases where a person, for whom no

other diagnosis is possible, has come under medical care because of the maladaptive effect of a drug on which he is not dependent and that he has taken on his own initiative to the detriment of his health or social functioning.

2. Overdoses. Overdose cases must include sufficient information so that the

following coding principles may be applied:

a. Drug abuse overdoses. These are usually cases in which an individual

abusing drugs inadvertently takes a dose larger than he can tolerate physiologically. This may happen, for example, when the purity of his usual dose has been increased by the supplier's inclusion of a smaller proportion of cutting material in the product. Or an individual may take his previously accustomed dose after his physiological tolerance has been lowered by a period of abstinence from the drug. The term "overdose" may also be applied to cases of severe reaction, including sudden deaths, when the drug abuser may not have exceeded his usual dose.

b. The cause of admission code in drug abuse overdose cases will be the

appropriate poisoning code from the Poisoning by Drugs, Medicaments, and Biological Substances section of ICD-9-CM (categories 96Ø-979). The appropriate code for drug abuse will be selected from the drug dependence categories (3Ø4) or the Nondependent Abuse of Drugs category (3Ø5) and added as an additional code. The

cause of injury code will be 7Ø-, with third digit from Appendix B of the DOD coding guidelines manual (STANAG 2Ø5Ø). This code is defined as "Poisoning by ingestion of

toxic substance

taken by methods other than ingestion.

" It should also be used for cases in which the toxic substance was

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3.

For diagnosis qualified as "due to" or "secondary to" alcoholism, both the disease

condition and alcohol use (category (3Ø3) will be coded; for example, pancreatitis due to alcoholism will be coded 577.Ø and 3Ø3.9Ø. Use the same principle if disease condition is "due to" or "secondary to" drug abuse. As appropriate also code 9Ø9.Ø (Late effects, poisoning). For some conditions, a combined diagnosis code points to alcoholism as the cause of the disorder or physical complication. In such instances, the use of the one code is sufficient; for example, alcoholic psychosis (category 291) ; alcoholic cirrhosis of liver (571.2) and acute alcohol hepatitis (571.1). However, if alcohol dependence or abuse is associated with the disorder or physical complication, both will be coded.

APPLICATION

Drug and Alcohol

When admission is for both drug abuse and drug dependency, the drug dependency will be the principal diagnosis:

EXAMPLE:

DIAGNOSIS: Cocaine dependence, Marijuana, abuse.

3Ø4.2Ø 3Ø5.2Ø

PRINCIPLE XIII. HEART CONDITIONS AND HYPERTENSION

1. Diseases relating to the circulatory system are difficult to code due to the many

synonymous terms and phrases used by physicians in writing the narrative description of the disease process. The code(s) assigned depends on the words used in the diagnostic statement. Carefully read and adhere to all written codes. The use of codes which classify conditions to "other" or "unspecified" is discouraged.

2. ICD-9-CM provides fourth and fifth digits in many categories specifically relating to

the circulatory system. It is very important to follow the basic coding rule to always locate the condition in the Alphabetic Index and verify in the Tabular List.

3. The alphabetic Index provides a table to classify hypertension whether as a sole

condition or in combination with other disease conditions.

a. To code hypertensive disease, refer to the table on pages 375-377 in Volume 2.

Specificity is provided by the terms malignant, benign, or unspecified.

b. Hypertension when associated with specific heart and renal conditions in a

cause-and-effect linkage are coded to categories 4Ø2, 4Ø3, or 4Ø4 as appropriate. When using specific combination codes involving hypertension with heart and/or renal conditions, the type of hypertension will determine the assignment of the fourth or fifth digit.

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c.

Heart conditions listed in 428, 429.Ø-429.3, 429.8, and 429.9 described as due

to hypertension or hypertensive are coded to the 4Ø2 category. It is important to alert the medical staff of the need to differentiate between (1) hypertensive heart disease and (2) heart disease with nonrelated hypertension.

d. Renal conditions classified to categories 585, 586, or 587 with any condition

classified to category 4Ø1 or described as hypertensive renal disease is coded to the 4Ø3 category.

e. A supplemental code for hypertension is used in addition to the principal code to

completely classify a diagnosis specified as "with hypertension" or "and hypertension."

4. A separate three-digit category 412 is provided to classify the diagnosis "old

myocardial infarction." "Old" is defined as healed, old, or past, as evidenced by history, or diagnosed as a result of an abnormal EKG or other special investigation and currently asymptomatic. This code will never be used as principal diagnosis, but is to be used when appropriate as an additional code.

5. A repeat myocardial infarction occurring during the same period of hospitalization as

that for the acute myocardial infarction is coded to the specific site involved provided the site is different from the previous site; for example, patient admitted with diagnosis of acute myocardial infarction of anterolateral wall (code 41Ø.) and while recovering in the hospital, patient experiences a "repeat myocardial infarction of inferoposterior wall" (code 41Ø.3). Both codes would be used and in the correct sequence as they occurred.

6. The best rule to follow in assigning codes relating to cerebrovascular diseases is

use as many codes as necessary to identify all the component parts of a complex diagnostic statement unless the Alphabetic Index or Tabular List directs otherwise.

a. Conditions classifiable to cerebrovascular disease, codes 43Ø-438, include

those with mention of hypertension. An additional code should be used to identify the hypertension and will follow the CVA-related codes.

b. If the cause for a cerebrovascular accident (CVA) is known, code 436 should not

be used as the principal diagnosis. Review the record, especially CT brain scan reports for causes such as thrombosis, embolism.

c. Conditions resulting from the acute cerebrovascular disease stated as residuals

will be coded as additional codes. If the condition is still present at the time of discharge, it will also be coded as an additional code. If conditions are stated as transient and result from the cerebrovascular disease, omit coding.

d. When coding late effects of cerebrovascular disease, sequence the residual

code first followed by code 438.

7. ICD-9-CM differentiates between the conditions specified as high blood pressure

(hypertension) and elevated blood pressure without a diagnosis of hypertension.

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a. The diagnosis of "high blood pressure" is classified to category 4Ø1 (Ess ential

hypertension).

b. The diagnosis of "elevated blood pressure" without the term "hypertension" is

classified to code 796.2 (elevated blood pressure reading without diagnosis of hypertension).

8. Most cases of chronic valvular heart disease are acquired and due to a previous

attack of acute rheumatic fever (usually unrecognized) resulting in stenosis or incompetence of the valves. The mitral valves are the most commonly affected. In ICD-9-CM, some of these resultant disorders of the mitral valve are classified to the section on rheumatic diseases, while others are not, unless the diagnosis specifies the condition as rheumatic. Disorders of the aortic valve must be specified as rheumatic in order to be classified to section 396. When both the mitral and aortic valves are involved, whether specified or not, the condition is classified to code 396, the section on rheumatic diseases.

9. Ischemic heart disease occurs as a result of the lack of blood flow to the heart due

to partial or complete obstruction of the coronary artery. This disease may be identified by such terms as arteriosclerotic heart disease, coronary ischemia, or coronary artery disease. Sequencing of this disease depends on the reason for admission. When hypertension is present as a secondary condition to ischemic heart disease, sequence the ischemic heart disease before the hypertension code.

10. The diagnosis arteriosclerotic cardiovascular disease (ASCVD) requires two codes.

Code 429.2 identifies the cardiovascular disease but does not identify it as being due to arteriosclerosis (code 44Ø.9). The correct codes for ASCVD are 429.2 and 44Ø.9. The exclusion note under 44Ø.9. should be interpreted as "use additional code" to identify the site of the arteriosclerosis (cardiovascular). It is not specified in code 44Ø.9.

11. When assigning codes to complications of surgical care resulting from surgery, the

"excludes" note under code 997.1 needs clarification of the term "long-term."

a. Subcategory 997.1 classifies cardiac complications that occur during the

immediate postoperative period or during the continuous period of hospitalization in which the surgery was performed.

b. Subcategory 429.4 classifies "long-term" cardiac complications resulting from

cardiac surgery performed during a previous episode of care, regardless of the time- span between the surgery and the complications.

c. Subcategory 997.1 is used also to classify immediate cardiac complications

resulting from any type of procedure. Subcategory 429.4 is used to classify "long-term" cardiac complications resulting from cardiac surgery only. The surgery must have been performed during a previous episode of care.

d. Subcategory 996.4Ø3 is used to classify occlusion of coronary artery bypass

grafts over a period of time (no specific time limits.).

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APPLICATION

Heart Conditions and Hypertension

1. Code the condition(s) resulting from the acute cerebrovascular disease only if stated

to be a residual and is still present at discharge. If conditions are stated to be transient, do not code.

EXAMPLE:

DIAGNOSIS: Left common carotid artery occlusion. Transient ischemic attack

433.1

2. Certain disease conditions classified to the circulatory system are assigned

combination codes (heart, renal, and hypertension) when diagnostic statements clearly indicate a cause-and-effect relationship between the condition(s) and hypertension.

EXAMPLES:

DIAGNOSIS: Congestive heart failure due to hypertensive heart disease

4Ø2.91

DIAGNOSIS: Congestive heart failure with hypertension, essential, benign

428.Ø 4Ø1.1

PRINCIPLE XIV. INJURIES

1. Chapter 17, entitled Injuries and Poisoning, comprise a major section of ICD-9-CM.

Categories 8ØØ-999 include fractures, dislocations, sprains, burns, poisoning, complications of surgical and medical care, and various other types of trauma.

2. Although a number of combination codes are provided for classifying multiple

injuries of the same type (that is, fractures involving more than one anatomical location and burns of multiple sites, etc), the basic coding rule should be followed when possible. The basic coding rule states: "Multiple coding is not used if the classification provides a combination code that fully describes all of the elements of the diagnostic or procedure statement." Injuries classifiable to more than one subcategory should be coded separately whenever possible.

3. ICD-9-CM provides subcategory codes to identify injuries considered to be

complicated for categories 872-897. Burns classified to categories 94Ø-949 do not provide codes at fourth or fifth-digit level to identify complications. Diagnostic statements specifying burns as infected will also use code 958.3 as an additional code.

4. Late Effects of Injuries. Late effects of diseases and injuries are classified to the

condition identifying the residual. An additional code is used to identify the cause of the late effect. (See principle XV.)

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5.

Fractures are classified as open or closed. Coding personnel should review the

descriptions in Volume 1, page 735, that are frequently used in diagnostic statements that identify fractures as open or closed. Fractures not specified as open or closed are coded as closed.

6. Categories 94Ø-949 are provided for coding burns whether from chemicals or other

causes. Burns of the same anatomical site but of different degrees should be coded to the appropriate subcategory identifying the most severe degree. If a burn is stated to be infected, in addition to the code(s) used to identify the burn, also use code 958.3 to identify the infection.

a. Category 948 is used to classify burns according to percent of body surface

involved. This category is primarily designed for use as an additional code with categories 94Ø-947 to indicate the percent of body surface involved. It may be used as a solo code when the site of the burn is not specified, but the percentage of body surface involvement is specified.

b. Category 948 is unique in the coding structure. This category is designed to be

used as a subcategory fourth-digit code or as a subclassification fifth-digit code whichever is applicable. The fourth digit will be used to indicate total percent of body surface burn. The fifth digit is for percent of body surface of third -degree burn. The military coders will always assign a fifth digit when using this category. If the total percent of body surface is specified and there is no percentage for third -degree burn or the percent for third-degree burn is less than 10 percent, use the fifth digit "Ø."

7. Cause of injury codes for any condition coded with codes 692.71, 8ØØ-999, V713-

V716, and E93Ø-E949 codes will be taken from STANAG 2050. See Appendix B of

Triservice Disease and Procedure Coding Guidelines, ICD--9-CM , dated 1 January

1991.

8. Sequencing of Injuries.

a. Multiple injuries: the most severe or life-threatening injury is the principal

diagnosis.

b. If injuries are of equal importance, the principal diagnosis is the one for which a

definitive surgical or nonsurgical procedure is performed.

APPLICATION

1. Multiple coding is not used if the classification provides a combination code fully

describing all elements of the diagnostic or procedure narrative.

EXAMPLE:

DIAGNOSIS: Closed fracture of right radius and ulna

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813.83

2.

CD-9-CM provides subcategory codes to identify injuries considered to be

complicated for categories 872-879. Burns classified to categories 94Ø-949 do not provide codes at fourth- or fifth-digit level to identify complications; therefore, diagnostic statements specifying burns as infected will require two or more codes.

EXAMPLES:

DIAGNOSIS: Laceration of right upper arm with delayed healing

88Ø.13

DIAGNOSIS: Third-degree burn, left forearm, infected

943.31 958.3

3. Category 948 is used to classify burns according to percent of body surface

involved. Military coders will use the fifth digit "Ø" for percent of body surface with no third-degree burn or third-degree burn of less than 10 percent.

EXAMPLES:

DIAGNOSIS: Third-degree burn to face, neck, and chest,

946.3 948.22

23

percent of body surface

DIAGNOSIS: Second-degree burn to face, neck, and chest,

946.2 948.2Ø

23 percent of body surface

PRINCIPLE XV. LATE EFFECTS

1. Late effects are those inactive residual effects of indefinite duration after termination

of the acute phase of the illness or injury. The term "late effect" includes those conditions/residuals specified as:

a. Late.

b. Due to an old injury.

c. Due to a previous illness or injury.

d. Due to an injury or illness that occurred 1 year or more ago.

NOTE: The 1 year or more is not a hard, fast rule. If sufficient time has elapsed between the acute phase of the illness or injury and the development of a residual, then disregard the 1-year rule.

2. Late effects are classified by the residuals and by the cause of the late effect. The

late-effect code can never be used as the principal diagnosis. Also the late -effect code can never be the cause for disability separation or failure to meet entrance standards.

3. Categories to identify the cause of the late effect are 137, 138, 139, 268.1, 326, 438,

and 905 through 909. As previously stated, these codes can never be used as principal diagnosis or as medical reasons for disability separation. They will always be used as additional codes when applicable.

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4.

Conditions frequently described in diagnostic statements as residuals and late

effects are:

a. Malunion fracture.

b. Traumatic arthritis following fracture.

c. Hemiplegia, cerebrovascular thrombosis 1 year ago.

d. Scarring due to third-degree burn.

e. Contracture tendons due to poliomyelitis.

f. Sterility due to mumps.

5. When coding a late effect of an illness or injury and a code for both the residual and

the late effect are provided, the code for the residual must be sequenced first with the appropriate code to show cause (late effect) as an additional code.

APPLICATION

Both the residual and the late effect must be coded. The code for the residual is sequenced first.

EXAMPLE:

DIAGNOSIS: Nonunion of left ulna due to fracture 8 months ago

733.82 905.2

PRINCIPLE XVI. ORGAN AND TISSUE TRANSPLANTS

1. Potential Donor. Patients are sometimes admitted for predonation examination to

determine tissue compatibility prior to organ/tissue donation. These patients are potential organ/tissue donors and are coded with the diagnostic code V7Ø.8 (Examination of potential donor). This code indicates the patient is not serving as a donor during the current episode of hospitalization, and therefore, the record would not have a procedure code for organ/ tissue removal.

2. Donor. Category V59 (Donor) is to be used for patients who serve as organ/tissue

donor during the current continuous period of hospitalization. The admission diagnosis is Organ/Tissue Donor (specific type) and requires an appropriate subcategory code from the V59 category. Use of any V59 subcategory code indicates the patient did serve as an organ/tissue donor and therefore, the record requires a surgical procedure code indicating organ/ tissue removal.

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3.

The V7Ø.8 (Examination of potential donor) code will not be used on the same

record as the V59 (Donor) category code.

4. Initial Transplant Recipient.

Patients admitted for an injury or chronic disease

process necessitating an initial organ/tissue transplant will have that condition coded as the principal diagnosis. An additional subcategory code from the V42 (Organ or tissue replaced by transplant) category will be used as an additional code to indicate the specific organ/tissue transplanted. The recipient's surgical procedure indicating the organ/tissue transplanted will always be indicated and coded as the principle procedure.

When an admission occurs due to a

complication and/or rejection of a previously transplanted organ/tissue, the cause of admission code is selected from the 996.8 through 996.99 subcategories and used as the principal diagnosis. An additional code from category V42 (Organ or tissue replaced by transplant) is required to denote the specific organ involved.

5. Recipient Complications and/or Rejections.

6. Follow-up. At specified intervals transplant patients are admitted solely for

examination and testing. When the admission is solely for follow -up care (status post with no complication) code V67Ø will be the principal diagnostic code. A code from the V42 category is selected to indicate the organ or tissue replaced by transplant. The disease process (or injury) which led to the initial transplant will not be coded.

7. All subcategory codes in the V42 (Organ or tissue replaced by transplant) category

are status codes to indicate the presence of a transplanted organ/tissue.

APPLICATION

1. A surgical procedure for organ/tissue removal is not appropriate with the

predonation examination for tissue compatibility diagnosis.

EXAMPLE:

DIAGNOSIS: Examination of potential kidney donor

V7Ø.8

2. The organ donor requires a diagnostic code to indicate the specific organ donated

and a surgical procedure code for the specific organ/tissue removed.

EXAMPLE:

DIAGNOSIS: Kidney donor

V59.4

PROCEDURE: Total nephrectomy, right

55.51

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3.

An initial transplant recipient requires the diagnosis necessitating the transplant be

coded as the principal diagnosis and an additional diagnostic code from category V42 to denote the specific organ/tissue transplanted. The principal surgical procedure will be the specific organ/tissue transplanted.

EXAMPLE:

DIAGNOSIS: End state renal disease

585.Ø V42.Ø

PROCEDURE: Renal transplant

55.69

4. Use a subcategory code from 996 category to show cause of admission for rejection

and/or complication of organ transplant, and an additional code from V42 category to show specific organ transplanted and now causing rejection.

EXAMPLE:

DIAGNOSIS: Rejection of cadaver kidney transplant

996.8 V42.Ø

5. An admission solely for follow-up of organ/tissue transplant will have code V67.0 as

the principle diagnosis.

EXAMPLE:

DIAGNOSIS: Status post renal transplant follow-up PROCEDURE: Transplant done 6 months ago for end stage renal disease

V67.Ø V42.Ø

PRINCIPLE XVII. AIDS AND HIV INFECTIONS

1. AIDS AND HIV. AIDS is an acronym for Acquired Immunodeficiency Syndrome.

HIV is an acronym for Human Immunodeficiency Virus. The spectrum of HIV infections can be divided into three categories:

a. Ø42 - HIV infection with specified secondary infections and malignant

neoplasms.

b. Ø43 - HIV infection with other specified manifestations in the absence of either

specified secondary infections or malignant neoplasms.

c. Ø44 - Other HIV infections not classifiable above.

2. Code Category. The selection of the appropriate Ø42-Ø44 code is determined

solely by the terminology used for the HIV infection. Codes Ø42, Ø43, and Ø44 are mutually exclusive and only one code from the Ø42-Ø44 series should be used on the same record. This code may change on subsequent admissions. Priority is given to Ø42 over Ø43 and Ø44; Ø43 is given priority over Ø44.

MD0753

A-48

3.

Manifestations. The manifestations of the HIV infection should be clearly identified

in order to select the appropriate code. Use the alphabetical table provided in the ICD- 9-CM addendum as an index to assist in the selection of the most appropriate code for the infection and any associated manifestation(s).

a. The term "with" implies that the condition or manifestation of HIV infection need

only be listed on the record. Terms such as "and" and "in association with" will be considered in the same manner as "with."

EXAMPLES:

DIAGNOSES: Acute lymphadenitis with AIDS, Stage 3

Kaposi's sarcoma associated with AIDS, Stage 6

Burkitt's tumor, Stage 6

AIDS-like disease, Stage 4

683, Ø42.9, 795.8--3

173, Ø42,2, 795.8--6

2ØØ.2, Ø42.2, 795.8--6

Ø43.9, 795.8--4

b. The term "due to" denotes a causal relationship. The physician must state the

relationship between HIV infections and other conditions.

EXAMPLES:

DIAGNOSES: Dementia due to HIV infection, Stage 5

298.9, Ø43.1, 795.8--5

Acquired immunodeficiency syndrome, Stage 6

Disseminated candidiases caused by AIDS, Stage 6

Ø42.9, 795.8--6

112.5, Ø42.1, 795.8--6

4. HIV Code Extenders. To accommodate the DRG groupers and still retain the

specificity required by DOD to identify the progressive stage of an HIV infection, the following "stage" code extenders are available:

795.8— 1 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 1.

795.8— 2 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 2.

795.8— 3 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 3.

795.8— 4 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 4.

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795.8— 5 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 5.

795.8— 6 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 6.

795.8— 9 Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage unspecified or unknown.

5. Sequencing.

a. The principal diagnosis would be selected based on the individual discharge.

The HIV infection codes can be used as either a principal or other diagnosis. The note "with" and "due to HIV infection" do not imply sequencing.

b. A manifestation associated with an HIV infection, when found after study to have

been chiefly responsible for the hospitalization, is coded as the principal diagnosis. This is followed than by one of the Ø4 . subcategory codes and appropriate stage code. (NOTE: Except for Stage 1 and unspecified, Stage 9).

c. When there is no manifestation, code the HIV infection using as principal

diagnosis one of the Ø4 . codes with the appropriate stage code. The Ø4 . code will be the principal diagnosis.

d. Follow-up Examination. Patients with positive HIV are seen at regular intervals

for follow-up examination; these cases should be coded as follows:

(1) For patients who have an identified manifestation at the end of the hospital stay, code the manifestation and appropriate Ø4 . subcategory code. The manifestation is selected as the principal diagnosis. The V67. code for follow-up is unnecessary. Code also the appropriate stage code.

(2) For patients who demonstrate no obvious manifestation, code V67. with the appropriate stage code and the appropriate Ø4 .Ø code. The follow-up V67. will be the principal diagnosis.

e. HIV stage codes are usually additional codes. They may be the principal

diagnosis or sole diagnosis only in the following circumstances:

(1) HIV Stage Unspecified (795.8--9) can be used when the patient has been identified as HIV positive serology, and is en route for evaluation and staging. It may occasionally represent a nonmilitary inpatient for whom no staging has been done.

(2) HIV Stage 1 (795.8--1) can be used when the patient has been so staged and demonstrates no manifestations.

f. Laboratory examination.

Previous codes in this category are no longer used.

(1) The V72.6- serology codes (four DOD-unique) are for use only; for outpatients. We have deleted the V72.6- for inpatients but must leave the system intact for the outpatient US active duty data base. That system collects negative as well as positive serologies to accommodate the complete formula for rates and percentages.

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(2) There should be no code for false positive on inpatient records . Because we require two Elisa and a Western Blot before a diagnosis is made, the chances of a false positive are negligible.

(3) For hospital inpatients, there will be no need for a diagnosis or code on the medical record face sheet to reflect "negative serology - HIV." We do not diagnose or code other negative laboratory findings; there is no need to do so with HIV.

APPLICATION

1. The manifestation chiefly responsible for the hospitalization is the principal

diagnosis and is sequenced first, followed by the Ø4 . HIV infection code. Code also all other manifestations and the stage code.

DIAGNOSES: HIV Dementia

AIDS, Stage 6

Candida Esophagitis

EXAMPLE:

Ø42.9

112.8Ø

298.9

2. When a patient is admitted for a follow-up examination, code to V67.59 and code

the stage of infection.

EXAMPLE:

DIAGNOSES: Follow-up exam

V67.59

HIV Antibody Positive, Stage 2

795.8--2

3. When hospitalization is for a condition unrelated to the HIV infection, that condition

is the principal diagnosis.

EXAMPLE:

DIAGNOSES: Closed Head Injury, MV

Bladder Contusion

Fracture, Closed, Right Acetabulum

HIV Infection

HIV Positive, Stage 1 of Infection

Ø44.9

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867.Ø

854.Ø

8Ø8.Ø

795.8--1

PRINCIPLE XVIII. SPECIAL DIAGNOSIS

1. Viral (Infectious) Hepatitis.

a. The code numbers in ICD-9-CM for viral hepatitis will be used. However, to

provide greater specificity for DOD use, this category has been expanded by use of DOD code extenders, which are included in Appendix A of the Triservice Disease and Procedure Coding Guidelines, dated 1 January 1991.

b. There is no longer a requirement to denote drug use/nonuse when coding

hepatitis conditions.

c. Post-transfusion hepatitis will be coded 999.8 and Ø7Ø.3--1.

d. Post-vaccination hepatitis will be coded 999.9 and Ø7Ø.3--1.

2. Diabetes Mellitus.

a. Category 25Ø is used to classify diabetes mellitus. Fourth-digit classifications

are used to identify the presence of coma or systemic manifestations. The fifth-digit subclassifica-tion will specify the type of diabetes. When the physician does not specify the type of diabetes, a fifth digit of "Ø" is assigned.

Fifth-digit subclassifications:

Ø -- Adult onset and NOS (AODM) Noninsulin Dependent Diabetes (NIDDM) Maturity Onset Diabetes (MODM) Type II Diabetes

1 -- Juvenile type (JODM) Insulin Dependent Diabetes (IDDM) Adult Onset with Insulin Dependence Type I Diabetes

b. To use the fifth digit of "1," insulin dependent must be noted somewhere in the

medical record or as part of the stated final diagnosis. Do not assume a patient has insulin dependent diabetes simply because the patient is receiving insulin. Sometimes Type II diabetics require temporary use of insulin when they are hospitalized for surgery or other illness. Consult the physician for clarification in such cases.

c. System Manifestations.

(1) Categories 25Ø.4-25Ø.8 are used to classify diabetes with systemic manifestations, which represent a cause and effect relationship with the diabetes. These codes are presented together as an inseparable pair in the Alphabetic Index. These paired codes are sequenced so that the underlying cause (diabetes) is always positioned first and followed by the manifestation code.

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(2) The physician should specify in the diagnosis that the condition is diabetic or due to diabetes; otherwise, it is presumed not to be caused by diabetes.

NOTE: An exception is diabetic gangrene or diabetes with gangrene leads the coder to the code denoting diabetes as the underlying cause of the gangrene, 25Ø.7Ø [785.4].

d. Uncontrolled diabetes.

Diabetes described as brittle or uncontrolled is to be

interpreted as diabetes mellitus, complicated. Brittle diabetes mellitus is difficult to control because of rapid fluctuation in the blood sugar. Brittle diabetes mellitus may occur in either the juvenile or the adult-onset type.

ICD-9-CM CODE EXTENDERS

Add these codes to the indicated categories in ICD-9-CM, Volume 1. These codes are to be used with records having a date of disposition on or after 1 January 1989.

Ø4Ø89— Ø Toxic shock syndrome Ø4Ø89— 9 Other specified bacterial diseases, excluding toxic shock syndrome

Ø7ØØ— Ø Viral hepatitis A with hepatic coma, lab test confirmed

Ø7ØØ— 1

Viral hepatitis A with hepatic coma, lab test not reported or negative

Ø7ØØ— 2

Viral hepatitis A with hepatic coma, lab test notperformed

Ø7Ø1— Ø

Viral hepatitis A without mention of hepatic coma, lab test confirmed

Ø7Ø1— 1

Viral hepatitis A without mention of hepatic coma, lab test not reported or

Ø7Ø1— 2

negative Viral hepatitis A without mention of hepatic coma, lab test not performed

Ø7Ø2— Ø

Viral hepatitis B with hepatic coma, lab test confirmed

Ø7Ø2— 1

Viral hepatitis B with hepatic coma, lab test not reported or negative

Ø7Ø2— 2

Viral hepatitis B with hepatic coma, lab test not performed

Ø7Ø3— Ø

Viral hepatitis B without mention of hepatic coma, lab test confirmed

Ø7Ø3— 1

Viral hepatitis B without mention of hepatic coma, lab test not reported or

Ø7Ø3— 2

negative Viral hepatitis B without mention of hepatic coma, lab test not performed

Ø7Ø4— 3

Non A, Non-B hepatitis with hepatic coma

Non A, Non-B hepatitis without mention of hepatic coma

Ø7Ø4— 9

Other specified viral hepatitis, excluding Non-A, Non-B hepatitis, with

Ø7Ø5— 3

hepatic coma

Ø7Ø5— 9

Other specified viral hepatitis, excluding Non-A, Non-B hepatitis, without

Ø888— Ø

mention of hepatic coma

Ø888— 9

Lyme disease Other specified arthropod-borne diseases, excluding Lyme's disease

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A-53

4461— Ø

Kawasaki disease

Legally induced abortion, elective

4461— 9

Acute febrile mucocutaneous lymph node syndrome (MCLS), excluding

635xx— Ø

Kawasaki disease

635xx— 1

Legally induced abortion, therapeutic

635xx— 9

Legally induced abortion, unspecified

638x— Ø

Failed attempted abortion, elective

638x— 1

Failed attempted abortion, therapeutic

638x— 9

Failed attempted abortion, unspecified

6542— Ø

Uterine scar from previous cesarean section

6542— 9

Uterine scar from previous surgery, excluding previous cesarean section

7958— 1

Positive serological or viral cu lture findings for human immunodeficiency virus (HIV), stage 1

7958— 2

Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 2

7958— 3

Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 3

7958— 4

Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 4

7958— 5

Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 5

7958— 6

Positive serologic al or viral culture findings for human immunodeficiency virus (HIV), stage 6

7958— 9

Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage unspecified or unknown

V714— Ø

Observation following other accident, head injury ruled out

V714— 9

Observation following other accident, excluding head injury

V716— Ø

Observation following other inflicted injury, head injury ruled out

V716— 9

Observation following other inflicted injury, excluding head injury

7958— 2

Positive serological or viral culture findings for human immunodeficiency virus (HIV), stage 2

MD0753

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APPLICATION

1. Use the DOD code extenders when coding hepatitis conditions.

EXAMPLE:

DIAGNOSIS: Hepatitis B, no lab confirmation and no coma

2. Diabetes mellitus. Use fifth digits to denote insulin dependent or noninsulin

depending; use the fourth digits to denote complications and/or manifestations.

Ø7Ø.3--1

EXAMPLES:

DIAGNOSIS: Diabetes mellitus, juvenile, brittle

25Ø.41

DIAGNOSIS: Diabetic nephropathy

583.81

3. When diabetes mellitus is specified as brittle on uncontrolled, assign the code

identifying the specific complication present ; if any is stated. Otherwise, assign 25Ø.9- with the appropriate fifth-digit code.

EXAMPLES:

DIAGNOSIS: Diabetes mellitus, uncontrolled; ketoacidosis

25Ø.1Ø

DIAGNOSIS: Diabetes mellitus, brittle

25Ø.9Ø

MD0753

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APPENDIX B - EXCERPTS FROM VOLUME I International Classification of Diseases, 9th Revision, Clinical Modification

TABULAR LIST

117.8 Infection by dematiacious fungi, [ Phaehyphomyocsis] Infection by dematiacious fungi, such as Cladosporium trichoides [bantianum], Dreschlera hawaiiensis, Phialophora gougerotii, Phialophora jeanselmi

117.9 Other and unspecified mycoses

118

Opportunistic mycoses Infection of skin, subcutaneous tissues, and/or organs by a wide variety of fungi generally considered to be pathogenic to compromised hosts only (e.g., infection by species of Alternaria, Dreschlera, Fusarium)

HELMINTHIASES (120-129)

120

Schistosomiasis [bilharziasis]

120.0

Schistosoma haematobium Vesical schistosomiasis NOS

120.1

Schistosoma mansoni Intestinal schistosomiasis NOS

120.2

Schistosoma japonicum Asiatic schistosomiasis NOS Katayama disease or fever

120.3

Cutaneous Cercarial dermatitis Infection by cercariae of Schistosoma

Schistosome dermatitis Swimmers' itch

120.8

Other specified schistosomiasis Infection by Schistosoma:

Infection by Schistosoma

bovis

spindale

intercalatum

Schistosomiasis

mattheii

chestermani

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B-1

NEOPLASMS

154.3

Anus, unspecified

 
 

Excludes:

anus:

 

margin (172.5, 173.5) skin (172.5, 173.5) perianal skin (172.5, 173.5)

154.8

Other Anorectum Cloacogenic zone Malignant neoplasm of contiguous or overlapping sites of rectum, rectosigmoid junction, and anus whose point of origin cannot be determined

155 Malignant neoplasm of liver and intrahepatic bile ducts

155.0 Liver, primary Carcinoma:

liver, specified as primary hepatocellular liver cell Hepatoblastoma

155.1 Intrahepatic bile ducts Canaliculi biliferi Interlobular:

bile ducts

biliary canals

Intrahepatic biliary passages canaliculi gall duct

Intrahepatic biliary passages canaliculi gall duct
Intrahepatic biliary passages canaliculi gall duct

Excludes:

hepatic duct (156.1)

155.2 Liver, not specified as primary or secondary

156 Malignant neoplasm of gallbladder and extrahepatic bile ducts

156.0 Gallbladder

156.1 Extrahepatic bile ducts Biliary duct or passage NOS Common bile duct

MD0753

Cystic duct Hepatic duct Sphincter of Oddi

B-2

NERVOUS SYSTEM AND SENSE ORGANS

380.4

Impacted cerumen Wax in ear

380.5

Acquired stenosis of external ear canal Collapse of external ear canal

380.50 Acquired stenosis of external ear canal, unspecified as to cause

380.51 Secondary to trauma

380.52 Secondary to surgery

380.53 Secondary to inflammation

380.8

Other disorders of external ear

380.81

Exostosis of external ear canal

380.89

Other

380.9

Unspecified disorder of external ear

381 Nonsuppurative otitis media and Eustachian tube disorders

381.0 Acute nonsuppurative otitis media Acute tubotympanic catarrh Otitis media, acute or subacute:

Excludes:

catarrhal

exudative

transudative

with effusion

otitic barotrauma (993.0)

381.00 Acute nonsuppurative otitis media, unspecified

381.01 Acute serous otitis media Acute or subacute secretory otitis media

381.02 Acute mucoid otitis media Acute or subacute seromucinous otitis media Blue drum syndrome

MD0753

B-3

RESPIRATORY SYSTEM

485 Bronchopneumonia, organism unspecified

Bronchopneumonia:

Pneumonia:

hemorrhagic

lobular

terminal

segmental

Pleurobronchopneumonia

Excludes:

bronchiolitis (acute) (466.1) chronic (491.8) lipoid pneumonia (507.1)

486 Pneumonia, organism unspecified

487 Influenza

Excludes:

hypostatic or passive pneumonia (514) influenza with pneumonia, any form (487.0) inhalation or aspiration pneumonia due to foreign materials (507.0-507.8) pneumonitis due to fumes and vapors (506.0)

Excludes:

hemophilus influenzae [H.influenzae]:

infection NOS (041.5) larygitis (464.0) meningitis (320.0) pneumonia (482.2)

487.0

With pneumonia Influenza with pneumonia, any form Influenzal:

bronchopneumonia

pneumonia

487.1

With other respiratory manifestations Influenza NOS Influenzal:

laryngitis pharyngitis respiratory infection (upper) (acute)

487.8

With other manifestations Encephalopathy due to influenza Influenza with involvement of gastrointestinal tract

MD0753

Excludes:

"intestinal flu" [viral gastroenteritis] (008.8)

B-4

CONDITIONS IN THE PERINATAL PERIOD

773.3 Hydrops fetalis due to isoimmunization

Use additional code, if desired, to identify type of isoimmunization (773.0-773.2)

773.4 Kernicterus due to isoimmunization

Use additional code, if desired, to identify type of isoimmunization (773.0-773.2)

773.5 Late anemia due to isoimmunization

774 Other perinatal jaundice

774.0 Perinatal jaundice from hereditary hemolytic anemias

Code also underlying disease (282.0-282.9)

774.1 Perinatal jaundice from other excessive hemolysis Fetal or neonatal jaundice from:

brusing drugs or toxins transmitted from mother infection polycythermia swallowed maternal blood

Use additional code, if desired, to identify cause

Excludes:

jaundice due to isoimmunization (773.0-773.2)

774.2 Neonatal jaundice associated with preterm delivery Hyperbilirubinemia or prematurity Jaundice due to delayed conjugation associated with preterm delivery

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B-5

SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS

782.6 Pallor and flushing

782.61 Pallor

782.62 Flushing Excessive blushing

782.7 Spontaneous ecchymoses Petechiae

Excludes:

ecchymosis in fetus or newborn (772.6) purpura (287.0-287.9)

782.8 Changes in skin texture Induration Thickening

}

of skin

782.9 Other symptoms involving skin and integumentary tissues

783 Symptoms concerning nutrition, metabolism, and development

783.0 Anorexia Loss of appetite

Excludes:

anorexia nervosa (307.1) loss of appetite of nonorganic origin (307.59)

783.1 Abnormal weight gain

Excludes:

excessive weight gain in pregnancy (646.1) obesity (278.0)

783.2 Abnormal loss of weight

783.3 Feeding difficulties and mismanagement Feeding problem (elderly) (infant)

MD0753

Excludes:

feeding disturbance or problems:

in newborn (779.3) of nonorganic origin (307.50-307.59)

B-6

TABULAR LIST

783.4

783.5

783.6

Lack of expected normal physiological development

Delayed milestone

Failure to gain weight

Failure to thrive

Lack of growth Physical retardation Short stature

Excludes:

delay in sexual development and puberty

(259.0)

specific delays in mental development

Polydipsia Excessive thirst

(315.0-315.9)

Polyphagia Excessive eating Hyperalimentation NOS

783.9

Excludes:

disorders of eating of nonorganic origin (307.50-307.59)

Other symptoms concerning nutrition, metabolism, and development Hypometabolism

Excludes:

abnormal basal metabolic rate (794.7) dehydration (276.5) other disorders of fluid, electrolyte and acid-base balance (276.0-276.9)

784 Symptoms involving head and neck

Excludes:

784.0 Headache

Facial pain

Excludes:

encephalopathy NOS (348.3) specific symptoms involving neck classifiable to 723 (723.0-723.9)

Pain in head NOS

atypical face pain (350.2) migraine (346.0-346.9) tension headache (307.81)

MD0753

B-7

SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS

784.1 Throat pain

Excludes:

dysphagia (787.2) neck pain (723.1) sore throat (462) chronic (472.1)

784.2 Swelling, mass, or lump in head and neck Space-occupying lesion, intracranial NOS

784.3 Aphasia

Excludes:

784.4 Voice disturbance

developmental aphasia (315.31)

784.40

Voice distubrance, unspecified

784.41

Aphonia Loss of voice

784.49

Other

Change in voice

Hypernasality

Dysphonia Hoarseness

Hyponasality

784.5 Other speech distubance Dysarthria Dysphasia

Slurred speech

MD0753

Excludes:

stammering and stuttering (307.0) that of nonorganic origin (307.0, 307.9)

784.6 Other symbolic dysfunction

Excludes:

developmental learning delays (315.0-315.9)

784.60

Symbolic dysfunction, unspecified

784.61

Alexia and dyslexia Alexia (with agraphia)

784.69

Other

Acalculia

Agraphia NOS

Agnosia

Apraxia

B-8

APPENDIX C – EXCERPTS FROM VOLUME 2 International Classification of Diseases, 9 th Revision, Clinical Modification

INDEX TO DISEASES

Anthropophobia

Anomaly, anomalous (congenital) (unspecified type) – continued

 

Anoxia continued intrauterine – continued liveborn infant – see Distress, fetal,

vitreous humor

743.9

specified type NEC

743.51

vulva

752.40

liveborn infant myocardial – see Insufficiency, coronary, newborn 768.9 mild or moderate (Apgar score 4-7)

wrist (joint)

755.50

 

Anomia 784.69

Anonychia 757.5

Acquired

703.8

 

768.6

Anophthalmos, anophthalmus (clinical)

severe (Apgar score 0-3)

768.5

 

(congenital) (globe)

743.00

 

pathological

799.0

acquired

360.89

Anteflexion see Anteversion

Anopsia (altitudinal) (quadrant ) 368.46

Antenatal

Anorchia 752.8 Anorchism, anorchidism 752.8 Anorexia 783.0

 

care, normal pregnancy first V22.0

V22.1

 

screening (for)

V28.9

hysterical

300.11

based on amniocentesis NEC

V28.2

nervosa

307.1

chromosomal anomalies

V28.0

Anosmia (see also Disturbance, sensation)

raised alphafetoprotein levels

V28.1

781.1

chromosomal anomalies

V28.0

hysterical

300.11

fetal growth retardation using

postinfectional 478.9

   

ultrasonics

V28.4

psychogenic

306.7

isoimmunization V28.5 malformations using ultrasonics

 

traumatic

951.8

V28.3

Anosognosia 780.9

 

raised alphafetoprotein levels in

Anosphrasia 781.1

 

amniotic fluid

V28.1

Anosteoplasia 756.50 Anotia 744.09 Anovulatory cycle 638.0 Anoxemia 799.0

specified condition NEC Antepartum.--.see condition Anterior see also condition

spinal artery compression syndrome 721.1 Antero-occlusion 524.2 Anteversion cervix (see also Anteversion, uterus)

V28.8

newborn

770.8

Anoxia 799.0

 

altitude

993.2

cerebral

348.1

621.6

 

with

femur (neck), congenital 755.63

 

abortion – see Abortion, by type, with specified complication NEC ectopic pregnancy (see also categories

uterus, uterine (cervix) (postinfectional)

(postpartal, old)

621.6

 

congenital 752.3

633.0-633.9)

639.8

in pregnancy or childbirth

654.4

molar pregnancy (see also categories

763.8

630-632)

639.8

affecting fetus or newborn causing obstructed labor

660.2

complicating

   

affecting fetus or newborn

763.1

 

delivery (cesarean) (instrumental)

Anthracosilicosis (occupational) 500

669.4

Anthracosis (lung) (occupational) lingua 529.3

Anthrax

022.9

500

ectopic or molar pregnancy 639.8 obstetric anesthesia or sedation 668.2 during or resulting from a procedure

with pneumonia

022.1 [484.5]

 

997.0

colitis 022.2

following

 

cutaneous 022.0

 

abortion 639.8

gastrointestinal 022.2

ectopic or molar pregnancy newborn (see also Distress, fetal, liveborn infant) 768.9

639.8

intestinal 022.2

pulmonary 022.1

respiratory 022.1

due to drowning

994.1

 

septicemia 022.3

heart – see Insufficiency, coronary

specified manifestation NEC

022.8

high altitude

993.2

 

Anthropoid pelvis

755.69

 

intrauterine

with disproportion (fetopelvic)

653.2

 

fetal death (before onset of labor) 768.0

763.1

during labor

768.1

affecting fetus or newborn causing obstructed labor

660.1

 
 

affecting fetus or newborn

763.1

Anthropophobia

300.29

MD0753

C-1

INDEX TO DISEASES

Jaundice

Jaccoud's nodular fibrositis, chronic (Jaccoud's syndrome) 714.4 Jackson's membrane 751.4 paralysis or syndrome 344.8 veil 751.4 Jacksonian epilepsy 345.5 seizures (focal) 345.5 Jacob's ulcer (M8090/3)--see Neoplasm, skin, malignant, by

site

Jacquet's dermatitis (diaper dermatitis) 691.0 Jadassohn's blue nevus (M8780/0--see Neoplasm, skin, benign disease (maculopapular erythroderma) 696.2 intraepidermal epithelioma (M8096/0)

-- see Neoplasm, skin, benign

Jadassohn-Lewandowski syndrome (pachyonychia congenita) 757.5 Jadassohn-Pellizari's disease (anetoderma).701.3 Jadassohn-Tieche nevus (M8780/0— see Neoplasm, skin, benign Jaffe-Lichtenstein (-Uehlinger) syndrome 252.0 Jahnke's syndrome (encephalocutaneous angiomnatosis) 759.6 Jakob-Creutzfeldt disease or syndrome 046.1 with dementia 290.10 Jaksch (-Luzet) disease or syndrome (pseudoleukemia infantum) 285.8 Jamaican neuropathy 349.82 paraplegic tropical ataxic-spastic syndrome 349.82 Janet's disease (psychasthenia) 300.89 Janiceps 759.4 Jansky-Bielschowsky amaurotic familial idiocy 330.1 Japanese B type encephalitis 062.0 river fever 081.2 seven-day fever 100.89 Jaundice (yellow) 782.4 acholuric (familial) ( splenomegalic) (see also Spherocytosis)

282.0

acquired 283.9 breast milk 774.39 catarrhal (acute) 070.1

with hepatic coma 070.0

MD0753

J

C-2

Jaundice (yellow)--continued catarrhal (acute)--continued chronic 571.9 epidemic--see Jaundice, epidemic cholestatic (benign) 782.4 chronic idiopathic 277.4 epidemic (catarrhal) 070.1 with hepatic coma 070.0 leptospiral 100.0 spirochetal 100.0 febrile (acute) 070.1 with hepatic coma 070.0 leptospiral 100.0 spirochetal 100.0 fetus or newborn 774.6 due to or associated with ABO antibodies 773.1 incompatibility, maternal/fetal 773.1 isoimmunization 773.1 absence or deficiency of enzyme system for bilirubin conjugation (congential) 774.39 blood group incompatibility NEC 773.2 breast milk inhibitors to conjugation 774.39 associated with preterm delivery 774.2 bruising 774.1 Crigler-Najjar syndrome 277.4 [774.31] delayed conjugation 774.30 associated with preterm delivery 774.2 development 774.39 drugs or toxins transmitted from mother 774.1 G-6-PD deficiency 282.2 [774.0] galactosemia 271.1 [774.5] Gilbert's syndrome 277.4 [774.31] hepatocellular damage 774.4 hereditary hemolytic anemia (see also Anemia, hemolytic) 282.9 [774.0] hypothyroidism, congential 243 [774.31] incompatibility, maternal/fetal NEC 773.2 infection 774.1 inspissated bile syndrome 774.4 isoimmunization NEC 773.2 mucoviscidosis 277.01 [774.5]

INDEX TO DISEASES

Lambliasis

Lacertation--continued

uterus--continued

with--continued molar pregnancy (see categories 630-632) 639.2 following abortion 639.2 ectopic or molar pregnancy 639.2 nonpuerperal, nontraumatic 621.8 obstetrical trauma NEC 665.1 old (postpartal) 62.18 vagina with abortion--see Abortion, by type, with damage to pelvic organs ectopic pregancy (see categories 633.0-633.9)

639.2

molar pregnancy (see categories 630-632) 639.2 perineal involvement, complicating delivery 664.0 complicating delivery 665.4 first degree 664.0 second degree 664.1 third degree 664.2 fourth degree 664.3 high 665.4 muscles 664.1 sulcus 665.4 wall 665.4 following abortion 639.2 ectopic or molar pregnancy 639.2 nonpuerperal, nontraumatic 623.4 old (postpartal) 623.4 valve, heart--see Endocarditis vulva with

abortion--see Abortion, by type, with damage to pelvic organs ectopic pregnancy (see categories 633.0-633.9)

639.2

molar pregnancy (see also categories 630-632)

639.2

complicating delivery 664.0 following abortion 639.2 ectopic or molar pregnancy 639.2

nonpuerperal, nontraumatic 624.4 old (postpartal) 624.4 Lachrymal--see condition

Lachrymonasal duct --see condition

Lack of appetite (see also Anorexia) 783.0 care in home V60.4 of infant (at or after birth) 995.5 affecting parent or family V61.21 specified person NEC 995.81 coordination 781.3

MD0753

C-3

Lack of --- continued development--see also Hypoplasia physiological