Chapter 3
ICD-9-CM Official Guidelines (Section I): General Rules
McGraw-Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.


After studying this chapter, you should be able to:
1. 2. 3. 4. 5. Understand the content and source of ICD-9-CM ³General Coding Guidelines.´ Describe how the correct coding process uses both the Alphabetic Index and the Tabular List to assign codes. Apply the coding guidelines on the level of detail. Explain the coding of conditions that are an integral part of the disease process. Explain the coding conditions that are not an integral part of the disease process.

10. 9.3-3 LEARNING OUTCOMES (Cont¶d) 6. Explain the rules governing the coding of the late effects of previous diseases and conditions. Differentiate coding guidelines for multiple codes and combination codes. . Understand the coding implications of diagnostic terms stated as impending or threatened. 7. 8. Briefly discuss the content of the chapter-specific coding guidelines. Understand the guidelines for coding accurate and chronic conditions.

3-4 KEY TERMS ‡ Acute ‡ Causal condition ‡ Chapter-specific guidelines ‡ Chronic ‡ Code first notes ‡ Combination code ‡ Impending ‡ Integral ‡ Late effect Mandatory multiple coding Neoplasm Table Residual condition Sign Specificity Symptom Threatened .

3-5 ³General Coding Guidelines´: Inpatient and Outpatient ‡ Apply to all settings and all providers of healthcare ‡ Apply whether coding for an inpatient or outpatient setting ‡ Appear in the Coding Clinic® for ICD-9-CM (published by AHA) ‡ Appear in the official government version of ICD9-CM .

3-6 Use of both the Alphabetic Index and the Tabular List The coder must use both the Alphabetic Index and the Tabular List when locating and assigning codes and must not rely solely on only one volume. as errors will occur in code assignment if only one volume is used. .

or the site of disease. four.3-7 Level of Detail in Coding primary rule states that both diagnosis and procedure codes are to include the highest number digits available for the highest level of specificity ICD-9-CM Diagnosis Codes Composed of either three. the cause of the disease. the fourth and fifth digit provide additional specificity regarding the type of disease. or five digits. . Typically. with three digits always before the decimal point.

Two-digits category codes serve as the heading.3-8 Level of Detail in Coding (cont¶d) ICD-9-CM Procedure Codes (Volume3) Have either three or four digits. . category is further subdivided into three-digit and sometimes four digit codes that provide greater detail.

Step 3: Are the signs and symptoms integral to the medical condition? YES = Do not code the sign/symptom separately NO = Assign the separate code for the sign/symptom Step 4: Verify all codes. and Integral Conditions Step 1: Determine the patient¶s signs and symptoms. Step 2: Determine the medical condition of the patient. Symptoms.3-9 Coding Decisions for Signs. .

3-10 Coding Decisions (Conditions that are an integral part of a disease process) The coding rule states that codes for signs and symptoms that are INTEGRAL to the disease should not be assigned. so only pneumonia would be coded) .SYMPTOM (not easily measured and subjective) Cough. cough ± SIGN (easily measured and objective) Dyspnea . EX: Pneumonia TYPICAL SIGNS AND SYMPTOMS fever. and dyspnea are integral to pneumonia. fever.

ascites must be coded also. Ex: Cirrhosis of the Liver (symptoms of ascites ± not routinely associated with Cirrhosis of the Liver) Since ascites is not integral to Cirrhosis of the Liver.3-11 Coding Decisions (Conditions that are not integral part of a disease process) Additional signs and symptoms that may not be associated with a disease process should be coded when present. .

3-12 Determining Signs. Symptoms. and Integral Conditions How can a coder determine whether a sign or symptom is integral to the disease process? Can be obtained by: .referring to AHA Coding Clinic guidelines .online resources .the study of disease and pathophysiology .

use additional code notes .code. if applicable.code first note . any causal condition first note .3-13 Multiple Coding for a Single Condition Indicates when two codes may be required to report a condition (called mandatory multiple coding) .

3-14 Combination Codes Combination code is one code that classifies:  two diagnoses  a diagnosis with an associated manifestation  a diagnosis with an association complication .

and separate subentries exist in the Alphabetic Index at the same indentation level. code both and sequence the acute (subacute) code first.1 recurrent 577.0 acute (edematous) (hemorrhagic) (recurrent) annular 577.0 apoplectic 577.0 chronic (infectious) 577. Example: Pancreatitis 577.0 calcereous 577.1 .3-15 Acute and Chronic Conditions If the same condition is described as both acute (subacute) and chronic.

1 acute 574.0 chronic 574.2 ____________________________________________ Note ± Use the following fifth-digit subclassification with category 574: 0 without mention of obstruction 1 with obstruction ____________________________________________ with cholecystitis 574.1 .3-16 Acute and Chronic Conditions (cont¶d) Example: Cholelithiasis (impacted) (multiple) 574.

3-17 Acute and Chronic Conditions Code Assignment Flow Chart Step 1: Is the condition documented as both acute and chronic? YES = Go to Step 2 NO = Follow standard coding process Step 2: Reference the main term in the Alphabetic Index Step 3: Are the subterms acute and chronic listed at the same indentation level? YES = Go to Step 4 NO= Follow standard coding process Step 4: Assign both codes. Step 5: Verify both codes in the Tabular List . sequencing the acute code first.

3-18 Late Effects A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has been terminated. A late effect generally requires two codes. . followed by the code for the late effect (code using the main term late). with the code or condition or nature of the late effect (code the condition/residual) listed first.

3-19 LATE EFFECTS (cont¶d) Step 1: Is the condition a late effect? YES = Go to Step 2 NO = Code the condition Step 2: Identify the residual condition Step 3: Is the residual condition document? YES = Code the residual NO = Do not code the residual .

first reference the Alphabetic Index to determine whether the condition has a subterm for impending or threatened.3-20 Impending or Threatened Condition If a condition documented at the time of discharge as impending or threatened did occur. it should be coded as a confirmed diagnosis. If so. If the condition did not occur. . Also reference the main terms impending or threatened to determine a specific code for the condition. assign the code verifying it in the Tabular List.

3-21 Impending or Threatened Condition (cont¶d) Example: Impending cerebrovascular accident or attack 435.1 _________________________________________________________ .0 myocardial infarction 411.9 coronary syndrome 411.1 delirium tremens 291.

.3-22 Impending or Threatened Condition (cont¶d) Example:( this example illustrates how to code impending gangrene due to decubitus ulcer of the lower back) Gangrene. gangrenous (anemia) (cellulitis) (dermatitis) (Dry) (infective) (moist) (pemphigus) (septic) (skin) (statis)(ucler) . by site with gangrene mesentric embolism or infarction 557. Therefore.03).0 with hernia ± see Hernia. . and the decubitus ulcer would be coded as document (707.1 intestine. hernia ± see Hernia.0 laryngitis 464. the code for gangrene would not be assigned. by site with gangrene hospital noma 528.00 There is no subterm for impending in the Alphabetic Index. intestinal (acute) (hemorrhagic) (massive) 557.

Codes 001-139 Neoplasms ± Codes 140-239 Endocrine. Nutritional.3-23 Chapter-Specific Coding Guidelines Infections and Parasitic Diseases . and Metabolic Disease and Immunity Disorders ± Codes 240-279 Diseases of the Blood and Blood Forming Organs ± Codes 280-289 Mental Disorders ± Codes 290-319 Diseases of the Nervous System and Sense Organs ± Codes 320-389 Diseases of the Circulatory System ± Codes 390-459 Diseases of the Respiratory System ± Codes 460-519 Diseases of the Digestive System ± Codes 520-579 Diseases of the Genitourinary System ± Codes 580-629 .

and the Puerperium ± Codes 630-677 Diseases of the Skin and Subcutaneous Tissue ± Codes 680-709 Diseases of the Musculoskeletal System and Connective Tissue ± Codes 710-739 Congenital Anomalies ± Codes 740-759 Certain Conditions originating in the Perinatal Period ± Codes 760-779 Symptoms.3-24 Chapter-Specific Coding Guidelines(cont¶d) Complications of Pregnancy. and Ill-Defined Conditions ± Codes 780-799 Injury and Poisoning ± Codes 800-999 Classification of Factors Influencing Health Status and Contact with Health Service ± SUPPLEMENTAL ± V01-V86 Supplemental Classification of External Causes of Injury and Poisoning ± E CODES ± E800-E999 . Signs. Childbirth.

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