ICD-9-CM Professional

Transcription

1 2009 ICD-9-CM Professionl for Hospitls Volumes 1, 2, & 3 Interntionl Clssifiction of Diseses 9th Revision Clinicl Modifiction Sixth Edition Edited by: nit C. Hrt, RHI, CCS, CCS-P Melind S. Stegmn, MB, CCS Beth Ford, RHIT, CCS Ingenix is committed to providing you with the ICD-9-CM code updte informtion you need to code ccurtely nd to be in complince with HIP regultions. In cse of doption of dditionl ICD-9-CM code chnges effective pril 1, 2009, Ingenix will provide these code chnges to you t no dditionl cost! Just check bck t to review the ltest informtion concerning ny new code chnges. Codes Vlid October 1, 2008, through September 30, 2009

2 Coding Guidelines Effective October 1, 2007 Nrrtive chnges pper in bold text. Items underlined hve been moved within the guidelines since November 15, The guidelines include the updted V Code Tble The Centers for Medicre nd Medicid Services (CMS) nd the Ntionl Center for Helth Sttistics (NCHS), two deprtments within the U.S. Federl Government s Deprtment of Helth nd Humn Services (DHHS) provide the following guidelines for coding nd reporting using the Interntionl Clssifiction of Diseses, 9 th Revision, Clinicl Modifiction (ICD-9-CM). These guidelines should be used s compnion document to the officil version of the ICD-9CM s published on CD-ROM by the U.S. Government Printing Office (GPO). These guidelines hve been pproved by the four orgniztions tht mke up the Cooperting Prties for the ICD-9-CM: the mericn Hospitl ssocition (H), the mericn Helth Informtion Mngement ssocition (HIM), CMS, nd NCHS. These guidelines re included on the officil government version of the ICD-9-CM, nd lso pper in Coding Clinic for ICD-9-CM published by the H. These guidelines re set of rules tht hve been developed to ccompny nd complement the officil conventions nd instructions provided within the ICD-9-CM itself. These guidelines re bsed on the coding nd sequencing instructions in Volumes I, II nd III of ICD-9-CM, but provide dditionl instruction. dherence to these guidelines when ssigning ICD-9-CM dignosis nd procedure codes is required under the Helth Insurnce Portbility nd ccountbility ct (HIP). The dignosis codes (Volumes 1-2) hve been dopted under HIP for ll helthcre settings. Volume 3 procedure codes hve been dopted for inptient procedures reported by hospitls. joint effort between the helthcre provider nd the coder is essentil to chieve complete nd ccurte documenttion, code ssignment, nd reporting of dignoses nd procedures. These guidelines hve been developed to ssist both the helthcre provider nd the coder in identifying those dignoses nd procedures tht re to be reported. The importnce of consistent, complete documenttion in the medicl record cnnot be overemphsized. Without such documenttion ccurte coding cnnot be chieved. The entire record should be reviewed to determine the specific reson for the encounter nd the conditions treted. The term encounter is used for ll settings, including hospitl dmissions. In the context of these guidelines, the term provider is used throughout the guidelines to men physicin or ny qulified helth cre prctitioner who is leglly ccountble for estblishing the ptient s dignosis. Only this set of guidelines, pproved by the Cooperting Prties, is officil. The guidelines re orgnized into sections. Section I includes the structure nd conventions of the clssifiction nd generl guidelines tht pply to the entire clssifiction, nd chpter-specific guidelines tht correspond to the chpters s they re rrnged in the clssifiction. Section II includes guidelines for selection of principl dignosis for non-outptient settings. Section III includes guidelines for reporting dditionl dignoses in non-outptient settings. Section IV is for outptient coding nd reporting. Section I. Conventions, generl coding guidelines nd chpter specific guidelines. Conventions for the ICD-9-CM 1. Formt: 2. bbrevitions. Index bbrevitions b. Tbulr bbrevitions 3. Punctution 4. Includes nd Excludes Notes nd Inclusion terms 5. Other nd Unspecified codes. Other codes b. Unspecified codes 6. Etiology/mnifesttion convention ( code first, use dditionl code nd in diseses clssified elsewhere notes) 7. nd 8. With 9. See nd See lso B. Generl Coding Guidelines 1. Use of Both lphbetic Index nd Tbulr List 2. Locte ech term in the lphbetic Index 3. Level of Detil in Coding 4. Code or codes from through V Selection of codes through Signs nd symptoms 7. Conditions tht re n integrl prt of disese process 8. Conditions tht re not n integrl prt of disese process 9. Multiple coding for single condition 10. cute nd Chronic Conditions 11. Combintion Code 12. Lte Effects 13. Impending or Thretened Condition C. Chpter-Specific Coding Guidelines 1. Chpter 1: Infectious nd Prsitic Diseses ( ). Humn Immunodeficiency Virus (HIV) Infections b. Septicemi, Systemic Inflmmtory Response Syndrome (SIRS), Sepsis, Severe Sepsis nd Septic Shock 2. Chpter 2: Neoplsms ( ). Tretment directed t the mlignncy b. Tretment of secondry site c. Coding nd sequencing of complictions d. Primry mlignncy previously excised e. dmissions/encounters involving chemotherpy, immunotherpy nd rdition therpy f. dmission/encounter to determine extent of mlignncy g. Symptoms, signs, nd ill-defined conditions listed in Chpter 16 ssocited with neoplsms h. dmission/encounter for pin control/mngement 3. Chpter 3: Endocrine, Nutritionl, nd Metbolic Diseses nd Immunity Disorders ( ). Dibetes mellitus 4. Chpter 4: Diseses of Blood nd Blood Forming Orgns ( ). nemi of chronic disese 5. Chpter 5: Mentl Disorders ( ) Reserved for future guideline expnsion 6. Chpter 6: Diseses of Nervous System nd Sense Orgns ( ). Pin - Ctegory Chpter 7: Diseses of Circultory System ( ). Hypertension b. Cerebrl infrction/stroke/cerebrovsculr ccident (CV) c. Postopertive cerebrovsculr ccident d. Lte Effects of Cerebrovsculr Disese e. cute myocrdil infrction (MI) 8. Chpter 8: Diseses of Respirtory System ( ). Chronic Obstructive Pulmonry Disese [COPD] nd sthm b. Chronic Obstructive Pulmonry Disese [COPD] nd Bronchitis c. cute Respirtory Filure d. Influenz due to identified vin influenz virus (vin influenz) 9. Chpter 9: Diseses of Digestive System ( ) Reserved for future guideline expnsion 10. Chpter 10: Diseses of Genitourinry System ( ). Chronic kidney disese 11. Chpter 11: Complictions of Pregnncy, Childbirth, nd the Puerperium ( ). Generl Rules for Obstetric Cses b. Selection of OB Principl or First-listed Dignosis c. Fetl Conditions ffecting the Mngement of the Mother d. HIV Infection in Pregnncy, Childbirth nd the Puerperium e. Current Conditions Complicting Pregnncy f. Dibetes mellitus in pregnncy g. Gesttionl dibetes h. Norml Delivery, Code 650 i. The Postprtum nd Periprtum Periods j. Code 677, Lte effect of compliction of pregnncy k. bortions 12. Chpter 12: Diseses Skin nd Subcutneous Tissue ( ) Reserved for future guideline expnsion 13. Chpter 13: Diseses of Musculoskeletl nd Connective Tissue ( ). Coding of Pthologic Frctures 14. Chpter 14: Congenitl nomlies ( ). Codes in ctegories , Congenitl nomlies 15. Chpter 15: Newborn (Perintl) Guidelines ( ). Generl Perintl Rules 2009 ICD-9-CM Revised text in bold font. Coding Guidelines 1

3 Injury nd Poisoning INJURY ND POISONING Tbulr List INTRCRNIL INJURY, EXCLUDING THOSE WITH SKULL FRCTURE ( ) 2 intrcrnil injury with skull frcture ( nd , except.0 nd.5) open wound of hed without intrcrnil injury ( ) skull frcture lone ( nd with.0,.5) Note: The description with open intrcrnil wound, used in the fourth-digit subdivisions, includes those specified s open or with mention of infection or foreign body. The following fifth-digit subclssifiction is for use with ctegories : 0 unspecified stte of consciousness 1 with no loss of consciousness 2 with brief [less thn one hour] loss of consciousness 3 with moderte [1-24 hours] loss of consciousness 4 with prolonged [more thn 24 hours] loss of consciousness nd returen to pre-existing conscious level 5 with prolonged [more thn 24 hours] loss of consciousness without return to pre-existing conscious level Use fifth-digit 5 to designte when ptient is unconscious nd dies before regining cosciousness, regrdless of the durtion of the loss of consciousness 6 with loss of consciousness of unspecified durtion 9 with concussion, unspecified H: 1Q, 93, Concussion 1 commotio cerebri 2 concussion with: cerebrl lcertion or contusion ( ) cerebrl hemorrhge ( ) hed injury NOS (959.01) H: 2Q, 96, 6; 4Q, 90, With no loss of consciousness Concussion with mentl confusion or disorienttion, without loss of consciousness k With brief loss of consciousness Loss of consciousness for less thn one hour H: 4Q, 03, 76; 1Q, 99, 10; 2Q, 92, With loss of consciousness of 30 minutes or less CC Excl: , , , , , , 905.0, , , , With loss of consciousness from 31 to 59 minutes With moderte loss of consciousness Loss of consciousness for 1-24 hours With prolonged loss of consciousness nd return to pre-existing conscious level Loss of consciousness for more thn 24 hours with complete recovery With prolonged loss of consciousness, without return to pre-existing conscious level With loss of consciousness of unspecified durtion Concussion, unspecified Corpus cllosum Cerebrum Hypothlmus Brin Optic chism Hypophysis Pons Mmillry body Peduncle Medull oblngt Precentrl gyrus (motor) nterior horn of lterl ventricle Intrventriculr formen Third ventricle Lterl sulcus Inferior horn of lterl ventricle Cerebrl queduct Lterl perture Centrl sulcus Interventriculr formen Fornix Third ventricle Pinel body Corpor qudrigemin Cerebrl queduct Vermis Fourth ventricle Medin perture Spinl cord Postcentrl gyrus (sensory) Body nd posterior horn of lterl ventricle Fourth ventricle Medin perture ' 851 Cerebrl lcertion nd contusion H: 4Q, 96, 36; 1Q, 93, 22; 4Q, 90, k Cortex (cerebrl) contusion st [0-6, 9] without mention of open intrcrnil wound CC Excl: For codes : , , , , , k Cortex (cerebrl) contusion with open [0-6, 9] intrcrnil wound H: 1Q, 92, 9 k Cortex (cerebrl) lcertion without [0-6, 9] mention of open intrcrnil wound k Cortex (cerebrl) lcertion with open [0-6, 9] intrcrnil wound 10 k Cerebellr or brin stem contusion st [0-6, without 9] mention of open intrcrnil wound CC Excl: For codes : , , , , , k Cerebellr or brin stem contusion [0-6, 9] with open intrcrnil wound k Cerebellr or brin stem contusion [0-6, 9] with open intrcrnil wound 10 HC = only for vlid CC or MCC codes. Requires fifth-digit. Vlid digits re in [brckets] under ech code. See beginning of section for codes nd definitions. 8 Newborn ge: 0 9 Peditric ge: 0-17 x Mternity ge: y dult ge: Mjor CC Condition CC Condition 7 HIV Relted Dx 328 Volume 1 October Ingenix

4 Tbulr List INJURY ND POISONING k Cerebellr or brin stem lcertion ' 854 Intrcrnil injury of other nd unspecified nture 1 brin injury NOS cvernous sinus intrcrnil injury 2 ny condition clssifible to hed injury NOS (959.01) H: 1Q, 99, 10; 2Q, 92, 6 [0-6, 9] with open intrcrnil wound k Other nd unspecified cerebrl [0-6, 9] lcertionnd contusion, without mention of open intrcrnil wound Brin (membrne) NOS H: 4Q, 96, 37 k Other nd unspecified cerebrl [0-6, 9] lcertion nd contusion, with open intrcrnil wound ' 852 Subrchnoid, subdurl, nd extrdurl hemorrhge, following injury 2 Cerebrl contusion or lcertion (with hemorrhge) ( ) DEF: Bleeding from lining of brin; due to injury. k Subrchnoid hemorrhge following [0-6, 9] injury without mention of open intrcrnil wound Middle meningel hemorrhge following injury k Subrchnoid hemorrhge following [0-6, 9] injury with open intrcrnil wound k Subdurl hemorrhge following injury [0-6, 9] without mention of open intrcrnil wound CC Excl: For code : , , , ; For codes : , , , , , H: 4Q, 96, 43; For codes : 4Q, 07, 107 k Subdurl hemorrhge following injury [0-6, 9] with open intrcrnil wound k Extrdurl hemorrhge following [0-6, 9] injury without mention of open intrcrnil wound Epidurl hemtom following injury k Extrdurl hemorrhge following [0-6, 9] injury with open intrcrnil wound ' 853 Other nd unspecified intrcrnil hemorrhge following injury k Without mention of open intrcrnil [0-6, 9] wound Cerebrl compression due to injury Intrcrnil hemtom following injury Trumtic cerebrl hemorrhge H: 3Q, 90, 14 k With open intrcrnil wound [0-6, 9] CC Excl: See code: k Without mention of open s T [0-6, 9] intrcrnil wound CC Excl: For codes : , , , , , H: For code : 2Q, 05, 6 k With open intrcrnil wound [0-6, 9] INTERNL INJURY OF THORX, BDOMEN, ND PELVIS ( ) 1 blst injuries blunt trum bruise concussion injuries (except cerebrl) of internl crushing orgns hemtom lcertion puncture ter trumtic rupture 2 concussion NOS ( ) flil chest (807.4) foreign body entering through orifice ( ) injury to blood vessels ( ) Note: The description with open wound, used in the fourth-digit subdivisions, includes those with mention of infection or foreign body. ' 860 Trumtic pneumothorx nd hemothorx H: 2Q, 93, 4 DEF: Trumtic pneumothorx: ir or gs leking into pleurl spce of lung due to trum. DEF: Trumtic hemothorx: blood buildup in pleurl spce of lung due to trum Pneumothorx without mention of open wound into thorx CC Excl: , , , , , , , , Pneumothorx with open wound into thorx Hemothorx without mention of open wound into thorx Hemothorx with open wound into thorx Pneumohemothorx without mention of open wound into thorx Pneumohemothorx with open wound into thorx ' 861 Injury to hert nd lung 2 injury to blood vessels of thorx ( ) k Hert, without mention of open wound into thorx H: 1Q, 92, 9 Injury nd Poisoning HC = only for vlid CC or MCC codes. Requires fifth-digit. Vlid digits re in [brckets] under ech code. See beginning of section for codes nd definitions. ' dditionl Digit Required Uncceptble PDx Mnifesttion Code Hospitl cquired Condition wx Revised Text l New Code s k Revised Code Title 2008 Ingenix October 2008 Volume 1 329

5 Tbulr List OPERTIONS ON THE MUSCULOSKELETL SYSTEM Body Lterl view of frctured body of thorcic vertebr Vertebrl body Frctured vertebr Disc Vertebroplsty Percutneous Vertebrl ugmenttion Fusion or refusion of 4-8 vertebre H: 1Q, 07, 20; 14Q, 03, Fusion or refusion of 9 or more vertebre H: 4Q, 03, 99 s Percutneous vertebroplsty Injection of bone void filler (cement) (polymethylmethcrylte) (PMM) into the disesed or frctured vertebrl body 2 kyphoplsty (81.66) wpercutneous vertebrl ugmenttion (81.66)x H: w2q, 08, 15x s Percutneous vertebrl ugmenttion wrcuplsty Insertion of infltble blloon, bone tmp, or other device displcing (removing) (compcting) bone to crete spce (cvity) (void) prior to the injection of bone void filler (cement) (polymethylmethcrylte) (PMM) or other substnce Kyphoplsty SKyphoplsty Spineoplstyx 2 wpercutneous vertebroplsty (81.65)x H: 1Q, 07, 5, 7; 3Q, 06, 13; 4Q, 04, 126 ' 81.7 rthroplsty nd repir of hnd, fingers, nd wrist 1 rthroplsty of hnd nd finger with: externl trction or fixtion grft of bone (chips) or crtilge internl fixtion device or prosthesis 2 opertions on muscle, tendon, nd fsci of hnd ( ) DEF: Plstic surgery of hnd, fingers nd wrist joints Spinous process Spinl cord Lmin Tube The cvity is filled with bone cement Inflted blloon Injection of bone cement into frcture site rthroplsty of metcrpophlngel nd interphlngel joint with implnt rthroplsty of metcrpophlngel nd interphlngel joint without implnt H: 1Q, 93, Totl wrist replcement rthroplsty of crpocrpl or crpometcrpl joint with implnt rthroplsty of crpocrpl or crpometcrpl joint without implnt H: 3Q, 93, Other repir of hnd, fingers, nd wrist ' 81.8 rthroplsty nd repir of shoulder nd elbow 1 rthroplsty of upper limb NEC with: externl trction or fixtion grft of bone (chips) or crtilge internl fixtion device or prosthesis Totl shoulder replcement H: w2q, 08, 5x Prtil shoulder replcement Repir of recurrent disloction of shoulder H: 3Q, 95, Other repir of shoulder Revision of rthroplsty of shoulder H: 1Q, 02, 9; 4Q, 01, 51; 2Q, 00, 14; 3Q, 93, Totl elbow replcement Other repir of elbow ' 81.9 Other opertions on joint structures rthrocentesis Joint spirtion 2 tht for: rthrogrphy (88.32) biopsy of joint structure ( ) injection of drug (81.92) DEF: Insertion of needle to withdrw fluid from joint Injection of therpeutic substnce into joint or ligment H: 2Q, 00, 14; 3Q, 89, Suture of cpsule or ligment of upper extremity 2 tht ssocited with rthroplsty ( , , 81.84) Suture of cpsule or ligment of nkle nd foot 2 tht ssocited with rthroplsty ( ) Suture of cpsule or ligment of other lower extremity 2 tht ssocited with rthroplsty ( , 81.59) Other repir of joint rthrocentesis 3 ' dditionl Digit Required Vlid OR Procedure Non-OR Procedure djunct Code 2008 Ingenix October 2008 Volume Femur Needle ccess into fluid filled knee joint Ptell (kneecp) Fluid-filled joint cpsule Tibi Opertions on the Musculoskeletl System