Official ICD-9-CM Guidelines for Inpatient Coding and Reporting
Official ICD-9-CM Guidelines for Inpatient Coding and Reporting
Official Exam Dates: May 19, 2001 and Sept. 15, 2001. The AHIMA Web site now has the certification guides available for download. Go to www.ahima.org/certification for instructions regarding the CCS and CCS-P exams.
We will address the importance of the Official ICD-9-CM Guidelines for inpatient records in this issue of CCS-Prep! This document is approved by the four cooperating parties, which include the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Health Care Financing Administration (HCFA) and National Center for Health Statistics (NCHS). Although it may be "old hat" for many of you, it is crucial that you know these guidelines before taking the exams. So don't take review of these guidelines lightly. Many a question is missed without clear understanding of these guidelines!
The official guidelines should be the basis on which all coding and sequencing decisions are made, but only when the ICD-9-CM codebook does not provide specific direction. A copy can be obtained by contacting the NCHS at www.cdc.gov/nchswww/data/icdguide.pdf. This publication also includes the official guidelines for outpatient and physician coding in section 12, which will be discussed in another issue of CCS Prep! The revisions to the guidelines are also reproduced in Coding Clinic issues 4Q 1997 pp. 59-60, 4Q 1996 pp. 72-79, 4Q 1995 pp. 33-49 and 1Q 1990 pp. 3-8.
Although all of the guidelines are equally important, we will discuss a few of the inpatient guidelines in this segment. We will review the outpatient guidelines in a future issue. It is important to know the differences between the two types, as they will affect your inpatient and outpatient/office coding.
General Inpatient Coding Guidelines
1.1 Use both the alphabetic index and tabular listing when locating and assigning a code. You would be very surprised to learn how many coders assign incorrect codes because they "code" from the tabular list only. The index gives valuable information on how to classify the diagnosis. For example, a diagnosis of congestive heart failure (CHF) with rheumatic aortic and mitral valve disease may prompt the coder to assign code 428.0 for the CHF. Upon looking at the CHF index entry, one will find that rheumatic CHF is assigned to code 398.91. Coding Clinic 1Q 1995 page 6 also addresses this situation. In addition, always use all the digits of a code.
1.4, 2.3 Acute and chronic conditions. If a condition is documented as both acute/subacute and chronic, code the acute/subacute condition first, followed by the chronic condition. For example, if the physician documents acute and chronic osteomyelitis (foot), both 730.07 (acute osteomyelitis, foot) and 730.17 (chronic osteomyelitis, foot) would be reported. Code 730.07 is sequenced first.
1.5, 1.6 Combination and multiple coding. This will be addressed in a future CCS-Prep! column.
1.7 Late Effect. A late effect is a residual condition that occurs after the acute phase of illness or injury. There is no time limit on when the late effect code can be used. Two codes are required. The first code listed is the residual condition or nature of the late effect and the second code is the cause of the late effect. For example, if a patient has scarring and contracture as a result of a burn to the neck, code 709.2 would be listed first, followed by 906.5 (late effect of burn of eye, face, head and neck). An E code will not be assigned on the CCS and CCS-P examinations unless it is for a reaction to a therapeutic drug (E930-E949).
1.8 Uncertain Diagnosis. For inpatient cases, code all "rule-out," "suspected," "likely," "questionable," "possible" or "still to be ruled-out" as if it existed. For example, the physician documents "upper abdominal pain, rule-out acute cholecystitis." Assign code 575.0 for this diagnosis. It is important to understand that this only applies to inpatient records.
Selection of Principal Diagnosis
2.1 Codes for symptoms, signs and ill-defined conditions. Codes for signs and symptoms from Chapter 16 of ICD-9-CM are not reported as a principal diagnosis when a related definitive diagnosis has been established. For example, a patient is admitted with fever, severe abdominal pain, nausea and vomiting. A diagnosis of acute appendicitis is made. The coder should report only 540.9 (acute appendicitis without peritonitis) in this case. The symptoms are considered integral to the condition of acute appendicitis.
2.4 Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis. When two or more interrelated conditions potentially meet the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the ICD-9-CM tabular list or alphabetic index indicate otherwise. This includes conditions listed within the same ICD-9-CM chapter. For example, a patient is admitted with acute CHF and unstable angina. On admission the physician treats both conditions, the CHF with IV Lasix and the unstable angina with nitrates. Either 428.0 (CHF) or 411.1 (unstable angina) may be listed as principal diagnosis. If only one of these conditions was addressed, then that condition would be listed as the principal diagnosis.
2.5 Two or more diagnoses that equally meet the definition for principal diagnosis. This is similar to guideline 2.4. However, this guideline addresses the unusual circumstance where two or more diagnoses equally meet the criteria for principal diagnosis. For example, a patient is admitted with both acute CHF and acute pneumonia. The physician places the patient on IV Gentamycin for the pneumonia and IV Lasix for the CHF. Either 486 (pneumonia, NOS) or 428.0 (CHF) may be sequenced as the principal diagnosis because both were symptomatic, present on admission and treated.
2.7 A symptom followed by contrasting/comparative diagnoses. For the principal diagnosis, when a symptom(s) is followed by contrasting/comparative diagnoses, the symptom code is sequenced first and the contrasting/comparative diagnoses should be coded as suspected conditions. For example, a patient is admitted with acute epigastric abdominal pain, and the physician entertains the diagnoses of acute pyelonephritis and acute gastritis. The patient is given antacids and antibiotics. Urine C/S taken after administration of antibiotics is negative and abdominal X-rays are negative. The physician documents "epigastric abdominal pain, acute pyelonephritis vs. acute gastritis." Assign code 789.06 (epigastric abdominal pain) as the principal diagnosis, followed by 590.10 (acute pyelonephritis) and 535.00 (acute gastritis without hemorrhage) as secondary diagnoses.
Reporting Other (Additional) Diag-noses (Page 19 of the certification guide, Appendix B, gives examples as well.)
3.2 Diagnoses not listed in the final diagnostic statement. If the physician documents what appears to be a condition in the body of the record, but has not included the diagnosis in the final diagnostic statement, query the physician as to whether the diagnosis should be added. An example of this is a notation of "positive C/S of urine with E. Coli, greater than 100,000" in the progress notes. Patient is administered Cipro. Query the physician as to whether E. Coli urinary tract infection (599.0, 041.4) should be added to the final diagnostic statement. In addition, it could be that the patient has a particular type of infection, such as pyelonephritis or cystitis. It is important to know that the diagnosis must be documented by a physician somewhere in the medical record. Coders should not code from ancillary reports like labs unless confirmed by the physician. A notation of 100,000 E. Coli present on C/S does not constitute a diagnosis.
3.3 Conditions that are an integral part of a disease process. Conditions that are an integral part of a documented disease process should not be assigned as additional codes. For example, a patient is admitted with sweating/chills, fever, elevated WBCs and shallow breathing. The physician diagnosed pneumonia and starts the patient on IV antibiotics. Assign code 486 (pneumonia) only. Codes for the integral symptoms of sweating/chills, fever, elevated WBCs and shallow breathing would not be assigned as they are components of the pneumonia itself.
3.5 Abnormal findings. Abnormal findings (laboratory, X-ray, pathologic and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are abnormal and the physician has ordered other tests or diagnostics to evaluate the condition or prescribed treatment, the physician should be asked whether or not the condition should be added. For example, the coder sees that the patient's hemoglobin and hematocrit have dropped three points after surgery, and the physician has ordered a transfusion of packed red blood cells. The physician should be queried as to the clinical significance of these abnormal findings and treatment, and if anemia should be added as a diagnosis to the final diagnostic statement.
As stated, we have reviewed just a few of the official inpatient guidelines. We suggest that you review all of the guidelines in depth. They continue with sections 4-12.
In future issues, we will be discussing in some manner these other official guidelines pertaining to neoplasms, poisonings, hypertension, obstetrics, newborn coding, trauma, HIV and outpatient services.
In the meantime, take this quick quiz to test your knowledge:
1. The UHDDS and Official Guidelines Section 2 definition of principal diagnosis is:
a) the diagnosis that the physician lists in the final diagnostic statement first.
b) the most severe condition listed by the physician.
c) The condition established after study to occasion the admission of the patient to the hospital.
2. An eponym in ICD-9-CM is:
a) the name of a disease, procedure or structure usually named after the person who discovered it or described it.
b) another word for the term in question, with the same meaning.
c) a word for a procedure that sounds like another word.
3. A diagnosis of moderate malnutrition is documented by the dietician on a nutrition assessment form. This is the only place that malnutrition is documented. Treatment is rendered for the malnutrition. The diagnosis:
a) should be reported, as it is documented in the record and treated.
b) the physician should be queried to validate the diagnosis' significance.
c) should not be reported.
4. A patient is admitted with acute exacerbation of COPD. It is noted that the patient is status post cataract extraction three months prior to admission. Code V45.61 should be reported.
5. While an inpatient, a patient has a CT scan of the head. Procedure code 87.03 should be reported.
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Patricia Maccariella-Hafey is manager of coding review services at United Audit Systems Inc. (UASI), a national consulting company offering multifaceted HIM management and coding review services, headquartered in Cincinnati.