Coding Guidelines Revised

Vol. 17 •Issue 1 • Page 6
CCS Prep!

Coding Guidelines Revised

Review some of the major additions and changes to the chapter-specific guidelines, effective Nov. 15, 2006.

This month’s CCS Prep! column focuses on the ICD-9-CM Official Guidelines for Coding and Reporting, which were revised effective Nov. 15, 2006. These revisions have been approved by the four cooperating parties for ICD-9-CM, which include the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS) and National Center for Health Statistics (NCHS).

As indicated in previous CCS Prep! columns, the Official Guidelines are the only official source for coding rules when the ICD-9-CM classification system itself does not provide direction. The conventions, general guidelines and chapter-specific guidelines apply to the proper use of ICD-9-CM, regardless of the health care setting. This column reviews some of the major additions and changes to the chapter-specific guidelines. Appendix I, Present on Admission Reporting Guidelines, which was added on Oct. 1, 2006, is also discussed.

Chapter Specific Guidelines

SIRS, Sepsis, Severe Sepsis and Septic Shock–Changes, additions and clarifications have been made to the coding and sequencing of Septicemia, SIRS, Sepsis, Severe Sepsis and Septic Shock.

Definition of the terms SIRS, septicemia and sepsis and severe sepsis are provided:

Septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi or other organisms.

Systemic inflammatory response syndrome (SIRS) generally refers to the systemic response to infection, trauma/burns or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea and leukocytosis.

Sepsis generally refers to SIRS due to infection.

Severe sepsis generally refers to sepsis with associated acute organ dysfunction.

The coding of SIRS, sepsis and severe sepsis requires a minimum of two codes. The first code identifies the underlying cause such as infection or trauma followed by a code from subcategory 995.9, Systemic inflammatory response syndrome (SIRS).

If the reason for admission is either sepsis or SIRS with a localized infection, sequence the code for the systemic infection first (038.xx, 112.5, etc.), followed by a code from either code 995.91, Sepsis, or 995.92, Severe sepsis. If the causal organism is not documented, assign code 038.9, Unspecified septicemia. Then assign the code for localized infection. If the reason for admission is the localized infection and the sepsis develops after admission, sequence the localized infection first, followed by the code for the systemic infection, then code 995.9X.

Acute organ dysfunction must be associated with the sepsis to assign the severe sepsis code. If a patient has sepsis and an acute organ dysfunction, but the documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92.

Septic shock indicates the presence of severe sepsis. For all cases of septic shock, sequence the code for the systemic infection first, followed by codes 995.92 and 785.52; for septic shock. Assign additional codes for any other acute organ dysfunctions.

If sepsis or severe sepsis is documented as associated with a non-infectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the non-infectious process should be sequenced first, followed by the code for the systemic infection and either code 995.91, Sepsis, or 995.92, Severe sepsis. If the sepsis or severe sepsis meets the definition of the principal diagnosis, the systemic infection and sepsis codes should be sequenced before the code for the non-infectious condition.

SIRS can develop due to a non-infectious process, as a result of trauma, malignancy, pancreatitis or other non-infectious process. When no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction, or 995.94, Systemic inflammatory response syndrome due to non-infectious process with acute organ dysfunction. If an acute organ dysfunction is documented, the appropriate code for the acute organ dysfunction should be assigned in addition to code 995.94.

The coding of septicemia, sepsis, severe sepsis, SIRS and septic shock is very confusing. It is important to review this entire section of the coding guidelines for a complete understanding on how to code these conditions. It is important to note that the guideline for coding septicemia has not changed. If the documentation in the medical record indicates streptococcal septicemia only code 038.0 is assigned. This can be confusing to the coder. When septicemia only is documented, or the documentation is unclear the physician should be queried.

Category 338, Pain–Guidelines have been added on the proper usage of codes in new category 338, Pain. Codes in category 338 may be used in conjunction with codes from other categories to provide more detail about acute or chronic pain and neoplasm-related pain.

A code from subcategories 338.1, Acute pain, or 338.2, Chronic pain, should not be assigned if the underlying diagnosis is known unless the reason for the encounter is pain control/ management and not management of the underlying condition.

Code 338.3, Neoplasm related pain (acute) (chronic), should be assigned when the pain is documented as being related, associated or due to cancer, primary or secondary malignancy or tumor regardless of whether the pain is acute or chronic. This code may be assigned as the principal diagnosis when the stated reason for the admission is pain control or pain management. The underlying neoplasm should be reported as an additional diagnosis. When the reason for the admission is treatment or management of the neoplasm and pain associated with the neoplasm is also documented, code 338.3 may be assigned as an additional diagnosis.

Fractures—Fracture guidelines have also been added. Traumatic fractures are coded as acute fractures with codes from categories 800-829 while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter and evaluation and treatment by a new physician.

Fractures are coded using the aftercare codes from subcategories V54.0, V54.1, V54.8 or V54.9, for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment and follow up visits following fracture treatment.

Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. Malunion and nonunion, should be reported with a code from subcategory 733.8, Malunion or nonunion of fracture.

Acute Respiratory Failure–Guidelines have been added to address the correct usage and sequencing of code 518.81, Acute respiratory failure. Code 518.81 may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines that provide sequencing direction take precedence.

Chronic kidney disease and kidney transplant status–Patients who have undergone kidney transplant may still have some form of chronic kidney disease. Therefore, the presence of chronic kidney disease does not necessarily indicate a transplant complication. Assign the appropriate category 585 code for the stage of the chronic kidney disease and code V42.0, Kidney transplant status. If a transplant complication such as failure or rejection is documented, it is appropriate to assign the complication code. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.

V Codes—New guidelines have been provided for coding patient encounters for routine laboratory and radiology testing. Codes V72.5, Radiological examination, not elsewhere classified and V72.6, Laboratory examination, may be used if the reason for the patient’s encounter is for routine laboratory/radiology testing in the absence of any signs, symptoms or associated diagnosis. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom or diagnosis, it is appropriate to assign both V72.5 and/or V72.6 and the code describing the reason for the non-routine test.

This year’s update also includes a new V code table format that will make it easier to use and to update. The table contains columns to identify when a V code is classified as the first listed diagnosis, first or additional diagnosis, additional only and non-specific diagnosis.

Present on Admission Guidelines

The Present on Admission (POA) guidelines are to be used as a supplement to the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator for each diagnosis and external cause of injury code reported on the UB-04 and 837 Institutional claim forms.

The guidelines apply to all claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to regulation mandating the collection of the POA information. POA is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered as POA. The POA indicator is assigned to both the principal and secondary diagnoses.

Medical record documentation from any provider involved in the care and treatment of the patient may be used to support the determination of whether a condition was POA or not. In this context, the term provider means a physician or any qualified health care practitioner who can legally establish the patient’s diagnosis.

A list of categories and codes exempt from POA reporting is provided in the guidelines. These codes are exempt because they represent circumstances that do not represent a current disease or injury or are always present on admission.

POA Reporting Options:




W–Clinically undetermined

Unreported/Not used–Exempt from POA reporting

Reporting Definitions

Y = present at the time of inpatient admission

N = not present at the time of inpatient admission

U = documentation is insufficient to determine if condition is present on admission

W = provider is unable to clinically determine whether condition was present on admission or not

Assign Y for any condition the provider explicitly documents as being POA. Assign Y for conditions that were diagnosed prior to admission. For example: hypertension, diabetes mellitus, asthma.

Assign Y for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred. Diagnoses subsequently confirmed after admission are considered POA if at the time of admission they are documented as suspected, possible, rule out, differential diagnosis or constitute an underlying cause of a symptom present at admission.

Assign N for any condition the provider explicitly documents as not present at the time of admission.

Assign U when the medical record documentation is unclear as to whether the condition was present on admission. U should not be routinely assigned and should be used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.

Assign W when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission.

When a code is on the exempt list the POA field is left blank. This is the only circumstance in which the field may be left blank.

A copy of the revised ICD-9-CM guidelines can be found at

Take the following quiz to test your knowledge of the guidelines.

1. A patient is admitted for repair of an abdominal aneurysm. However, the aneurysm ruptures after hospital admission. What POA indicator is assigned for the ruptured abdominal aneurysm?

a. Y

b. N

c. U

d. W

2. A patient is admitted to the emergency department from the physician’s office because of possible pneumonia. The patient was admitted to the hospital and put on a respirator. It was determined that the patient has severe sepsis due to the pneumonia with resulting acute respiratory failure. What would be the correct code assignment?

a. 486, 038.9, 995.92, 518.81

b. 038.9, 995.91, 518.81, 486

c. 518.81, 486, 038.9, 995.92

d. 038.9, 995.92, 518.81, 486

3. A patient is admitted with respiratory failure due to pneumocystis carinii, which is due to AIDS. What would be the correct code assignment?

a. 042, 518.81, 136.3

b. 518.81, 042, 136.3

c. 136.3, 042, 518.81

4. A patient is admitted to the hospital in acute renal failure due to dehydration. The patient has chronic kidney disease, benign essential hypertension, and Type II diabetes (controlled) with diabetic nephropathy. What would be the correct code assignment?

a. 276.51, 584.9, 403.11, 585.6, 250.40, 583.81

b. 584.9, 276.51, 403.11, 585.6, 250.40, 583.81

c. 584.9, 276.51, 403.10, 585.9, 250.40, 583.81

d. 276.51, 584.9, 403.10, 585.9, 250.40, 583.81

Coding Clinic is published quarterly by the AHA.

CPT is a registered trademark of the AMA.

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS, an Ingenix company (

Answers to CCS Prep!: 1. b. N or not present on admission is assigned as the POA indicator. Although the aneurysm was POA, the “ruptured” component of the code description did not occur until after admission; 2. d. Code 038.9 is assigned to identify the systemic infection. Code 995.92 is assigned instead of code 995.91 to identify severe sepsis. The acute organ dysfunction, respiratory failure, is coded to 518.81. Because the type of pneumonia is unknown it is coded to 486, Pneumonia, organism unspecified; 3. a. HIV, 042, is sequenced first because there is a chapter-specific guideline that provides sequencing directions specifying that if a patient is admitted for an HIV-related condition, the principal diagnosis should be 042, followed by additional diagnosis codes for all reported HIV-related conditions. Codes 518.81, Respiratory failure and 136.3, pneumocustis carinii are assigned as secondary diagnoses; 4. c. Instructions in Coding Clinic Third Quarter, 2002, provide guidelines on the code assignment of acute renal failure due to dehydration. Patients with physician documentation of acute renal failure due to dehydration are coded to acute renal failure, 584.9, as the principal diagnosis and the dehydration, 276.51 as a secondary diagnosis. Benign hypertension with chronic renal failure is coded to 403.10 with the additional code, 585.9, to identify the unspecified chronic renal failure. Code also 250.40 and 583.81 for the diabetic nephropathy.