ICD-9-CM Code Book Re-Visited

Taking the CCS exam is nerve racking enough for new coders. Some CCS veterans recall the experience with varying degrees of angst and some of us with psycho-physical effects such as sweaty palms, slight nausea, and extreme anxiety. But going back to my own experience made me think about the real reason for the emotional conflagration that I experienced – coding on the encoder! I went to the test site (which shows how old I am) with my books as requested, never thinking about what coding strictly from the code book really meant. The encoder had ingrained many habits in my production cycle that were not compatible with efficient book coding. So, I thought a good review of the basics of the code book would be useful, just in case you have to use it when you take your exam in the future.

Main Terms

As experienced coders we understand that the main term is what we use to find the right code in ICD-9-CM. When using a logic-based encoder, we often stop using the key main terms from the book to expedite or streamline the coding tree to encompass diseases, conditions and procedures that are linked together in a logic-based encoder. After a year of typing in “pregnancy” and coding the entire encounter using the looping logic in the encoder for all complications and procedures performed, I forgot how to find what I was looking for in the book. So let’s take a look at some of the key, main terms you need to remember when using the book exclusively.



Obstetrical Trauma


Encounter (for)
























Lack of



Maternal condition






When using the book to locate main terms, remember the concept of “circumstances of admission.” Why did the patient come in for treatment? The patient may have a fracture, but did he come in for a “follow-up” exam. Another trick that works is to look up the condition on the internet and look for alternative disease names. Try searching some of these synonyms as your main term. The best way to avoid the consequences of this confidence-shaking delay in code location is to become familiar with the book again before you take the test. There are many text books out there with practice cases. Do two or three at a time using the code book; you will be amazed at how fast it comes back to you.

Using the Book

Parentheses. Parentheses enclose non-essential modifiers in the index. When coding, reading these modifiers before searching for your code can save a ton of time. For example, let’s say you’re coding Spurious Encephalitis and you are not sure what differentiates spurious encephalitis from encephalitis. Under encephalitis included in the non-essential modifier is the word “spurious.” You can now code Encephalitis, knowing that spurious is a non-essential modifier. For example:

  • Encephalitis (bacterial) (chronic) (hemorrhagic) (idiopathic) (non idiopathic) (spurious) (sub-acute)

Square Brackets. Square Brackets are used to display synonyms, alternative wording or explanatory phases. They also indicate which fifth digits apply to certain codes. For example:

  • Psychodysleptics [hallucinogents]

Slanted Brackets. Slanted Brackets are found in the alphabetic index and they indicate the addition of a second code is mandatory. For example:

  • Ebstein’s disease (diabetes) 250.4X [581.81]

Instructional Notations

Includes Notes. Includes notes identify additional diagnostic statements that are applicable to the code. Reading these notations may help to identify diseases documented in the record by different providers, but the same disease. For example:

Myotonic Muscular dystrophy
Dystrophia myotonica
Myotonia atrophica
Myotonic dystrophy
Proximal myotonic myopathy (PROMM)
Steinert’s disease

Excludes Notes. The Excludes notes are used to signal the coder that the conditions listed are not assigned to the code listed. This notation also lets the coder know the possible choices that are more appropriate for this diagnosis. Awareness of the Excludes notes can promote correct code choice when documentation is contradictory. For example:

Organic sleep apnea
Cheyne-Stokes breathing (786.04)
Hypersomnia with sleep apena NOS (780.53)
Insomnia with sleep apena NOS (780.51)
Sleep apnea in newborn (770.81-770.82)
Sleep apnea NOS (780.57)

Code First the Underlying Disease. This instructional note indicates that the code cannot be a principal diagnosis or that it should not be sequenced before the underlying disease. These directions are only found in the tabular list. Applying the instructions seen below can save a coder many lost points for incorrect sequencing on the exam. For example:

Hepatopulmonary Syndrome
Code first underlying liver disease

  • Alcoholic cirrhosis of liver (571.2)
  • Cirrhosis of liver without mention of alcohol (571.5)

Use an Additional Code. This instruction tells the coder to use an additional code to provide further information. This note is found in the tabular. Not coding extra information that is required leads to point deductions on the exam. For example:

Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptoms (LUTS). Use an additional code to identify symptoms:
Incomplete bladder emptying (788.21)
Nocturia (788.43)
Straining on urination (788.65)
Urinary frequency (788.41)
Urinary hestiancy (788.64)
Urinary incontinence (788.30-788.39)
Urinary obstruction (599.69)
Urinary retention (788.20)
Urinary urgency (788.63)
Weak urinary stream (788.62)

The ICD-9-CM code book employees conventions and guidelines to help the user locate the correct code. It is not feasible to memorize some of these rules or conventions, as they change with the drop of a hat. The important thing to remember is that the book is a tool and it has rules of use. Periodic review of these basic rules will always benefit a professional coder. The encoder allows the user to create “short cuts” in code location while striving for production excellence. Remember, your way of coding on the encoder works for you. The code book rules work when using the book or when using the encoder.

This month’s column has been prepared by Sandra Draper, RHIT, CCS, director of training and development for Precyse (www.precyse.com), which provides services and technologies that capture, organize, secure and analyze healthcare data and transform it into actionable information, supporting the delivery of quality patient care and optimizing operating performance.

Take the quiz and test your knowledge on page 2.

Quiz: List the main terms for the following diagnoses using the code book:

Screening for colon cancer

Spontaneous breech delivery

Abnormally formed uterus

Adjustment of a growth rod

Death of fetus

PAP smear

Ulcerative chronic tonsillitis