ICD-9-CM Official Guidelines for Coding and Reporting Revised Effective April 1, 2005

Vol. 15 •Issue 9 • Page 12
CCS Prep!

ICD-9-CM Official Guidelines for Coding and Reporting Revised Effective April 1, 2005

This month’s CCS Prep! column focuses on the ICD-9-CM Official Guidelines for Coding and Reporting, which were revised effective April 1, 2005. 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. Changes were made to the introduction and to a number of chapter-specific guidelines.

Introduction: The following important information was added to the introduction section of the guidelines: Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all health care settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals.

The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.

The above additions are significant because they now specifically state that adherence to these guidelines is required under HIPAA. In the past many parties did not follow these guidelines because they had developed their own or were not even aware of their existence.

Section I outlines the conventions, general coding guidelines and chapter specific guidelines. Nothing significant was done to the portion outlining the conventions for the ICD-9-CM except for some minor restructuring. However, as mentioned above, there are a number of significant additions and changes to the chapter-specific coding guidelines. Specifically, guidelines for assigning sepsis as principal or secondary diagnosis have been added, as have instructions on the coding of septic shock and SIRS. Guidelines for coding diabetes mellitus, CVA, chronic obstructive pulmonary disease (COPD) and bronchitis, and COPD and asthma have also been added. Many of the additions are consistent with instructions previously provided in Coding Clinic for ICD-9-CM.

New Guidelines for Sepsis as principal diagnosis or secondary diagnosis:

Sepsis as principal diagnosis: If sepsis is present on admission, and meets the definition of principal diagnosis, the underlying systemic infection code (e.g., 038.xx, 112.5, etc.) should be assigned as the principal diagnosis, followed by code 995.91, Systemic inflammatory response syndrome due to infectious process without organ dysfunction, as required by the sequencing rules in the Tabular List. Codes from subcategory 995.9 can never be assigned as a principal diagnosis. This addition to the guidelines reiterates the Code First underlying systemic infection note for code 995.9X in the Tabular List.

Sepsis as secondary diagnoses: When sepsis develops during the encounter, the sepsis codes may be assigned as secondary diagnoses, following the sequencing rules provided in the Tabular List.

Documentation unclear as to whether sepsis present on admission: If the documentation is not clear whether the sepsis was present on admission, the provider should be queried. After provider query, if sepsis is determined at that point to have met the definition of principal diagnosis, the underlying systemic infection (038.xx, 112.5, etc.) may be used as principal diagnosis along with code 995.91, Systemic inflammatory response syndrome due to infectious process without organ dysfunction.

Sequencing of septic shock: Septic shock is a form of organ dysfunction associated with severe sepsis. A code for the initiating underlying systemic infection followed by a code for SIRS (code 995.92) must be assigned before the code for septic shock. The code for septic shock cannot be assigned as a principal diagnosis.

Septic shock without documentation of severe sepsis: Septic shock cannot occur in the absence of severe sepsis. A code from subcategory 995.9 must be sequenced before the code for septic shock. The use additional code note and the code first note in the Tabular list provide sequencing instructions.

This is an important change. Previously the guidelines indicated that if septic shock is documented, it is necessary to code first the initiating systemic infection or trauma, then either code 995.92 or 995.94, followed by code 785.52. It went on to indicate that when the diagnosis of septicemia with shock or the diagnosis of general sepsis with septic shock is documented, code and list the septicemia first and report the septic shock code as secondary condition. It went on to state that the septicemia code assignment should identify the type of bacteria if it is known.

It is very important to note that the new guideline specifies that septic shock cannot occur without severe sepsis. One of the SIRS codes 995.9X would always be assigned when septic shock is documented.

Sepsis due to a postprocedural infection: Sepsis resulting from a postprocedural infection is a complication of care. For such cases code 998.59, Other postoperative infections, should be coded first followed by the appropriate codes for the sepsis. Sequencing guidelines for coding sepsis should then be followed for the assignment of additional codes.

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 is documented the physician should be queried asking if the patient has sepsis.

Guidelines for coding Encounters for prophylactic organ removal have been added to Neoplasm section. These guidelines are consistent with advice previously published in Coding Clinic but does include additional instructions on coding instances where there is a malignancy of one site and prophylactic removal of another site to prevent either a new primary malignancy or metastatic disease. A code for the malignancy should be assigned in addition to a code from subcategory V50.4, Prophylactic organ removal. A code from subcategory V50.4 should not be assigned if the patient is having organ removal for treatment of a malignancy, such as the removal of the testes for the treatment of prostate cancer.

Guidelines have been added to Chapter 3 specific to coding diabetes mellitus. The additions are consistent with changes made to the definitions of type I and type II diabetes mellitus effective Oct. 1, 2004. These guidelines are detailed in a previous CCS Prep! column titled “Brush Up on Guidelines for Coding Diabetes Mellitus.”

New guidelines for coding diabetes mellitus and the use of insulin are included. For patients with type II diabetes who routinely use insulin, code V58.67, Long-term (current) use of insulin should be assigned to indicate that the patient uses insulin. Code V58.67 may also be assigned for type I diabetes, if desired. This is consistent with instructions in Coding Clinic 4th Quarter 2004.

Guidelines on coding insulin pump malfunction have also been added. An underdose of insulin due to an insulin pump failure is coded to 996.57, Mechanical complication due to insulin pump, followed by the appropriate diabetes mellitus code. Code 996.57 is also assigned for a malfunction causing an overdose of insulin followed by code 962.3, Poisoning by insulins and antidiabetic agents and the appropriate diabetes mellitus code.

Cerebral infarction/stroke/cerebrovascular accident (CVA): Comprehensive coding guidelines for cardiovascular disease have not been included in this revision. However, guidelines related to the new indexing of CVA to default code 434.91, Acute, but ill-defined, cerebrovascular disease have been added as have instructions on coding postoperative cerebrovascular accidents. Both of these issues have been previously addressed in Coding Clinic.

Guidelines for Chapter 8 Diseases of Respiratory System have been added specific to Chronic Obstructive Pulmonary Disease [COPD] and Asthma and COPD with Bronchitis. The coding of these conditions are often confusing to the coder especially in light of the many changes that have occurred in the classification and indexing of these conditions.

Coding COPD and Asthma: The new guidelines indicate that due to the overlapping nature of the conditions that make up COPD and asthma, there are many variations in the way these conditions are documented. When selecting the correct code for the documented type of COPD and asthma, it is essential to first review the index, and then verify the code in the tabular list. There are many instructional notes under the different COPD subcategories and codes. It is important that all of these notes be reviewed to assure correct code assignment. If status asthmaticus is documented with any type of COPD or with acute bronchitis, the status asthmaticus should be sequenced first. It supersedes any type of COPD including that with acute exacerbation or acute bronchitis. If documentation indicated both status asthmaticus and acute exacerbation only the 5th digit 1 indicating status asthmaticus should be assigned.

Acute bronchitis with COPD: When acute bronchitis is documented with COPD, code 491.22, Obstructive chronic bronchitis with acute bronchitis, should be assigned. It is not necessary to also assign code 466.0. The acute bronchitis included in code 491.22 supersedes the acute exacerbation. Code 491.22 is a new code effective Oct. 1, 2004, and was created to alleviate confusion caused by previous index changes related to coding acute bronchitis with COPD.

Chapter 14 Congenital Anomalies: Guide-lines have been added and indicate that codes from this chapter may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code identifying the history of the anomaly should be assigned instead.

Chapter 15 Newborn Guidelines: These have been revised and include a number of guidelines previously published in Coding Clinic. Of note are guidelines for coding newborn sepsis. Code 771.81, Septicemia [sepsis] of newborn with a secondary code from category 041, Bacterial infection in conditions classified elsewhere. A SIRS code or a code from category 038, Septicemia should not be used on a newborn record.

V Code Table: The V code table identifies which V codes may be assigned as principal/first listed diagnosis or as additional codes. This table was previously published separately but is now included in the official guidelines.

Sections II and III of the guidelines provide guidance on the selection of principal and additional diagnoses. The care settings that are required to follow these guidelines have been expanded to include all non-outpatient settings (acute care, short-term, long-term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc.). However, the guideline for reporting uncertain diagnosis is applicable only to short-term, acute, long-term care and psychiatric hospitals.

Section IV provides guidelines for assigning diagnoses for all outpatient services. No significant changes were made to this section.

The official guidelines should be the principal basis on which all coding and sequencing decisions are made, but only when the ICD-9-CM codebook does not provide specific direction. All changes to the official guidelines should be reviewed in detail. A copy of the revised ICD-9-CM Official Guidelines for Coding and Reporting can be downloaded from the NCHS Web site at www.cdc.gov/nchs/data/icdguide.pdf.

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

1. A patient with type I diabetes is seen in the physician’s office for routine care. During the visit, the physician adjusts the patient’s insulin dosage. Should code V58.67, Long-term [current] use of insulin, be assigned as a secondary diagnosis for this case?

a. Yes

b. No

c. May be coded but not required

2. The patient presented to the hospital with expressive aphasia, speech slurring and left-sided weakness. It is determined that the patient had suffered a hemispheric stroke with some residual expressive aphasia, suggestive of cortical infarct. The attending physician recorded acute ischemic cerebrovascular accident. What are the appropriate code assignments?

a. 434.91, 784.3, 780.79

b. 436, 784.3, 780.79

c. 434.90, 784.3, 780.79

3. A patient with known COPD is admitted with acute bronchitis. The physician documents acute bronchitis, exacerbated COPD. How should this case be coded?

a. 466.0, 496

b. 491.22

c. 491.21

4. 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 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

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 Inc. (www.hssweb.com).

Answers to CCS PREP!: 1. c: Code V58.67 may be assigned for type I diabetes, if desired. However, all type I diabetics require insulin therapy via shots or pumps because their body does not produce insulin; 2. a: Assign code 434.91, Cerebral artery occlusion, unspecified, as the principal diagnosis. The fifth digit 1 is required to indicate a cerebral infarction. Code 784.3, Aphasia; and code 780.79, Other malaise and fatigue, should be assigned as additional diagnoses; 3. b: Assign code 491.22, Obstructive chronic bronchitis with acute bronchitis. Although the patient also has an exacerbation of his COPD, acute bronchitis often exacerbates an existing COPD; therefore, only one code from subcategory 491.2 is necessary; 4. d. Code 038.9 is assigned to identify the severe sepsis. Code 995.92 is assigned instead of code 992.51 to identify SIRS due to infectious process with organ dysfunction. The respiratory failure, which is the organ dysfunction, is coded to 518.81. Because the type of pneumonia is unknown it is coded to 486, Pneumonia, organism unspecified.

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