Revisions Address New ICD-9 Codes, Part 2

This month’s CCS Prep! column focuses on additional revisions to the ICD-9-CM Official Guidelines for Coding and Reporting, which become effective Oct. 1, 2008. This is the second half of a two-part column on the new ICD-9-CM diagnosis codes and related coding guidelines for secondary diabetes mellitus and ventilator associate pneumonia. Coding guideline changes unrelated to new codes as well as those for present on admission reporting are also summarized. 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 last month’s CCS Prep! column, these 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.

Secondary Diabetes Mellitus
New codes have been created to report secondary diabetes mellitus. Secondary diabetes mellitus refers to elevated blood sugar levels that develop as the result of another medical condition such as cystic fibrosis. Secondary diabetes may also develop when pancreatic tissue is destroyed by disease, such as chronic pancreatitis.

Twenty new diagnosis codes have been created to report secondary diabetes mellitus. New category 249, Secondary diabetes, has been created and includes the following new subcategories:

249.0 Secondary diabetes mellitus without mention of complication

249.1 Secondary diabetes mellitus with ketoacidosis

249.2 Secondary diabetes mellitus with hyperosmolarity

249.3 Secondary diabetes mellitus with other coma

249.4 Secondary diabetes mellitus with renal manifestations

249.5 Secondary diabetes mellitus with ophthalmic manifestations

249.6 Secondary diabetes mellitus with neurological manifestations

249.7 Secondary diabetes mellitus with peripheral circulatory manifestations

249.8 Secondary diabetes mellitus with other specified manifestations

249.9 Secondary diabetes mellitus with unspecified complication

The following fifth-digits are to be used with the codes in category 249:

0 not stated as uncontrolled, or unspecified

1 uncontrolled

Coding guidelines have been added to the diabetes mellitus section in Chapter 3 to address the reporting and sequencing of these new secondary diabetes codes. While many of the guidelines are similar to those for reporting codes in category 250, Diabetes Mellitus, there are some differences. The following guidelines are specifically related to those differences.

Codes in category 249 identify complications and manifestations associated with secondary diabetes mellitus. Secondary diabetes is always caused by another condition or event such as cystic fibrosis, malignant neoplasm of pancreas or adverse effect of drug, or poisoning.

Sequencing: When assigning codes for secondary diabetes and its associated conditions, codes from category 249 must be sequenced before the codes for the associated conditions. For example, secondary diabetes with diabetic nephrosis is assigned to code 249.40, followed by 581.81. However, the sequencing of the secondary diabetes codes and the codes that identify the cause of the diabetes is based on the reason for the encounter, as well as ICD-9-CM sequencing conventions, and chapter-specific guidelines.

If a patient is seen for treatment of the secondary diabetes or one of its associated conditions, a code from category 249 is sequenced as the principal or first-listed diagnosis, with the cause of the secondary diabetes sequenced as an additional diagnosis. For example, a patient is seen for secondary diabetes. Cystic fibrosis is identified in the history as the established cause of the secondary diabetes. A code from category 249 is listed first followed by a code for the cystic fibrosis.

In contrast, if the patient is seen for the treatment of the condition causing the secondary diabetes, the code for the cause should be sequenced first followed by a code from category 249. For example, if the same patient as in the previous example is seen for cystic fibrosis, the cystic fibrosis is listed first followed by a code from category 249 to report the secondary diabetes.

Due to the surgical removal of all or part of the pancreas: A code from category 249 should not be assigned for secondary diabetes mellitus due to the surgical removal of all or part of the pancreas. Assign code 251.3, Postsurgical hypoinsulinemia, instead. Code also any diabetic manifestations such as diabetic nephrosis, 581.81.

Review the 2008 CCS Prep column titled “Get Ready for Secondary Diabetes Mellitus Coding,” for additional advice on the use of the new secondary diabetes mellitus codes.

Ventilator associated pneumonia (VAP)
Hospital-associated pneumonia is a common hospital-associated infection. The primary risk factor for the development of hospital-associated pneumonia is mechanical ventilation. VAP was reported using code 999.9, Other and unspecified complication of medical care, NEC, along with the appropriate pneumonia code. The Center for Disease Control and Prevention (CDC) and CMS jointly requested that a new code be created to identify VAP because a unique code did not exist. As a result, new code 997.31, Ventilator associated pneumonia, has been created.

The following coding guidelines have been added to Chapter 17 to provide instruction on reporting this new code.

Coding VAP: Code 997.31 should be assigned only when VAP has been specifically documented. An additional code to identify the organism, such as code 041.7, pseudomonas aeruginosa, should also be assigned. However, do not assign an additional code from categories 480-484 to identify the type of pneumonia.

Code 997.31 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator, but the provider has not specifically stated that the pneumonia is VAP.

If the documentation is unclear as to whether the patient has a pneumonia that is a complication attributable to the mechanical ventilator, the physician should be queried.

Pneumonia present on admission (POA): It is possible that a patient may be admitted with one type of pneumonia and subsequently develops VAP. In this instance, the principal diagnosis would be the appropriate code from categories 480-484 for the pneumonia diagnosed at the time of admission. Code 997.31 would be assigned as an additional diagnosis.

POA Reporting Guidelines A number of changes have been made to the POA guidelines. Although the reporting options have not changed, the fact that Medicare requires a POA value of 1 for diagnosis codes exempt from POA reporting has been added.

Timeframes: A new guideline titled “Timeframe for POA Identification and Documentation” has been added. This guideline reiterates the fact that there is no required timeframe as to when a provider must identify or document a condition to be present on admission. In some situations, it may not be possible to make a definitive diagnosis until a few days after admission. In some cases it may be several days before the provider arrives at a definitive diagnosis. For example a myocardial infarction may not be diagnosed for a patient admitted with chest pain until a few days after admission.

If at the time of code assignment the documentation is unclear as to whether a condition was POA, it is appropriate to query the provider for clarification.

Same diagnosis for two or more conditions: When the same diagnosis code applies to two or more conditions during the same encounter the following guidelines apply:

• Assign “Y” if all conditions were POA. For example, bilateral fracture of the same bone, same site, and both fractures were POA.

• Assign “N” if any of the conditions were not POA. For example, dehydration with hyponatremia is assigned to code 276.1, but only one of these conditions was POA.

A list of additional codes exempt from POA reporting and new Q&As have also been added to the POA section of the guidelines.

Additional Coding Guidelines ChangesThere are a number of changes to the guidelines in addition to those specifically related to the new ICD-9-CM codes and POA. These changes include the following:

Reporting Same Diagnosis Code More than Once: Each unique diagnosis code may be reported only once for an encounter. This applies to bilateral conditions or two different conditions classified to the same diagnosis code. This is an important addition because it clarifies the fact that you cannot assign the same diagnosis code more than once on the same claim. Previously there was no clear coding guideline on this topic.

Other Coding Topics With Guideline Changes

• Admissions/encounters for rehabilitation

• Treatment directed at the malignancy and malignant neoplasm of a transplanted organ

• Newborn sepsis clarification

• Transplant complications and chronic kidney disease and kidney transplant complications

• V codes and V code table

To fully understand all ICD-9-CM Official Guidelines for Coding and Reporting changes effective Oct. 1, 2008, coders should carefully review the document at

Additional information presented at the Coordination and Maintenance Meeting on the codes discussed in this column can be found at


After reviewing the new guidelines, test your knowledge with the quiz below.

1. A patient tested positive for Methicillin resistant Staphylococcus (MRSA) on routine nasal culture on admission to the hospital. During the hospitalization, he underwent insertion of a central venous catheter and later developed an infection and was diagnosed with MRSA sepsis due to central venous catheter infection. Which of the following is correct?

a. MRSA sepsis with POA “N”

b. MRSA colonization with POA “Y,” MRSA sepsis with POA “N”

c. MRSA sepsis with POA “Y”

2. A newborn was born in the hospital with birth complicated by nuchal cord entanglement. What POA indicator is reported for the nuchal cord entanglement?

a. Y

b. N

3. An 84-year-old male patient is admitted to the hospital with congestive heart failure. On admission, nursing notes document a Stage 1 decubitus ulcer over both buttocks. Four days after admission, nursing notes document progression to a grade III decubitus ulcer on the left buttock and stage II on the right. The physician confirms the presence of decubitus ulcers on both buttocks in her documentation. What is the appropriate diagnosis code and POA assignment for this case?

a. 428.0 Y, 707.05 Y, 707.21 Y

b. 428.0 Y, 707.05 Y, 707.23 N

c. 428.0 Y, 707.05 Y, 707.23 Y

d. 428.0 Y, 707.05 Y, 707.22 N, 707.23 N

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix ( Ingenix is a leader in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.

Coding Clinic for ICD-9-CM is published quarterly by the AHA.

1: b. Assign “Y” for the positive MRSA colonization. Assign “N” for the MRSA sepsis due to central venous catheter infection because the patient did not have a MRSA infection at the time of admission.

2. a. Assign “Y” for the nuchal cord entanglement on the baby’s record. Any condition that is present at birth or that developed in utero is considered POA, including conditions that occur during delivery.

3. d. Assign code 428.0 as the principal diagnosis. Code 707.05 is assigned as a secondary diagnosis to report the decubitus ulcer of both buttocks. Both codes have a POA value of Y because they were both POA. Codes 707.22 and 707.23 are assigned to indicate the progression of the decubitus ulcers from stage I to stages II on one buttock and stage III on the other. Both codes have a POA value of N because the patient was admitted with stage I ulcers that got worse during the hospital stay.