Study of the Official ICD-9 Guidelines Crucial

Vol. 12 •Issue 3 • Page 8

ccs prep!

Study of the Official ICD-9 Guidelines Crucial

Patricia Maccariella-Hafey, RHIA, CCS, CCS-P

In this issue of CCS Prep! we will address the importance of the Official ICD-9-CM Guidelines for Coding and Reporting (OCG) for inpatient records. The guidelines also address outpatient and physician office coding, which will be discussed in another issue of CCS Prep! The OCG are approved by the four cooperating parties, 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).

These guidelines have been in place for a long time, and CMS announced in 1989 that the Official Guidelines, as published in the Coding Clinic are the only official source for coding direction. Although many coders have been taught the guidelines, and know of them, it is surprising how many times they can be overlooked. The exams do test the coder’s knowledge of these so don’t take review of these guidelines lightly. Many a question is missed without clear understanding of these guidelines! Also of note is the fact that these guidelines are in the progress of being revised. The revisions should not affect the examinations if they are available at test time. We will keep you posted!

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 of the OCG can be obtained by contacting the NCHS at The guidelines are also available on the AHIMA Coding Communities of Practice Coding Web site as a community link and at the back of the Faye Brown Coding Handbook. 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.

Take some time now to locate the guidelines and review the inpatient guidelines. For the purpose of this issue, review OCG 1. General Inpatient Coding Guidelines, OCG 2. Selection of Principal Diagnosis, and OCG 3. Reporting Other (Additional) Diagnoses. We will discuss other OCG in upcoming issues of CCS Prep! When you are ready, take the following quiz to test your OCG knowledge.

Quiz Time

1. The UHDDS and OCG 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. The OCG above occurs in what section of the OCGs?


  • Section 1


  • Section 2


  • Section 3

    3. Neoplasm Coding Guidelines occur in what section of the OCGs?


  • Section 2.13


  • Section 3.2


  • Section 1.6

    4. 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:


  • should be reported, as it is documented in the record and treated.


  • the physician should be queried to validate the diagnosis’ significance.


  • should not be reported.

    5. A patient is admitted with chest pain. The patient has a history of prior reflux, but he indicates this pain is different. The patient had been lifting weights earlier in the day. A coronary etiology is worked up but found to be negative. The patient was given antacids and pain medication to ease the symptoms. The physician lists the diagnosis “chest pain due to costochondritis vs. indigestion.” What OCG applies to the coding of this case?


  • Section 2.6 Two or more comparative or contrasting diagnoses.


  • Section 2.4 Two or more interrelated conditions, each potentially meeting the definition of principal diagnosis.


  • Section 2.7 Symptom followed by contrasting/comparative diagnoses.

    6. What codes are reported for the above scenario in #5?


  • 786.50 chest pain


  • 786.50, chest pain, 733.6, costochondritis, and 536.8, indigestion


  • 733.6, costochondritis and 536.8, indigestion


  • OCG 2.9 addresses original treatment plans not carried out. If a patient is admitted for a cholecystectomy secondary to chronic cholecystitis, and the patient has a bout of atrial fibrillation that cancels the procedure:


  • Code the atrial fibrillation as principal


  • Code the chronic cholecystitis as principal


  • Code V64.1, Surgical procedure not carried out due to contraindication as principal

    8. Symptom codes can be reported as principal diagnosis if:


  • The patient is admitted with overdose of prescribed mediation


  • A definitive etiology is unknown


  • A residual or late effect is the reason for admission


  • A reason for the symptom is undetermined


  • b, c, and d above


  • All of the above

    9. When coding acute and chronic conditions:


  • Code only the acute problem


  • Code only the chronic problem


  • Code both the acute and chronic problem if codes exist for each

    10. If a patient has multiple injuries, code:


  • all the injuries, and any of them can be listed as principal


  • all the injuries, and list the most severe injury as determined by the MD as principal


  • the injury to which a procedure was done to address as the principal

    11. Excluding V codes, resolved conditions and procedures from previous admissions that have no bearing on the current stay:


  • Should always be coded since the MD listed it.


  • Are not reported and coded only if required by hospital policy.


  • The coder can use his/her discretion on whether they should be coded.

    12. How many “requirements” are listed to comprise the General Rule on the reporting of additional diagnoses: (in which only one is needed)


  • 3


  • 4


  • 5

    Below are some areas that can cause problems. Pay special attention to these areas:

    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.

    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.

    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.

    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.

    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.

    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.

    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.

    2.6 Two or more comparative or contrasting conditions. In the rare instance that two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology) they are coded as if confirmed and sequencing is based on the circumstances of admission.

    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.

    Reporting Other (Additional) Diagnoses

    (Page 21 of the 2002 certification guide, Appendix B, gives examples as well)

    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 as to whether or not the condition should be added.

    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.

    Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, coding education and contract coding for hospitals. The corporate office is headquartered in Pawley’s Island, SC.

    Coding Clinic is published quarterly by the American Hospital Association

    “CPT only© 2001 American Medical Association. All Rights Reserved.”