ICD-9-CM

for Hospitals – Volumes 1, 2 & 3

2014 Professional

International Classification of Diseases9th Revision

Clinical ModificationSixth Edition

Edited by:Anita C. Hart, RHIA, CCS, CCS-PMelinda S. Stegman, MBA, CCSBeth Ford, RHIT, CCS

Optum is committed to providing you with the ICD-9-CM code update information you need to code accurately and to be in compliance with HIPAA regulations. In case of adoption of additional ICD-9-CM code changes effective April 1, 2014, Optum will provide these code changes to you at no additional cost! Just check back at www.optumcoding.com/productalerts to review the latest information concerning any new code changes.

Codes Valid October 1, 2013, through September 30, 2014

IHP Prelimn.fm Page i W ednesday, June 20, 2012 10:44 AM

415–420.91 Diseases of the Circulatory System Tabular List

8 Newborn Age: 0 9 Pediatric Age: 0-17 x Maternity Age: 12-55 y Adult Age: 15-124 a Major CC Condition A CC Condition 7 HIV Related Dx 140 – Volume 1 • October 2012 2013 ICD-9-CM

415–

420.

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m Diseases of Pulmonary Circulation (415-417)

b 415 Acute pulmonary heart disease

415.0 Acute cor pulmonale a

2 cor pulmonale NOS (416.9)DEF: A heart-lung disease marked by dilation and failure of the right side of heart; due to pulmonary embolism; ventilatory function is impaired and pulmonary hypertension results.CC Excl: 415.0, 416.8-416.9, 459.89-459.9

c 415.1 Pulmonary embolism and infarctionPulmonary (artery) (vein): Pulmonary (artery) (vein):

apoplexy infarction (hemorrhagic)embolism thrombosis

2 chronic pulmonary embolism (416.2) personal history of pulmonary embolism (V12.55) that complicating:

abortion (634-638 with .6, 639.6)ectopic or molar pregnancy (639.6)pregnancy, childbirth, or the puerperium

(673.0-673.8)DEF: Embolism: Closure of the pulmonary artery or branch; due to thrombosis (blood clot).DEF: Infarction: Necrosis of lung tissue; due to obstructed arterial blood supply, most often by pulmonary embolism.AHA: 4Q, ‘90, 25

11 415.11 a Use additional code for associated septic pulmonary

embolism, if applicable, 415.12CC Excl: 415.11-415.19, 416.2, 444.01-444.09, 459.89-459.9AHA: 4Q, ‘95, 58TIP: Do not report code 997.39 Other respiratory complications, with code 415.11.

415.12 aSeptic embolism NOSCode first underlying infection, such as:

septicemia (038.0-038.9) 2 septic arterial embolism (449)CC Excl: See code: 415.11AHA: 4Q, ’07, 84-86

11 415.13 aCC Excl: See code 415.11AHA: 4Q, ’11, 107-108

11 415.19 aCC Excl: See code: 415.11AHA: 3Q, ’10, 10; 4Q, ’09, 86I26.99 Other pulmonary emb w/o acute cor pulmonale

b 416 Chronic pulmonary heart disease

416.0 Primary pulmonary hypertension AIdiopathic pulmonary arteriosclerosisPulmonary hypertension (essential) (idiopathic) (primary)2 pulmonary hypertension NOS (416.8)

secondary pulmonary hypertension (416.8)DEF: A rare increase in pulmonary circulation, often resulting in right ventricular failure or fatal syncope.CC Excl: 278.03, 416.0, 416.8-416.9, 417.8-417.9, 459.89-459.9I27.0 Primary pulmonary hypertension

416.1 Kyphoscoliotic heart disease ADEF: High blood pressure within the lungs as a result of curvature of the spine.CC Excl: 278.03, 416.0-416.1, 416.8-416.9

416.2 Chronic pulmonary embolism AUse additional code, if applicable, for associated long-term

(current) use of anticoagulants (V58.61) 2 personal history of pulmonary embolism (V12.55)DEF: A long-standing condition commonly associated with pulmonary hypertension in which small blood clots travel to the lungs repeatedly over many weeks, months, or years, requiring continuation of established anticoagulant or thrombolytic therapy.CC Excl: 415.11-415.19, 416.2, 444.01-444.09, 459.89-459.9AHA: 4Q, ’09, 85, 86

416.8 Other chronic pulmonary heart diseasesPulmonary hypertension NOSPulmonary hypertension, secondaryAHA: w1Q, ’12, 17;x 1Q, ’11, 10; 2Q, ’10,10I27.89 Other specified pulmonary heart diseases

416.9 Chronic pulmonary heart disease, unspecifiedChronic cardiopulmonary diseaseCor pulmonale (chronic) NOS

b 417 Other diseases of pulmonary circulation

417.0 Arteriovenous fistula of pulmonary vessels A

2 congenital arteriovenous fistula (747.32) DEF: Abnormal communication between blood vessels within lung.CC Excl: 417.0-417.9

417.1 Aneurysm of pulmonary artery A

2 congenital aneurysm (747.39)congenital arteriovenous aneurysm (747.32)

CC Excl: See code: 417.0

417.8 Other specified diseases of pulmonary circulationPulmonary: Pulmonary:

arteritis endarteritis

417.9 Unspecified disease of pulmonary circulation

Other Forms of Heart Disease (420-429)

b 420 Acute pericarditis1 acute:

mediastinopericarditismyopericarditispericardial effusionpleuropericarditispneumopericarditis

2 acute rheumatic pericarditis (391.0)postmyocardial infarction syndrome [Dressler's] (411.0)

DEF: Inflammation of the pericardium (heart sac); pericardial friction rub results from this inflammation and is heard as a scratchy or leathery sound.

420.0 A

Code first underlying disease, as:actinomycosis (039.8)amebiasis (006.8)chronic uremia (585.9)nocardiosis (039.8)tuberculosis (017.9)uremia NOS (586)

2 pericarditis (acute) (in):Coxsackie (virus) (074.21)gonococcal (098.83)histoplasmosis (115.0-115.9 with fifth-digit 3)meningococcal infection (036.41)syphilitic (093.81)

CC Excl: 391.0, 393, 420.0-420.99, 423.3-423.9, 459.89-459.9

c 420.9 Other and unspecified acute pericarditis

420.90 Acute pericarditis, unspecified APericarditis (acute): Pericarditis (acute):

NOS siccainfective NOS

CC Excl: See code: 420.0AHA: 2Q, ‘89, 12

420.91 Acute idiopathic pericarditis APericarditis, acute: Pericarditis, acute:

benign viralnonspecific

CC Excl: See code: 420.0

11 HAC when reported with procedure codes 00.85-00.87, 81.51, 81.52, 81.54 and POA = N

Iatrogenic pulmonary embolism and infarction

Septic pulmonary embolism

Saddle embolus of pulmonary artery

Other

I-10

I-10

RuptureStricture of pulmonary vessel

I-10

Acute pericarditis in diseases classified elsewhere

ICD9 V1 Hospital book.book Page 140 Tuesday, June 19, 2012 10:15 AM

Tabular List Diseases of the Circulatory System 420.99–423.2 Diseases of the Circulatory System

420.99–423.2

bc Additional Digit Required Unacceptable PDx Manifestation Code Hospital Acquired Condition wx Revised Text l New Code s Revised Code Title2013 ICD-9-CM Volume 1 – 141

Anatomy

Blood Flow

420.99 Other APericarditis (acute):

pneumococcalpurulentstaphylococcalstreptococcalsuppurative

PneumopyopericardiumPyopericardium2 pericarditis in diseases classified elsewhere

(420.0)CC Excl: See code: 420.0

b 421 Acute and subacute endocarditisDEF: Bacterial inflammation of the endocardium (intracardiac area); major symptoms include fever, fatigue, heart murmurs, splenomegaly, embolic episodes and areas of infarction.

421.0 Acute and subacute bacterial endocarditis a7Endocarditis (acute)(chronic) (subacute):

bacterialinfective NOSlentamalignantpurulentsepticulcerativevegetative

Infective aneurysmSubacute bacterial endocarditis [SBE]Use additional code to identify infectious organism [e.g.,

Streptococcus 041.0, Staphylococcus 041.1]CC Excl: 391.1, 397.9, 421.0-421.9, 424.90-424.99, 459.89-459.9AHA: 4Q, ‘08, 73; 1Q, ‘99, 12; 1Q, ‘91, 15I33.0 Acute and subacute infective endocarditis

421.1 a

Code first underlying disease, as:blastomycosis (116.0)Q fever (083.0)typhoid (fever) (002.0)

2 endocarditis (in):Coxsackie (virus) (074.22)gonococcal (098.84)histoplasmosis (115.0-115.9 with fifth-digit 4)meningococcal infection (036.42)monilial (112.81)

CC Excl: See code: 421.0

421.9 Acute endocarditis, unspecified a7

2 acute rheumatic endocarditis (391.1)CC Excl: See code: 421.0

b 422 Acute myocarditis2 acute rheumatic myocarditis (391.2)DEF: Acute inflammation of the muscular walls of the heart (myocardium).

422.0 a

Code first underlying disease, as:myocarditis (acute):

influenzal (487.8, 488.09, 488.19)tuberculous (017.9)

2 myocarditis (acute) (due to):aseptic, of newborn (074.23)Coxsackie (virus) (074.23)diphtheritic (032.82)meningococcal infection (036.43)syphilitic (093.82)toxoplasmosis (130.3)

CC Excl: 391.2, 398.0, 422.0-422.99, 429.0, 429.71-429.79, 459.89-459.9

c 422.9 Other and unspecified acute myocarditis

422.90 Acute myocarditis, unspecified a7Acute or subacute (interstitial) myocarditisCC Excl: See code: 422.0

422.91 Idiopathic myocarditis a7Myocarditis (acute or subacute):

Fiedler'sgiant cellisolated (diffuse) (granulomatous)nonspecific granulomatous

CC Excl: See code: 422.0

422.92 Septic myocarditis a7Myocarditis, acute or subacute:

pneumococcalstaphylococcal

Use additional code to identify infectious organism [e.g., Staphylococcus 041.1]

2 myocarditis, acute or subacute:in bacterial diseases classified elsewhere

(422.0)streptococcal (391.2)

CC Excl: See code 422.0

422.93 Toxic myocarditis a7DEF: Inflammation of the heart muscle due to an adverse reaction to certain drugs or chemicals reaching the heart through the bloodstream.CC Excl: See code: 422.0

422.99 Other a7CC Excl: See code: 422.0

b 423 Other diseases of pericardium2 that specified as rheumatic (393)

423.0 Hemopericardium ADEF: Blood in the pericardial sac (pericardium).CC Excl: 423.0-423.9, 459.89-459.9

423.1 Adhesive pericarditis AAdherent pericardium Pericarditis:Fibrosis of pericardium adhesiveMilk spots obliterative

Soldiers' patchesDEF: Two layers of serous pericardium adhere to each other by fibrous adhesions.CC Excl: See code: 423.0

423.2 Constrictive pericarditis AConcato's disease Pick's disease of heart (and liver)DEF: Inflammation identified by a rigid, thickened and sometimes calcified pericardium; ventricles of the heart not adequately filled; congestive heart failure may result.CC Excl: See code: 423.0

Superior venacava

Pulmonary arteryPulmonary vein

Pulmonary valve

Inferior vena cava

Left atrium

Aorta

Right atriumMitral valve

Right ventricle

Aortic valve

Tricuspid valve

Chordatendinae

Left ventricle

I-10

Acute and subacute infective endocarditis in diseases classified elsewhere

EndocarditisMyoendocarditisPeriendocarditis

acute or subacute

Acute myocarditis in diseases classified elsewhere

ICD9 V1 Hospital book.book Page 141 Tuesday, June 19, 2012 10:15 AM

00.22–00.49 Procedures and Interventions, Not Elsewhere Classified Tabular List

5 Bilateral Procedure 4 Non-covered Procedure 3 Limited Coverage Procedure wx Revised Text l New Code s Revised Code Title70 – Volume 3 • February 2012 2013 ICD-9-CM

00.2

2–00

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ified 00.22 Intravascular imaging of intrathoracic vessels

Aorta and aortic archIntravascular ultrasound (IVUS), intrathoracic vesselsVena cava (superior) (inferior)2 diagnostic ultrasound (non-invasive) of

other sites of thorax (88.73)

00.23 Intravascular imaging of peripheral vesselsImaging of:

vessels of arm(s)vessels of leg(s)

Intravascular ultrasound (IVUS), peripheral vessels2 diagnostic ultrasound (non-invasive) of

peripheral vascular system (88.77)

00.24 Intravascular imaging of coronary vesselsIntravascular ultrasound (IVUS), coronary vessels2 diagnostic ultrasound (non-invasive) of

heart (88.72)intracardiac echocardiography [ICE]

(ultrasound of heart chamber(s)) (37.28)

AHA: 3Q, ’06, 8

00.25 Intravascular imaging of renal vesselsIntravascular ultrasound (IVUS), renal vesselsRenal artery2 diagnostic ultrasound (non-invasive) of

urinary system (88.75)

00.28 Intravascular imaging, other specified vessel(s)

00.29 Intravascular imaging, unspecified vessel(s)

b 00.3 Computer assisted surgery [CAS]CT-free navigationImage guided navigation (IGN)Image guided surgery (IGS)Imageless navigationThat without the use of robotic(s) technologyCode also diagnostic or therapeutic procedure 2 robotic assisted procedures (17.41-17.49)

stereotactic frame application only (93.59)TIP: CAS includes three key activities: surgical planning, registration, and navigation; typically used in brain; cranial; ear, nose and throat (ENT); spinal; and orthopaedic surgeries.

00.31AHA: 4Q, ’04, 113

00.32AHA: 4Q, ’04, 113

00.33

00.34

00.35

00.39Computer assisted surgery NOS

b 00.4 Adjunct vascular system procedures These codes can apply to both coronary and peripheral vessels. These codes are to be used in conjunction with other therapeutic procedure codes to provide additional information on the number of vessels upon which a procedure was performed and/or the number of stents inserted. As appropriate, code both the number of vessels operated on (00.40-00.43), and the number of stents inserted (00.45-00.48).

Code also any:angioplasty (00.61-00.62, 00.66, 39.50)atherectomy (17.53-17.56)endarterectomy (38.10-38.18) insertion of vascular stent(s) (00.55, 00.63-00.65,

36.06-36.07, 39.90)other removal of coronary artery obstruction (36.09)

AHA: 4Q, ’05, 101

00.40Number of vessels, unspecified2 (aorto)coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

AHA: w4Q, ’11, 166-167;x 4Q, ’10, 113; 2Q, ’10, 8-9; 3Q, ’09, 13; 2Q, ’09, 12; 1Q, ‘07, 17; 3Q, ’06, 8; 4Q, ’05, 71, 106

Stenting Techniques on Vessel Bifurcation

00.412 (aorto)coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

AHA: 4Q, ’06, 119; 4Q, ’05, 105

00.422 (aorto)coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

00.432 (aorto)coronary bypass (36.10-36.19)

intravascular imaging of blood vessels (00.21-00.29)

00.44This code is to be used to identify the presence of a vessel bifurcation; it does not describe a specific bifurcation stent. Use this code only once per operative episode, irrespective of the number of bifurcations in vessels.

AHA: 4Q, ’06, 119

00.45Number of stents, unspecified AHA: w4Q, ’11, 167;x 4Q, ’10, 113; 3Q, ’09, 13; 4Q, ’05, 71

00.46AHA: 2Q, ’09, 12; 4Q, ’05, 105-106

00.47AHA: 4Q, ’06, 119

00.48

00.49Aqueous oxygen (AO) therapySSO2SuperOxygenation infusion therapyCode also any:

injection or infusion of thrombolytic agent (99.10)insertion of coronary artery stent(s) (36.06-36.07)intracoronary artery thrombolytic infusion (36.04)number of vascular stents inserted (00.45-00.48)number of vessels treated (00.40-00.43)open chest coronary artery angioplasty (36.03)other removal of coronary obstruction (36.09)percutaneous transluminal coronary angioplasty

[PTCA] (00.66)procedure on vessel bifurcation (00.44)transluminal coronary atherectomy (17.55)

2 other oxygen enrichment (93.96)other perfusion (39.97)

DEF: Method of reducing myocardial tissue damage via infusion of super-oxygenated blood directly to oxygen-deprived myocardial tissue in MI patients; typically performed as an adjunct procedure during PTCA or stent insertion.AHA: 4Q, ‘08, 162

Computer assisted surgery with CT/CTA

Computer assisted surgery with MR/MRA

Computer assisted surgery with fluoroscopy

Imageless computer assisted surgery

Computer assisted surgery with multiple datasets

Other computer assisted surgery

NOTE

Procedure on single vessel

T Stent

VStent

Y Stent

DoubleBarrel

Trouser

(doubledensity)

Procedure on two vessels

Procedure on three vessels

Procedure on four or more vessels

Procedure on vessel bifurcation

NOTE

Insertion of one vascular stent

Insertion of two vascular stents

Insertion of three vascular stents

Insertion of four or more vascular stents

SuperSaturated oxygen therapy

ICD9 V3 Hospital book.book Page 70 Tuesday, June 19, 2012 12:08 PM

Additional Digit Required Valid OR Procedure Non-OR Procedure Adjunct Code2013 ICD-9-CM Volume 3 – 133

Tabular List Operations on the Digestive System 46.1–46.80 Operations on the Digestive System

46.1–46.80

ab

b 46.1 ColostomyCode also any synchronous resection (45.49, 45.71-45.79,

45.8)2 loop colostomy (46.03)

that with abdominoperineal resection of rectum (48.5)

that with synchronous anterior rectal resection (48.62)

DEF: Creation of opening from large intestine through abdominal wall to body surface.

46.10

46.11

46.13

46.14 Delayed opening of colostomy

b 46.2 IleostomyCode also any synchronous resection (45.34, 45.61-45.63)2 loop ileostomy (46.01)DEF: Creation of artificial anus by bringing ileum through abdominal wall to body surface.

46.20

46.21

46.22DEF: Creation of opening from third part of small intestine through abdominal wall, with pouch outside abdomen.AHA: M-J, ‘85, 17

46.23

46.24 Delayed opening of ileostomy

b 46.3 Other enterostomyCode also any synchronous resection (45.61-45.8)

46.31 Delayed opening of other enterostomy

46.32 Percutaneous (endoscopic) jejunostomy [PEJ]Endoscopic conversion of gastrostomy to

jejunostomyPercutaneous (endoscopic) feeding enterostomy2 percutaneous [endoscopic]

gastrojejunostomy (bypass) (44.32)DEF: Percutaneous feeding enterostomy: Surgical placement of a (feeding) tube through the midsection of the small intestine through the abdominal wall.DEF: Conversion of gastrostomy to jejunostomy: Endoscopic advancement of a jejunostomy tube through an existing gastrostomy tube into the proximal jejunum.AHA: 3Q, ’10, 13

46.39 OtherDuodenostomy Feeding enterostomyAHA: 3Q, ‘89, 15

b 46.4 Revision of intestinal stomaDEF: Revision of opening surgically created from intestine through abdominal wall, to skin surface.

46.40

Plastic enlargement of intestinal stomaReconstruction of stoma of intestineRelease of scar tissue of intestinal stoma2 excision of redundant mucosa (45.41)

46.412 excision of redundant mucosa (45.33)AHA: 2Q, '05, 11

46.42

46.432 excision of redundant mucosa (45.41)AHA: 2Q, ‘02, 9TIP: Assign for a relocation of a stoma.

b 46.5 Closure of intestinal stomaCode also any synchronous resection (45.34, 45.49,

45.61-45.8)

46.50

46.51

46.52Closure or take-down of cecostomyClosure or take-down of colostomyClosure or take-down of sigmoidostomyAHA: 1Q, ’09, 5; 2Q, '05, 4; 3Q, ‘97, 9; 2Q, ‘91, 16; N-D, ‘87, 8

b 46.6 Fixation of intestine

46.60Fixation of intestine to abdominal wall

46.61Ileopexy

46.62Noble plication of small intestinePlication of jejunumDEF: Noble plication of small intestine: Fixing small intestine into place with tuck in small intestine.DEF: Plication of jejunum: Fixing small intestine into place with tuck in midsection.

46.63Cecocoloplicopexy Sigmoidopexy (Moschowitz)

46.64Cecofixation Colofixation

b 46.7 Other repair of intestine2 closure of:

ulcer of duodenum (44.42)vesicoenteric fistula (57.83)

46.71

46.72

46.73

AHA: 1Q, ‘10, 11

46.74

2 closure of:artificial stoma (46.51)vaginal fistula (70.74)

repair of gastrojejunocolic fistula (44.63)

46.75

46.762 closure of:

gastrocolic fistula (44.63)rectal fistula (48.73)sigmoidovesical fistula (57.83)stoma (46.52)vaginal fistula (70.72-70.73)vesicocolic fistula (57.83)vesicosigmoidovaginal fistula (57.83)

AHA: 3Q, ‘99, 8

46.79DuodenoplastyAHA: 3Q, ‘02, 11TIP: Assign for duodenoplasty, typically performed for infants with congenital duodenal webs and stenosis.

b 46.8 Dilation and manipulation of intestineAHA: 1Q, ‘03, 14

46.80

Correction of intestinal Reduction of:malrotation intestinal volvulus

Reduction of: intussusceptionintestinal torsion

2 reduction of intussusception with:fluoroscopy (96.29)ionizing radiation enema (96.29)ultrasonography guidance (96.29)

DEF: Correction of intestinal malrotation: Repair of abnormal rotation.DEF: Reduction of: Intestinal torsion: Repair of twisted segment. Intestinal volvulus: Repair of a knotted segment. Intussusception: Repair of prolapsed segment.AHA: 4Q, ‘98, 82TIP: Do not assign if the documentation indicates only “running or milking the bowel.” This is an integral component of other procedures.

Colostomy, not otherwise specified

Temporary colostomy

Permanent colostomy

Ileostomy, not otherwise specified

Temporary ileostomy

Continent ileostomy

Other permanent ileostomy

Revision of intestinal stoma, not otherwise specified

Revision of stoma of small intestine

Repair of pericolostomy hernia

Other revision of stoma of large intestine

Closure of intestinal stoma, not otherwise specified

Closure of stoma of small intestine

Closure of stoma of large intestine

Fixation of intestine, not otherwise specified

Fixation of small intestine to abdominal wall

Other fixation of small intestine

Fixation of large intestine to abdominal wall

Other fixation of large intestine

Suture of laceration of duodenum

Closure of fistula of duodenum

Suture of laceration of small intestine, except duodenum

Closure of fistula of small intestine, except duodenum

Suture of laceration of large intestine

Closure of fistula of large intestine

Other repair of intestine

Intra-abdominal manipulation of intestine, not otherwise specified

ICD9 V3 Hospital book.book Page 133 Tuesday, June 19, 2012 12:08 PM

2013 ICD-9-CM Coding Guidelines – 1

Official ICD-9-CM Guidelines for Coding and Reporting

Effective October 1, 2011

Note: Since no official ICD-9-CM addendum to the guidelines was released in 2012, the guidelines included in this book stand as the official guidelines effective October 1, 2012, through September 30, 2013.

The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO).

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.

These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in Volumes I, II and III of ICD-9-CM, but provide additional instruction. 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 healthcare settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

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 guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting.

Section I. Conventions, general coding guidelines and chapter specific guidelinesA. Conventions for the ICD-9-CM

1. Format:

2. Abbreviations

a. Index abbreviations

b. Tabular abbreviations

3. Punctuation

4. Includes and Excludes Notes and Inclusion terms

5. Other and Unspecified codes

a. “Other” codes

b. “Unspecified” codes

6. Etiology/manifestation convention (“code first”, “use additional code” and “in diseases classified elsewhere” notes)

7. “And”

8. “With”

9. “See” and “See Also”

B. General Coding Guidelines

1. Use of Both Alphabetic Index and Tabular List

2. Locate each term in the Alphabetic Index

3. Level of Detail in Coding

4. Code or codes from 001.0 through V91.99

5. Selection of codes 001.0 through 999.9

6. Signs and symptoms

7. Conditions that are an integral part of a disease process

8. Conditions that are not an integral part of a disease process

9. Multiple coding for a single condition

10. Acute and Chronic Conditions

11. Combination Code

12. Late Effects

13. Impending or Threatened Condition

14. Reporting Same Diagnosis Code More than Once

15. Admissions/Encounters for Rehabilitation

16. Documentation for BMI and Pressure Ulcer Stages

17. Syndromes

18. Documentation of Complications of Care

C. Chapter-Specific Coding Guidelines

1. Chapter 1: Infectious and Parasitic Diseases (001-139)

a. Human Immunodeficiency Virus (HIV) Infections

b. Septicemia, Systemic Inflammatory Response Syndrome (SIRS), Sepsis, Severe Sepsis and Septic Shock

c. Methicillin Resistant Staphylococcus aureus (MRSA) Conditions

2. Chapter 2: Neoplasms (140-239)

a. Treatment directed at the malignancy

b. Treatment of secondary site

c. Coding and sequencing of complications

d. Primary malignancy previously excised

e. Admissions/Encounters involving chemotherapy, immunotherapy and radiation therapy

f. Admission/encounter to determine extent of malignancy

g. Symptoms, signs, and ill-defined conditions listed in Chapter 16 associated with neoplasms

h. Admission/encounter for pain control/management

i. Malignant neoplasm associated with transplanted organ

3. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279)

a. Diabetes mellitus

4. Chapter 4: Diseases of Blood and Blood Forming Organs (280-289)

a. Anemia of chronic disease

5. Chapter 5: Mental Disorders (290-319)

Reserved for future guideline expansion

6. Chapter 6: Diseases of Nervous System and Sense Organs (320-389)

a. Pain - Category 338

b. Glaucoma

7. Chapter 7: Diseases of Circulatory System (390-459)

a. Hypertension