022.1 (anthrax) + 484.5 (pneumonia).
2.) False. “Multilobar pneumonia” simply refers to pneumonia affecting more than one lobe.
2.) True/False? “Mutilobar pneumonia” is synonymous with lobar pneumonia.
042 (AIDS) + 136.3 (Pneumocystosis)
2. Chronic obstructive bronchitis (491.2x).
3. Emphysema (492.8).
4. Chronic bronchitis with emphysema (491.20).
1. 491.2x (Chronic obstructive bronchitis)
2. 493.22 (Chronic obstructive asthma with acute exacerbation).
2. Is assigned a code for the pleural effusion (511.1) and an additional code for the responsible organism.
3. The malignant neoplasm is assigned as the first listed or principle diagnosis and an additional code for malignant pleural effusion (511.81) is added.
1. Pleural effusion due to tuberculosis.
2. Pleural effusion due to another bacterial infection.
3. Malignant pleural effusion.
2.) Principal diagnoses = 518.81 (acute respiratory failure) + 358.01 (Myasthenia gravis with acute exacerbation).
In both cases the acute respiratory failure is sequenced first because it is the reason for admission.
1.) A patient with emphysema (492.8) who develops acute respiratory failure (518.81). The patient is admitted through the emergency department for treatment of the respiratory failure.
2.) The patient with chronic Myasthenia gravis goes into acute exacerbation (358.01) and develops respiratory failure (518.81). The patient is admitted due to respiratory failure.
518.81 (acute respiratory failure) +
042 (AIDS) is sequenced first because of a chapter specific guideline that instruct the coder to assign 042 as the principle diagnoses. Always follow ICD-9 guidelines and instructional notes.
A patient is admitted to respiratory failure due to pneumocystis carinii, which is due to AIDS.
995.92 (severe sepsis) +
518.81 (acute respiratory failure).
The septisemia is sequenced first in this case because of chapter specific instructional notes to first code the underlining infection. Always follow ICD-9 guidelines and instructional notes.
A patient is admitted to the hospital with severe Staphylococcus aureus sepsis and acute respiratory failure.
2.) It is included in the codes for asthma so no additional code is assigned.
1.) Due to infection?
2.) In asthma?
Congestive heart failure (428.0).
Hypertensive heart disease (402.9x).
Rheumatic heart disease (391.x).
Rheumatic heart failure (congestive) (398.91).
2.) Congestive heart failure (428.0).
2.) Unless the heart failure is described as congestive or decompensated in which case a code for _______ is assigned?
2.) Only after mechanical ventilation has actually been initiated (original intubation initiated).
The period during which the weening process took pace is counted toward the duration time.
3.) a. Removal of the endotracheal tube (extubation). b. Discontinuance of ventilation for patients with tracheostomy after weening. c. Discharge or transfer while still on ventilation.
2.) The hours should be counted from when ______?
3.) The duration of mechanical ventilation ends with the following three events?
2.) Combination codes (455.2, internal hemorrhoids with other complications and 455.5, external hemorrhoids with other complications.) Do not assign combination codes for hemorrhoids with bleeding unless the physician specifically states a causal relationship.
1.) Hemorrhoids are incidental findings and unrelated to rectal bleeding.
2.) Bleeding is caused by hemorrhoids, as specified by the physician.
1.) Cirrhosis of liver (571.5) + varices (456.20).
2.) Portal hypertension (572.3) + varices (456.20),
1.) Bleeding esophageal varices with cirrhosis of liver.
2.) Bleeding esophageal varices in portal hypertension.
2.) No. Cholasterolosis is considered integral to other gallbladder pathologies and therefore should not be coded.
2.) When other pathology of the gallbladder is present, should the above condition be coded?
2.) An incisional ventral hernia is classified as ______?
3.) Hernias described as incarcerated or strangulated as _______?
2.) Bariatric surgery technique that involves removal of a portion of the stomach or the resecting or rerouting of the small intestines to a small stomach pouch?
3.) Bariatric surgery technique that reduces the size of the stomach using an implanted device such as gastric banding.
2.) Biliopancreatic diversion (BPD) (43.89).
3.) Another type of Biliopancreatic diversion (BPD) “Duodenal switch” procedure (requires three codes).
5. After care
3. Genetics susceptibility
V71 (most commonly used), V89 (maternal/fetal)
2.) Code category?
4th digit = presence of complications
5th digit = whether diabetes is out of control
2.) Diabetes mellitus Type II
4th digit = ?
5th digit = ?
2.) “diabetes” noted in chart without further specification defaults to__________?
2.) False. In the absence of further specificity, this should be coded as 790.2 (abnormal glucose)
2.) True/False “borderline diabetes” without further specification should be coded as diabetes mellitus.
b.) type I diabetes mellitus
2.) Poisoning by insulins and antidiabetic agents (962.3)
2.) An overdose of insulin as a result of pump malfunction codes to____________?
2.) 249.00 (secondary diabetes without mention of complication, not states as uncontrolled, or unspecified) + E932.0 (Adverse effect of therapuetic use of adrenal cortical steroids)
2.) Example: “steroid induced diabetes mellitus due to prolonged use of corticosteroids for an unrelated condition” is coded as________?
5th digit = whether diabetes is out of control
4th digit identifies______?
5th digit identifies______?
followed by 249 (secondary diabetes) and V88.11/V88.12 (acquired total/partial absence of pancreas) as an additional code.
2.) 251.3 + 249.00 + V88.11
2.) E.g. “postpancreatectomy dibetes mellitus”
2.) 249.4x – 249.8x and 250.4x – 250.8x
3.) as many as necessary to identify all associated diabetic contions the patient may have.
2.) code range for long-term complications of diabetes mellitus, secondary, types I & II?
3.) How many codes from these categories vcn be assigned?
type I/type 2 diabetes.
2.) (a.) code from category 249 is sequenced 1st.
(b.) carcinoma (157.9) should be sequenced 1st.
2. ) E.g. for a patient with secondary diabetes mellitus (249.x) post-inoperable cancer of the pancreas (157.9) how would the following be sequenced?
a.) pt. is being seen by endocrinologist for tx. of diabetes?
b.) pt. is being seen for tx. of carcinoma of pancreas?
2.) hyperosmolarity with/without coma
3.) other coma
2.) Diabetes with other coma, 249.3x/250.3x
1.) Diabetic ketoacidosis (DKA) codes to ______, is found mainly in type ____ diabetes and is, by definition________?
2.) Diabetes with hyperosmoarity is typically found in type _____ diabetes and codes to_____?
3.) This category includes patients with ketoacidosis who have progressed to a comatose state and also includes hypoglycemic coma in a patient with diabetes and insulin coma not otherwise specified. It codes to ______?
2.) 3 codes: Diabetes code (249/250.xx) + 403/404 code to id hypertensive kidney disease + 3rd code 585.x to id stage of chronic kidney disease (CKD)
3.) False. Senile cataracts are not true diabetic cataracts.
2.) Sequencing rule for diabetes with hypertensive kidney disease and chronic kidney disease stage x (I-V)?
3.) True/False? Senile cataracts with diabetes are true manifestations of diabetes & the same as snowflake (diabetic) cataracts.
2.) 775.0 (Syndrome of infant of diabetic mother) or 775.1 (Neonatal diabetes mellitus) is assigned only if such condition is documented.
3.) V30 + V18.0 (family history, diabetes) +V29.3 (obsevation/evaluation) if additional surveillance is required.
2.) 1.) Sequencing/coding rule for transient decrease in blood sugar or hyperglycemia in infants born to a diabetic mother?
3.) Sequencing/coding rule for normal infants born to a diabetic mother?
2.) 251.0 (coma), 251.1 (no coma), & 251.2 (NOS)
3.) E code added to indicate the responsible drug
4.) Poisoning (962.3) + E code for drug
2.) Codes for hypoglycmic reactions in non-diabetic patients with or without coma?
3.) Hypoglycemic shock or coma from insulin used as prescribed?
4.) Hypoglycemic shock or coma from incorrect use of insulin?
2.) BMI only. Overweight/Obesity coding must be based on physicians diagnosis.
2.) For what part of this can nurse/nutritionist notes be used?
Because there is no known cure for cystic fibrosis, most therapy is directed towards the complications & admission for cystic fibrosis itself is not common.
2.) Dementia in this case is coded to 294.1x.
The underlying disease is coded first. – e.g.
331.0 (Alzheimer’s) + 294.1x (dementia.
2.) Coding/sequencing rule for dementia due to physiological effects of underlying disease or condition – e.g. “dementia due to Alzheimer’s”?
2.) False. A diagnosis of “major depression” of “affective disorder” must be documented in the chart. “Depression” listed without further specificity is not enough.
2.) True/False? “Depression” (see above) is the same as an affective disorder such as major depression and can be coded accordingly.
316 (psychological factor) + 427.2 (asthma)
2.) 291.0, 291.3, ; 291.81
3.) 291.81 (withdrawal) + 303.91 (chronic alcoholism)
2.) Subcategories for withdrawal include _______?
3.) How are these are sequenced? – e.g. “”withdrawal due to chronic alcoholism”?
2.) Principle dx. should be the substance abuse/dependence code.
1.) Pt. admitted with a dx. of substance related psychosis?
2.) Pt. admitted for detox or rehab with no indication of withdrawal or psychotic symptoms?
2.) Physical condition is coded 1st + substance abuse/dependence code.
3.) Follow the usual guidelines for selecting
1.) pt admitted for detox or rehab of both drug and alcohol abuse or dependence. Both are treated.
2.) Pt. with a diagnosis of substance abuse or dependence is admitted for tx/eval. of a physical complaint related to the substance use?
3.) Pt. with a diagnosis of substance abuse or dependence is admitted because of an unrelated condition?
2.) 281; the specific type of deficiency, e.g., B12 vitamin deficiency.
2.) Other deficiency anemias are coded in category_______ with the 4th digit indicating ______?
2.) 285.1 (acute post-hemorrhagic anemia).
2.) When post operative anemia is due to acute blood-loss it codes to_______?
3.) When the diagnostic statement does not indicate whether the blood-loss anemia is acute or chronic it codes to_______?
1.) Anemia (285.xx) + chronic kidney disease (585).
2.) Anemia (285.xx) + code for neoplasm or malignancy
3.) Anemia (285.xx) + code for chronic condition.
1.) Anemia and chronic kidney disease.
2.) Anemia and neoplastic disease.
3.) Anemia of other chronic disease.
2.) Cickle-cell trait (282.5)
3.) Hb-SS disease with crisis (282.62) + an additional code to report the type of crisis e.g., acute chest syndrome, splenic, sequestration, etc…).
2.) When a child receives cickle-cell genes from one parent.
3.) Coding/sequencing when vaso-occlusive crisis or other crisis present with cickle-cell?
2.) Thalassemia minor
3.) Thalassemia major
2.) When the above identified genetic trait is inherited by one parent its called_____?
3.) When the above identified genetic trait is inherited by both parents its called_____?
2.) False. Bleeding from these medications does not necessarily indicate that a hemorrhagic disorder due to intrinsic circulating anti-coagulants is present.
3.) In the above situation, code for the condition and associated hemorrhage is assigned with an additional E code to indicate the responsible medication.
2.) True/False? Subcategory 286.5x can be assigned for bleeding in a patient who is being treated with Coumadin, Heparin, or other anti-coagulants.
3.) How is the above coded?
A patient is admitted following multiple episodes of hematemesis secondary to Coumadin therapy. No significant pathology was discovered. The Coumadin was discontinued and no recurrence of the bleeding occurs.
2.) False. Physician concurrence regarding the significant of the laboratory results should be confirmed before assigning (288.xx) codes.
2.) True/False? Codes for the above conditions can be assigned on the basis of laboratory findings alone.
Access the Coding Clinic
It is the coding clarification source for all coders.
What should Coders do if they come across a complex ICD-9 coding issue while coding radiology reports that they are not sure how to code something?
V22.1, supervision of other normal pregnancy(For complications of pregnancy, the above codes are not reported with codes 630-679)
Routine Outpatient Prenatal Visits
This guideline for prenatal visits applies when the prenatal visit occurs and the patient has no current complications.
Under these circumstances, the first-listed diagnosis is reported as either:
-If the patient is no longer being treated for cancer and it is clearly documented that the patient no longer has cancer, only the history of cancer should be coded
-Use the observation and evaluation codes (V71.X) when no other indication is listed e.g.
Assign code V71.1, for observation for suspected malignant neoplasm, as the primary dx for PET scans, when the scan is being done to determine “potential” spread of a malignancy
Diagnostic Radiology Coding Outpatient Coding Challenges:
Another confusing situation is when “rule-out metastasis” is ordered.
If there are no findings, only the original cancer site should be coded
Indication for test: Rule-out metastasis
Findings: Normal x-ray
What to Code:
If no signs or symptoms are documented, then the V71.xx code is appropriate
Diagnostic Radiology Coding Outpatient Coding Challenges:
Common Rule-Out Challenges
Example1: Indication for test: Rule-out pneumonia
Findings: Normal chest x-ray
Note: This is same as the previous screen’s example with “normal” findings on the radiology reports
Diagnostic Radiology Coding Outpatient Coding Challenges:
Indication for test: Rule-out appendicitis
Findings: Normal abdominal x-ray
What to Code?
For follow-up of a fracture, coders can use V54.X (other orthopedic aftercare) as the primary diagnosis
Also, many coders are faced with rule-out diagnosis when the patient is receiving follow-up or aftercare
Indication for test: Follow-up fracture
Findings: Normal x-ray
What to Code:
Answer: Trauma is not always indicative of injury. If there are no findings after diagnostic testing, assign code V71.4, Observation following other accident. However, the patient presents with symptoms (i.e., pain, swelling, tenderness, etc.) assign the appropriate code for the symptoms.
What is coded if the reason for the radiology service is specified only as “trauma”? e.g. CT scan following trauma:Question: CT scan ordered for treatment of injuries sustained for patient following an accident. Reason for the CT is documented on report as “trauma”. How should this be coded?
How should unconfirmed diagnoses described in terms such as “consistent with,” “compatible with,” “indicative of,” “suggestive of,” and “comparable with” be coded in the outpatient setting?
Diagnostic Test Ordered Due to Signs and/or Symptoms
If the physician has confirmed a diagnosis based on the results of the diagnostic test, the coder should ___________?
The abdominal pain would not be coded as it is a symptom of the diverticulitis.
Example: A patient is referred to a radiologist for an abdominal CT scan with a diagnosis of abdominal pain. The CT scan reveals numerous diverticula in the cecum and descending colon. The Impression on the CT report states a diagnosis of “diverticulitis with no evidence of diverticular abscess.
The radiologist should report a diagnosis of “knee pain” since this was the reason for performing the X-ray – Dx Code: 719.46 knee pain
What should be coded if the diagnostic test did not provide a diagnosis or was normal? Example: A patient is referred to a radiologist for a X-ray due to complaints of “knee pain”. The radiologist performs the x-ray, and the results are normal.
How should the results of diagnostic test are normal or non-diagnostic be coded when the referring physician records a diagnosis preceded by words that indicate uncertainty such as probable, suspected, questionable, rule out, or working?
If the Impression or Conclusion of the radiology report is an incidental finding and the radiologist states “incidental” then how would this be coded?
Dx Code: V76.12 for the screening and 793.89 for the breast calcification.
Diagnostic Tests Ordered in the Absence of Signs and/or Symptoms (e. g. screening tests)
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury and therefore no diagnosis documented on the order, Example: Asymptomatic patient coming in for a Screening mammogram, The mammogram Impression states breast calcifications are found.
How should this be coded?
Codes V76.12, V76.11
An ICD-9 code that describes the patient’s documented signs or symptoms such as a lump, pain, thickening, a change in size or shape of the breast
Assign code V76.12, Special screening for malignant neoplasm for this encounter
Coding Clinic, Second Quarter 2003
A healthy 40-year-old woman presents to the radiology department for a screening mammogram. The patient has no symptoms or known risks for breast cancer. How should this be coded?
Assign code V76.12, Special screening for malignant neoplasm, Breast, as the first listed diagnosis, since this was a screening mammogram
Even though a mass was found in the breast, the current visit for the mammogram is still considered a screening. Assign code 611.72, Lump or mass in breast, as an additional diagnosis
Screening mammogram with positive findings Coding Clinic, Second Quarter 2003 Page: 4 Question:
An asymptomatic 65-year-old woman has a screening mammogram, which revealed a breast mass
Assign code V76.11, Special screening for malignant neoplasm, Breast, Screening mammogram for high-risk patient, as the first-listed diagnosis, followed by code V16.3, Family history of malignant neoplasm, Breast
Note: High risk factors include a family history of breast cancer.
Screening mammogram due to family history Coding Clinic, Second Quarter 2003 Page: 4
A woman with no symptoms is referred for screening mammogram. The patient is considered high risk for breast cancer secondary to a family history of breast malignancy in the mother and sister. How should this encounter be coded?
-personal history of breast cancer (V10.3)
• family history of breast cancer (V16.3)
(In Mother, Sister)
• In Daughter
• Had her first baby after age 30 (V15.89)
• Has never had a baby (V15.89)
If there is documentation of these conditions then assign V76.11 as primary dx, with above conditions as a secondary dx
Screening Mammograms- Codes V76.11 High Risk
What constitutes “high risk”?
Assign code V76.12, Special screening for malignant neoplasm, Other screening mammogram, as the first-listed diagnosis. Code 610.1, Diffuse cystic mastopathy, should be assigned as an additional diagnosis
Fibrocystic breast disease is a normal variant, commonly found in normal breasts usually consisting of lumps
Also called diffuse cystic mastopathy chronic cystic mastitis, fibrocystic mastopathy and mammary dysplasia.
This exam would still be considered a screening mammogram and code V76.12 assigned as the first-listed diagnosis
Screening mammogram with known fibrocystic disease Coding Clinic, Second Quarter 2006 Page: 10 Question:
The physicians at our facilities order routine screening mammograms for patients with known fibrocystic disease of the breasts
Based on the guideline for screening that it is the testing for disease or disease precursors in seemingly well individuals it seems that code V76.12 would not be used since fibrocystic breast disease is documented
What should be the first-listed code for a screening mammogram on patients with fibrocystic disease of the breast?
Question: True/False? A diagnostic and screening mammograms are essentially the same and coded as such.
Code any positive findings found on the diagnostic mammogram. If there are no reported findings, assign the reason for the test as the first listed diagnosis. In this instance, assign code 611.72, Lump or mass in breast. Do not assign code V76.12, Special screening for malignant neoplasm, Breast, because this was not a screening mammogram.
A patient with a breast mass is referred to the radiology department for diagnostic mammogram. How should this be coded?
-When a follow-up exam is done to determine if there is any evidence of recurring or metastasizing cancers and no evidence of malignancy is found, this is classified to the V67 category for follow-up
-Assign code V10.3, Personal history of malignant neoplasm, Breast, as an additional diagnosis
– If the follow-up examination demonstrates recurrence or metastasis, a follow-up code from category V67 would not be used.
Coding Clinic, Second Quarter 2003 Page: 5 Question:
An asymptomatic patient with a history of breast cancer who is currently disease-free is referred for follow-up mammogram. What is the correct code assignment for this encounter?
V82 Special screening for other conditions
V82.8X Other specified conditions
V82.89 Other specified conditions
Encounters for osteoporosis screening:
Osteoporosis screening – Dexa Bone Scan
Code V82.8X, Other specified conditions, has been expanded with two new codes. A new code has been added for encounters for osteoporosis screening. This code is to identify the patient who presents for osteoporosis screening who is otherwise asymptomatic
Question: A postmenopausal patient is seen as an outpatient for a bone density study to evaluate for osteoporosis. She has no other signs or symptoms at the present time. What diagnosis code should be used to report this encounter?
Note: Physicians will use the terms “asthma” and “reactive airway disease” (RAD) interchangeably. When you see it documented as RAD it codes to 493.90 which codes to asthma unless it is documented by the physician “RAD, NOT as asthma”
If the dx states ” RAD Not as asthma” then the code assigned is 519.9 unspec disease of respiratory
Code this as the principal or first-listed diagnosis
These codes may be used in conjunction with pregnancy complication codes
Selection of Obstetric Principal or First-listed Diagnosis:
Prenatal outpatient visits for high-risk patients?
1.) Code: 648.23 (other current conditions in mother classifiable elsewhere, but complicating pregnancy, antepartum) + 285.9 (anemia, unspec.)
2.) Code: 648.93 (current condition in mother complicating pregnancy, antepartum) +
Current Conditions Complicating Pregnancy?
1.) Example: Patient is 39 weeks pregnant with slight anemia and is treated with iron?
2.) Example: the patient is 25 weeks pregnant and has COPD. Patient has a chest X-ray done?
2.) Treatment is directed at a current, acute disease or injury; the diagnosis code is to be used in these cases.
3.) Fitting and adjustment, and attention to artificial openings.
Categories of V Codes – Aftercare:
1.) Aftercare visit codes cover __________?
2.) The aftercare V codes should not be used if _________?
3.) Additional V code aftercare category terms include ____________?
4.) True/False? Status V codes may be used with aftercare V codes to indicate the nature of the aftercare.
A code from category V67 is used as the first-listed diagnosis when a patient is seen for evaluation after treatment of a disease or injury has been completed and the condition no longer exists
Aftercare terms to watch for in regards to fractures:
“Healed” vs. “Healing”
Follow-up visit for healed fracture: (Note: term “healed”)
Patient is an 18-year-old male who had previously sustained a comminuted right distal tibial fracture that had been treated. Is now being seen for follow-up X-rays. Conclusion states “Complete alignment and union of fracture with full range of motion” Is code V54.16 Aftercare for healing traumatic fracture of lower leg, assigned for this encounter?
In these cases, code V70.5, Health examinations would be the first listed diagnosis.
An example of an outpatient visit:
When a patient comes in for pre-employment physical exam
You may see a lab order with a dx of pre-employment physical
of the medication Coumadin
Additional dx code V58.61 would also be used to describe long-term use of the anticoagulant
Another example: A patient who is on Coumadin therapy may be required to visit a Coumadin clinic weekly until the levels of medication are adjusted
Lab order dx would be Coumadin monitoring
Step 2: Abstract the confirmed diagnoses to be coded based on that documentation
Step 3: Assign the correct ICD-9-CM diagnosis codes, following the ICD-9-CM rules and conventions.
Step 4: Sequence the codes based on Section IV of the ICD-9-CM Official Guidelines
Outpatient Code Assignment Flow: 4 steps
Code 719.46 for the knee pain, which is the problem for which the service is being done. This would be assigned second
Patients may receive only therapeutic services:
procedures done to treat conditions and injuries – during outpatient visits.
The ICD-9-CM code reported first represents the diagnosis, condition, problem, or other reason for the encounter
Examples: Physical Therapy, Occupational Therapy, Speech Therapy
For example: Physical therapy order for PT with a dx of knee pain documented
A fifth digit is required to indicate the type of pre-operative exam
The reason for the surgery is coded as an additional diagnosis
Codes would be V72.63 Pre-procedural lab exam as first listed code and 401.9 for the HTN as an additional code
When a patient receives a preoperative evaluation only,
For example: A patient is planning surgery for an abdominal aortic aneurysm The patient’s primary care physician sends her for lab work for pre-op evaluation. On the lab order it is documented “Pre-op eval, HTN”
V22.1, supervision of other normal pregnancy
These codes are only acceptable as the primary diagnosis
For complications of pregnancy, the above codes of V22.0 and V22.1 are NOT reported with codes 630-677
Routine Outpatient Prenatal Visits
The guideline for prenatal visits applies when the prenatal visit occurs and the patient has NO current complications
These are assigned as:
Patient who will be 16 yrs or less at expected time of delivery. Codes would be:
V23.81 elderly primigravida
V23.82 elderly multigravida
V23.83 young primigravida
V23.84 young multigravida
ICD defines high risk pregnancy as:
V23.42 history of ectopic pregnancy
V23.49 other poor obstetric history
V23.3 grand multiparity
Poor obstetric history includes:
“Pregnancy with inconclusive fetal viability”
This V code is assigned as the reason for an encounter to determine the viability of the pregnancy
Example: during the early weeks of pregnancy, it may be difficult for the physician to determine fetal viability. When the fetal heartbeat is not heard, an ultrasound is needed to confirm that the pregnancy is viable.
V codes are included in the alphabetic index under the following 7 key main terms:
1.)specific aftercare for a resolving disease, injury, or chronic condition. (e.g. removal of orthopedic pins)
2.) special therapy. (e.g. radiotherapy, chemotherapy, dialysis)
3.) other specific reason as opposed to illness or injury: (e.g.organ donor, prophylactic [preventative] care, counseling etc.)
4.) indicating the birth status of newborns.
V codes are used as the principle (or first-listed) diagnosis in the following four situations:
2.) To indicate the outcome of delivery for obstetric patients.
V codes are assigned as additional diagnosis codes in the following two situations:
– V10x = personal hx. of malignant neoplasm
– V12.4 = personal hx. of disorders of nervous system and sense organs.
– V16 – V19 = family history
1.) In what situation can a V code used to indicate patient history be assigned as principle (or first listed)?
2.)Which codes are assignable in this manner?
2.) Aftercare management incuding:
– continued care during healing phase
– fitting or adjustment of prosthetics, reconstruction following mastectomy, removal of fixation device, rehab (additional code for residual condition required with rehab)
– aftercare of Fx (e.g. cast change/removal)
– following surgery
3.) Generally listed first to explain reason for encounter
1.) V51 – V58 are?
2.) For what four purposes are they generally assigned?
3.) How are they generally sequenced?
True/False a V51 – V58 (aftercare V code) is typically assigned when a patient is admitted because of a complication of previous care.
2.) Followup V code is only assignable when no new conditions are found or treated and the followup exam remains the sole purpose for the admission. If new conditions are found/treated during the exam then the additional conditions/treatments are coded & V67.x is not assigned.
1.) What V code category is assigned as a principle diagnosis when a patient is admitted for the purpose of surveillance after the initial treatment of a disease or injury has been completed (followup examination)?
2.) When can a followup V code be assigned.
1.) V code designated for a followup examination following treatment with high risk medication when patient is no longer on medication?
2.)V code designated for followup examinations of patients currently on long-term therapeutic medication?
Code category for observation and evaluation of suspected condition that is not found?
1.) the suspected condition is found (in this case, the condition is coded & V71xx is not assigned.)
2.) a patient is admitted to a hospital for observation immediately following same day (outpatient) surgery.
B. 1.) V29, 2.) V89.xx
A. V71.xx are not assigned when 1.)_____or when 2.)_____?
B. Other observation codes include 1.) _______ for observation of a newborn and 2.)_______ designating observation for maternal and fetal conditions unconfirmed.
If a patient is admitted after a period in the outpatient observation unit for further evaluation unrelated to surgery the principle diagnosis is ________?
True/False V66.7 designating admission for palliative/hospice/end-of-life care can be a principle (or first listed diagnosis?
True/False V72.x designating “special investigative examinations” are only assigned as the reason for the encounter when no problem, symptom, diagnosis or condition is identified as the reason for the examination These designations are rarely appropriate for inpatient examinations and never assigned as additional codes.
What is the appropriate sequencing when V72.xx (special investigative examinations) codes are assigned preoperative evaluations?
2.) These codes are sequenced as:
a.) V code only
b.) V code as 1st or principle + code for condition or pathology.
1.) What is the range of V codes used to designate screening examinations?
2.) How are they sequenced when:
a.) no pathology found?
b.) pathology identified in screening?
V codes 76.11 (screening for high-risk patient) is only used when________?
2.) a family history, are assigned when family history is the reason for examination or treatment.
1.) personal history codes V10 -V15 are used to indicate____?
2.) Family history codes V16 -V19 are assigned to indicate ______?
2.) History codes = problem no longer exists
Status codes = problem is present/on-going
2.) What is the main difference between these (V codes mentioned above) and history V codes?
V60 -V63 are ________ codes which indicate other factors such as homelessness, social maladjustment, economic or job concerns which may affect patient care or prevent satisfactory compliance.
V16 – V19
History, Status, and Problem codes ordinarily can not be used as the principle diagnosis except for which exceptions?
2.) False. Codes from category V84 should not be used as principle (or first listed) diagnosis.
3.) The sequencing of V84 codes depend on the circumstances of the encounter.
1.) Codes from category V84 are used to report________?
2.) True/False these codes can be used as principle diagnosis.
3.) The proper sequencing of these codes depend on______?
True/False? Many V codes may be assigned as the principle (or first listed) diagnosis or as secondary diagnosis. However, ICD-9-CM “Official Guidelines for Coding and Reporting” contains a list of V codes that may only be reported as principle/first listed diagnosis. Codes from this list should not be reported if they do not meet the definition of principle or first listed diagnosis.
2.) The organism responsible for the condition.
2.) The primary axis for organization of this chapter is by________?
2.) Combination codes to identify the condition and the organism. e.g. Pneumonia due to Staphylococcus aureus = 482.41
3.) Dual Classification e.g. Pneumonia = 484.3 due to Whooping cough (Bordetella pertussis) = 033.0
(sequenced as: 033.0 Bordetella pertussis + Pneumonia 484.3)
For a diagnosis of chronic cystitis due to monilia:
which subterm should be selected?
2.) Has been expanded to 5th digit to include complications.
2nd = appropriate late effect code
The infection is not coded because it is no longer present.
2.) site or type
3.) method by which the tuberculosis was determined.
2.) The primary axis of tuberculosis categories are the _____ or _____ of the tuberculosis?
3.) The fifth-digit subclassification of tuberculosis is used to indicate the ____________?
It is improtant to differentiate between a diagnosis of tuberculosis and a positive tuberculin skin test without a diagnosis of active tuberculosis.
Positive results of a tuberculinskin tests including:
– nonspecific reaction to tuberlculin skin test without active tuberculosis
-Positive tuberculin skin test without active tuberculosis
-Abnormal result of Mantoux test
should be interpreted as a positive diagnosis of tuberculosis and coded from the 010 – 018 category.
2.) Physicians may use this term interchangeabley with ________?
– heartrate > 90 BPM
– respiratory rate > 20 breaths/min
– confusion/altered MS
2.) Ask the supervisor re. assigning a code. A query to get the physician to specify might be appropriate. DO NOT IGNORE clinical picture.
2.) if this clinical picture is present in the chart but there is no definitive diagnositc statement regarding “sepsis” or “SIRS” the coder should________ ?
2nd = Sepsis (995.91)/Severe sepsis (995.92)
3rd = other localized infection (only if present)
B.) The physician mus be queried for clarification to select principle dx.
A.) sepsis/severe sepsis develops after admission?
B.) The medical record is not clear regarding whether or not sepsis was present on admission?
2.) If infection occurs during labor code___________?
2.) 038.0 + 995.91
3.) systemic (038.xx.112.5 etc.) +
severe sepsis (995.92) +
any associated acute organ dysfunction
1.) Streptococcal septicemia
2.) Streptococcal sepsis
3.) severe sepsis
severe sepsis (995.92) +
septic shock (785.52) +
any associated acute organ dysfunction
Systemic (038.xx) +
Sepsis due to a postoperative infection
systemic (038.xx.112.5 etc.) +
severe sepsis (995.92) +
postoperative septic shock (998.02)
Postoperative septic shock
condition + responsible oganism
Therefore, “Chronic pyelonephritis due to gram-negative bacteria” would be coded as:
Chronic pyelonephritis (590.00) + gram-negative bacteria (0 41.85)
“Chronic pyelonephritis due to gram-negative bacteria”
gram-negative bacteria =0 41.85
Chronic pyelonephritis = 590.00
2.) Condition/infection + V09.xx code (fourth digit indicates the drug to which the organism/infection has become resistant)
2.) How are these codes sequenced?
2. A patients carrier status is indicated as with V02.5x codes.
2.) Coding to indicate that a patient is a carrier of an organism is assigned by ________?
2.) False. The diagnostic statement must indicate in positive terms that the patient has an HIV related illness.
2.) True/False? This code (see above) can also be assigned when diagnostic statement indicates that infection is “probable”, “possible”, “likely” or “?”.
2.) signs, symptoms or diagnosis
2.) When the patient shows signs or symptoms or has been diagnosed with a condition related to HIV infection the _________? should be coded rather than assigning the screening code
2.) Inconclusive results of an HIV test are reported as_____?
2.) 795.71 (nonspecific serologic evidence of HIV) (inconclusive HIV test)
3.) HIV antibodies can cross the placenta and remain for as long as 18 months without the newborn’s ever having been infected.
2.) A newborn with an HIV-positive mother testing positive on an ELISA or western blot test would be coded as ________?
3.) (see above) why is this coded as inconclusive?
additional codes for the related conditions.
2.) 1st code: unrelated condition (e.g. injury) as principle diagnosis, 2nd code: 042 (Human Immunodeficiency Virus HIV) +
additional codes for any related conditions.
2.) When a patient with HIV infection is admitted for treatment of an entirely unrelated condition such as an injury, the correct coding/sequencing for this encounter is_______?
2.) V08 would be assigned as an additional code.
2.) When an obstetric patient tests positive for HIV but has no signs, symptoms, or history of and HIV infection, the correct coding/sequencing for is____________?
2.) manifestation = Arthritis (711.50)
e.g. Arthritis (711.50) due to mumps (072.79)
2.) “Escherichia coli [E. coli]” E.- 041.49
1.) Coding of HIV infection/ AIDS, cancer
3.) Outpatient coding
Physician clarification is required for confirmation of disease. If a condition is not confirmed after clarification of record, a code for abnormal findings may be appropriate.
1.) 466.0 – Bronchitis – acute (subacute)
2.) 491.9 – Bronchitis – chronic
acute or subacute … 466.0
are assigned and sequenced?
=; 335.21 chronic poliomyelitis.
Poliomyelitis (acute) (anterior) (epidemic) 045.9
518.84 includes both acute and chronic respiratory failue.
2.) Precursor condition that actually existed is coded. e.g. Pt. admitted with a dx of “impending gangrene” but gangrene is averted with prompt tx.
Code is then assigned for the presenting situation that suggested the possibility of gangrene – “redness or swelling”
1.) Code for “threatened” or “impending” condition exists (either under main term, or condition is indented under terms “threatened” or “impending”:
2.) No code for “threatened” or “impending” condition is indexed.
1.) Residual condition – e.g. “Paralysis” – 344.40,
2.) Late effect code for causal condition (indexed under “Late” in most cases) e.g. “Late, effects, poliomyelitis” – 138
3.) If causal condition was an injury then a late effect E code would be assigned last. In the revious example an E code would not be assigned because poliomyelitis is not an injury.
e.g. “Sequela of old crush injuy to foot” = 906.4 – “late effect of crushing”
2.) When no late effect code is provided in the ICD-9, but the description in the medical record indicates that condition is a late effect, only the residual condition is coded. (do not code complications from previous surgeries as late effects)
3.) Late effect code has been expanded at the 4th and 5th digit to include residual conditions, then only the combination late effect code is assigned. – (only 438 codes – “late effects of CVA” have been expanded this way)
434.00 cerebral thrombosis, w/o mention of infarction also gets additional code of: 438.11 – late effects of CVA, with speech, language deficits/aphasia.
2.) Operative approaches are coded when opening of body cavity is followed solely by a diagnostic procedure such as a biopsy. In this case approach such as laparotomy is sequenced first followed by a code for the biopsy.
2.) When conversion to an open procedure is necessary, only code the open procedure followed by a V64.xx code to indicate the conversion.
2.) What is the appropriate coding for conversion from a laparoscopic, thoracoscopic, or arthroscopic approach to an open approach?
2.) When the endoscope is passed through more than one body cavity, the endoscopy code should indicate the most distant site.
code as: 1st endoscopy code + 2nd biopsy code.
2.) and 3.)
only code “closed biopsy” for brush and aspiration biopsies
1.) Closed – endoscopic
2.) Closed – brush
3.) closed – aspiration
2.) both procedure and biopsy are coded as:
1st = definitive procedure + 2nd biopsy
3.) “needle” is a closed biopsy. In this case, the terms “open”/”closed” refer to the biopsy itself not the surgical procedure. Coded as:
1st = definitive procedure + 2nd “closed” biopsy
4.) 1st = definitive procedure + 2nd = biopsy
1.) open (by way of incision) biopsy only.
2.) biopsy is incidental to removal of other tissue during a procedure.
3.) needle (closed) biopsy during an open surgical procedure.
4.) biopsy immediately before a surgical procedure begins (i.e. rapid-frozen-section exam)
2.) Code to the extent to which procedure was actually performed. In examples code only for: incision, endoscopy, or exploration of site, respectively.
3.) Procedure is still coded as performed.
1.) Cancelled procedures?
2.) Incomplete procedures – e.g. not completed because:
incision only, endoscopic approach unable to reach site,
cavity or space entered but procedure not competed?
3.) Procedure failed e.g. completed but goal of procedure not achieved?
1.) stent insertion (if stent insertion is part of a coronary angioplasty, code the angioplasty 1st.)
2.) number of vessels treated
3.) number of stents inserted
4.) procedure on vessel bifurcation (if vessel bifurcation present)
2.) 93.59 = immobilization
2.) code from subcategory 00.3x to indicate CAS.
2.) code from subcategory 17.4x to indicate robotic assisted surgery.