Combo with ICD-9-CM Guidelines & Conventions Review and 5 others

Anthrax which is the responsible organism in this case would be sequenced first.
022.1 (anthrax) + 484.5 (pneumonia).
Sequence pneumonia in anthrax: pneumonia = 484.5, anthrax = 022.1.
1.) False. A diagnosis that mentions the affected lobe is not classified as lobar pneumonia unless specifically documented by the physician.
2.) False. “Multilobar pneumonia” simply refers to pneumonia affecting more than one lobe.
1.) True/False? A diagnosis of pneumonia that mentions the affected lobe is classified as lobar pneumonia.
2.) True/False? “Mutilobar pneumonia” is synonymous with lobar pneumonia.
The code for AIDS (042) is always sequenced first.
For example:
042 (AIDS) + 136.3 (Pneumocystosis)
What is the correct coding for Pneumocystosis (136.3) associated with AIDS?
Both types of pneumonia must be coded therefore two codes would be assigned.
What is the appropriate coding when the diagnostic report indicates that a patient has both aspiration pneumonia as well as another type of pneumonia such as bacterial?
Code influenza (487.0) with an additional code assigned to identify the type of pneumonia.
How should influenza (487.0) with pneumonia be coded?
True. These subcategories represent another exception to the general guidelines that direct the coder to assign a code diagnosis qualiified as “suspected” or “possible” as if it were established.
True/False? Subcategories 488.0, 488.1, and 488.8 indicating cases of avian flu, identified (novel) 2009 H1N1 flu, or novel influenza A should not be assigned when the diagnostic statement indicates when the infection is “suspected”, “possible”, “likely”, or “?”.
1. Chronic obstructive asthma (493.2x)
2. Chronic obstructive bronchitis (491.2x).
3. Emphysema (492.8).
4. Chronic bronchitis with emphysema (491.20).
Four conditions that comprise of COPD?
True. The described conditions are synonymous and code to 491.21, obstructive chronic bronchitis, with acute exacerbation.
True/False? COPD in exacerbation, severe COPD in exacerbation, end stage COPD in exacerbation, decompensated COPD, exacerbation of COPD, and acute exacerbation of chronic obstructive bronchitis all code to the same thing.
Code 496 – find under: “obstruction”, “airway”, “chronic”.
When the medical record documentation indicates COPD without further specification, the correct code can be found under ______?
Two codes are required:
1. 491.2x (Chronic obstructive bronchitis)
2. 493.22 (Chronic obstructive asthma with acute exacerbation).
An overlapping condition of chronic obstructive asthma with an acute exacerbation with chronic obstructive bronchitis (COPD) should be coded with ________?
False. The code description for 491.22 obstructive chronic bronchitis contains acute bronchitis in its description. No additional code is necessary. Only assign 491.22.
True/False? A diagnosis of acute bronchitis with obstructive chronic bronchitis requires a code for the COPD (491.22) with an additional code for the acute bronchitis (466.0).
No. The acute bronchitis included in 491.22 supersedes the acute exacerbation.
If the documentation indicates acute bronchitis with COPD with acute exacerbation (491.22), is an additional code required to describe the acute exacerbation?
“Broncheo Asthma” for coding purposes is synonymous with ______?
Chronic obstructive asthma (493.2x).
Asthma characterized as obstructive or diagnosed in conjunction with COPD is classified as________?
False. Only the code with the fifth digit “1” should be assigned. This status asthmaticus supersedes acute exacerbation.
True/False? An asthma code (493.0x, 493.1x, 493.9x) with those numbers with a fifth digit “2” (with acute exacerbation) may not be assigned with an asthma code with a fifth digit of “1” (with status asthmaticus). What should be assigned?
1. Is included in the codes (012.0x, 010.1x).
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.
How are the following coded:
1. Pleural effusion due to tuberculosis.
2. Pleural effusion due to another bacterial infection.
3. Malignant pleural effusion.
When it is the condition established after study to be chiefly responsible for admission to the hospital and the selection is supported by the alphabetic index and tabular list. If it develops after admission it may be listed as a secondary diagnosis.
When can acute respiratory failure be assigned as the principle diagnosis?
1.) Principal diagnoses = 518.81 (acute respiratory failure) + 492.8 (other emphysema).
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.
Sequence the following:
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.
Principal diagnoses = 042 (AIDS) +
518.81 (acute respiratory failure) +
136.3 (pneumocystosis).
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.
Sequence the following:
A patient is admitted to respiratory failure due to pneumocystis carinii, which is due to AIDS.
Principal diagnoses = 031.11 (Staphylococcus aureus septisemia) +
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.
Sequence the following:
A patient is admitted to the hospital with severe Staphylococcus aureus sepsis and acute respiratory failure.
1.) Code for ARDS is assigned + an additional code for the responsible organism.
2.) It is included in the codes for asthma so no additional code is assigned.
How is adult respiratory distress syndrome (ARDS) assigned in the following situations:
1.) Due to infection?
2.) In asthma?
It is implicit to COPD and not assigned.
How should other pulmonary insufficiency, NEC in COPD be assigned?
Left ventricular failure (428.1).
Congestive heart failure (428.0).
Hypertensive heart disease (402.9x).
Rheumatic heart disease (391.x).
Rheumatic heart failure (congestive) (398.91).
Acute pulmonary edema that is cardiogenic is a manifestation of heart failure and included in the following code assignments_____?
1.) Left ventricular failure (428.1).
2.) Congestive heart failure (428.0).
1.) When pulmonary edema is present along with acute myocardial infraction, acute or sub acute ischemic heart disease, or coronary atherosclerosis it is assumed to be associated with _______?
2.) Unless the heart failure is described as congestive or decompensated in which case a code for _______ is assigned?
It should be reported if it is performed after admission or in the emergency department in the same hospital. If intubation or tracheostomy is performed elsewhere prior to admission or in an ambulance it can not be reported.
How should intubation or tracheostomy be coded?
1.) 96 consecutive hours.
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.
1.) Separate codes for invasive mechanical ventilation are used to indicate whether the patient was on the ventilator for fewer then or more then _______ hours?
2.) The hours should be counted from when ______?
3.) The duration of mechanical ventilation ends with the following three events?
True/False? When the condition of a patient has been on ventilation earlier deteriorates and subsequent period of mechanical ventilation is required two codes from category 96.7x should be assigned.
Post operative mechanical ventilation continues for more than 2 days or if the physician has clearly documented an unexpected extended period of mechanical ventilation.
Mechanical ventilation utilized during surgery is not coded when it is considered a normal part of surgery unless ______?
Assigned 519.01 as a complication and add an additional codes to identify the type of infection and the organism.
How is infection of a tracheostomy (519.01) assigned?
Only assign 557.0 (acute vascular insufficiency of intestine). 578.x to indicate GI bleeding is not used when a code for a specific condition such as ischemic colitis include hemorrhage or GI bleeding.
When a physician lists “GI bleeding (578.x) due to ischemic colitis (557.0)” and “hemorrhagic” is an inclusion term under code 557.0 how should this be coded?
Yes. If the physician documents a clinical diagnosis of GI bleeding the fact that no bleeding occurs during the episode of care does not preclude the assignment of a code that includes a mention of hemorrhage, or a code from category 578 when the cause of the bleeding can not be determined.
For patient with a documented diagnosis of GI bleeding should the GI bleeding still be coded if the patient is no longer bleeding at the time of the examination?
Only code the Mallory Weiss Tear.
For a Mallory Weiss Tear causing a GI bleed what should be coded?
578.9 is only assigned when after query the physician does not establish a causal relationship between the GI bleeding and the endoscopic findings. The combination codes describing hemorrhage should not be assigned unless the physician identifies a causal relationship.
In relation to GI bleeding and endoscopic findings, code 578.9 (hemorrhage of gastrointestinal track, unspecified) should only be assigned when ________?
1.) Assign a code for the bleeding (569.3, hemorrhage of rectum and anus) + an additional code for the hemorrhoids.
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.
For patients who present for a colonoscopy because of rectal bleeding, how should the following be coded:
1.) Hemorrhoids are incidental findings and unrelated to rectal bleeding.
2.) Bleeding is caused by hemorrhoids, as specified by the physician.
In both conditions, the underlining condition is coded first. For example:
1.) Cirrhosis of liver (571.5) + varices (456.20).
2.) Portal hypertension (572.3) + varices (456.20),
How are the following coded:
1.) Bleeding esophageal varices with cirrhosis of liver.
2.) Bleeding esophageal varices in portal hypertension.
1) Cholesterolosis.
2.) No. Cholasterolosis is considered integral to other gallbladder pathologies and therefore should not be coded.
1.) A condition characterized by abnormal deposits of cholesterol and other lipids in the lining of the gallbladder. In its defuse form it is also know as strawberry gallbladder.
2.) When other pathology of the gallbladder is present, should the above condition be coded?
Postcholecystectomy Syndrome.
A condition in which symptoms suggestive of biliary tract disease either persist or develop following cholecystectomy with no demonstrative cause or abnormality found on workup?
The adhesions and lysis are documented by the physician as having presented significant difficulty.
Coding a diagnosis of adhesions and a lysis is usually inappropriate unless____________?
1.) Site and type.
2.) Recurrent.
3.) Obstructed.
1.) Hernias are classified by _________ and ________ with combination codes to indicate any associated gangrene or obstruction.
2.) An incisional ventral hernia is classified as ______?
3.) Hernias described as incarcerated or strangulated as _______?
1.) Restrictive and malabsorptive.
2.) Malabsorptive.
3.) Restrictive.
1.) The two main types of bariatiric surgery are ______ and _______?
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.
1.) Roux-n-y gastric bypass (44.39).
2.) Biliopancreatic diversion (BPD) (43.89).
3.) Another type of Biliopancreatic diversion (BPD) “Duodenal switch” procedure (requires three codes).
Name three malabsorptive procedures?
V code (V53.51), fitting and adjustment of gastric lap band is assigned as the principle or first listed diagnosis. An additional code is assigned for the procedure (44.98, laparoscopic adjustment of size of adjustable gastric restrictable device). Additional V code (V45.86) bariatic surgery status maybe added as well.
How is the adjustment and fitting of a gastric band coded?
Main index entries for V codes in the alphabetic index vol. 2
1. Admission
2. Examination
3. History
4. Observation
5. After care
6. Problem
7. Status
V codes three other common categories?
1. Screening
2. Follow-up
3. Genetics susceptibility
Various V codes
Examination (Diagnostics)
Personnel V10-V15
Family V16-V19
Suspected conditions not found.
V71 (most commonly used), V89 (maternal/fetal)
Genetic susceptibility
1.) Diabetes mellitus
2.) 250
1.) A chronic disorder of impaired carbohydrate, protein and fat metabolism?
2.) Code category?
4th digit = presence of complications
5th digit = whether diabetes is out of control
2.) Diabetes mellitus Type II
1.) Diabetes is classified on 2 axis:
4th digit = ?
5th digit = ?
2.) “diabetes” noted in chart without further specification defaults to__________?
1.) False. “uncontrolled diabetes mellitus” or “diabetes mellitus out of control” must be specifically stated in the medical record in order to code for uncontrolled diabetes.
2.) False. In the absence of further specificity, this should be coded as 790.2 (abnormal glucose)
1.) True/False? “poorly controlled” or “poor control” in chart indicates uncontrolled diabetes.
2.) True/False “borderline diabetes” without further specification should be coded as diabetes mellitus.
Diabetes Mellitus Type I
Described as ketosis-prone or juvenile diabetes & characterized by the body’s failure to produce insulin at all or an absolute decrease in insulin production. Requires regular insulin injections.
Diabetes Mellitus Type II
Described as ketosis resistant or “adult-onset” diabetes ; characterized by the body’s inability to adequately utilize insulin. Patients may or may not require insulin.
a.) type II diabetes mellitus
b.) type I diabetes mellitus
For patients with type (a.)________ ? diabetes mellitus who routinely use insulin, V58.67 (Long term [current] use of insulin) is required unless insulin is only given temporarily to bring blood sugar under control. For patients with type (b.)________? diabetes mellitus, the use of the V58.67 code is optional.
Type II
a diagnosis of “Diabetes” not further specified in a medical record defaults to_________?
1.) Mechanical complication due to insulin pump )996.57)
2.) Poisoning by insulins and antidiabetic agents (962.3)
1.) Malfunction of an insulin pump codes to_________?
2.) An overdose of insulin as a result of pump malfunction codes to____________?
Secondary Diabetes
Diabetes that results from therapy such as the removal of the pancreas, infection,poisoning or use of certain medications.
1.) 249 + E code if applicable
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)
1.) Secondary diabetes that is drug induced, chemically induced, due to the postcarcinoma state of the pancreas, or due to infection is coded is coded to category_________?
2.) Example: “steroid induced diabetes mellitus due to prolonged use of corticosteroids for an unrelated condition” is coded as________?
4th digit = presence of complications
5th digit = whether diabetes is out of control
Category 249 for secondary diabetes is classified on 2 axis:
4th digit identifies______?
5th digit identifies______?
1.) 1st code 251.3 (postsurgical hypoinsulinemia)
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
1.) secondary diabetes due to pancreatectomy?
2.) E.g. “postpancreatectomy dibetes mellitus”
1.) 249.1x – 249.3x and 250.1x – 250.3x
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.
1.) code range for acute metablolic complications of diabetes mellitus, secondary, types I & II?
2.) code range for long-term complications of diabetes mellitus, secondary, types I & II?
3.) How many codes from these categories vcn be assigned?
1st code diebetes millitus (category 250) followed by additional 250 codes identifying complications/manifestations (unless manifestation is included in the basic code)
Sequencing rules for complications/manifestations in:
type I/type 2 diabetes.
1.) Sequencing of is based on the reason for the encounter. A code is also assigned for underlying condition that caused the dibetes (sequencing of this code also depends on the reason for encounter).
2.) (a.) code from category 249 is sequenced 1st.
(b.) carcinoma (157.9) should be sequenced 1st.
1.) Sequencing rules for complications/manifestations in secondary diabetes?
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?
1.) diabetic ketoacidosis (DKA)
2.) hyperosmolarity with/without coma
3.) other coma
Acute metabolic complications of diabetes include? (3 dxs)
1.) 249.1x/250.1x, type I, uncontroled.
2.) Diabetes with other coma, 249.3x/250.3x
Acute metabolic complications of diabetes:
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 ______?
1.) Diabetes code (249/250.xx) + manifestation/complication code.
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.
1.) Sequencing rule for diabetes with chronic complications including: renal, ocular, nervous, and peripheral vascular, and other?
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.
1.) 646.0x assigned 1st + additional code for diabetes (249/250)
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.
1.) Sequencing rule for diabetes mellitus complicating pregnancy? (648.0x).
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?
1.) 249.3x/250.3x or 249.8x/250.8x
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
1.) Codes for hypoglycmic reactions in patients with diabetes mellitus with or without coma?
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?
Category 278 + additional V code (V85.x) for BMI if it is documented. It is appropriate to use nurse/nutritionists notes for
2.) BMI only. Overweight/Obesity coding must be based on physicians diagnosis.
1.) Coding sequencing rule for overweight/obesity?
2.) For what part of this can nurse/nutritionist notes be used?
Complication as principle dx. + additional code for cystic fibrosis (277.0x).
Because there is no known cure for cystic fibrosis, most therapy is directed towards the complications & admission for cystic fibrosis itself is not common.
Coding/sequencing rule for admission due to complications of cystic fibrosis with pulmonary involvement?
1.) 294.2x with 5th digit denoting with/without behavioral disturbance.
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.
1.) Coding/sequencing rule for “dementia” not specified?
2.) Coding/sequencing rule for dementia due to physiological effects of underlying disease or condition – e.g. “dementia due to Alzheimer’s”?
1.) 311
2.) False. A diagnosis of “major depression” of “affective disorder” must be documented in the chart. “Depression” listed without further specificity is not enough.
1.) “depression” documented in the medical record without further specification defaults to code_________?
2.) True/False? “Depression” (see above) is the same as an affective disorder such as major depression and can be coded accordingly.
Use 316 code first to designate that physiological disorder is psychogenic in nature. e.g.
316 (psychological factor) + 427.2 (asthma)
Coding/sequencing rule for psychogenic diseases. e.g. psychogenic asthma?
False. These are coded differently in ICD-9-CM and can not be used interchangeably.
True/False in ICD-9-CM “abuse” and “dependence” are synonymous and may be used and coded interchangeably?
1.) 291 ; 292
2.) 291.0, 291.3, ; 291.81
3.) 291.81 (withdrawal) + 303.91 (chronic alcoholism)
1.) Alcohol-induced mental disorders are classified in category_____? and drug induced mental disorders are classified in category ________ respectively?
2.) Subcategories for withdrawal include _______?
3.) How are these are sequenced? – e.g. “”withdrawal due to chronic alcoholism”?
1.) Psychosis coded 1st + substance abuse/dependence code.
2.) Principle dx. should be the substance abuse/dependence code.
What should be the principle dx. in the following cases:
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?
1.) Either condition may be designated as principle dx.
2.) Physical condition is coded 1st + substance abuse/dependence code.
3.) Follow the usual guidelines for selecting
principle dx.
What should be the principle dx. in the following cases:
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?
“yellow bag”
Slang/short for detoxification for a patient who is physically dependent on drugs/alcohol using thiamine and multivitamins for nutrition as well as other medications?
A condition in which blood is deficient in the amount of hemoglobin in red blood cells or in the volume of red blood cells.
Only when a diagnosis of “anemia” is specified by the Physician in the diagnostic report.
Anemia can only be coded when_______?
Aplastic Anemia
A condition in which there is a deficiency of red blood cells because the bone marrow is failing to produce them.
1.) 280
2.) 281; the specific type of deficiency, e.g., B12 vitamin deficiency.
1.) Iron-deficiency anemias are classified in category______?
2.) Other deficiency anemias are coded in category_______ with the 4th digit indicating ______?
False. It is important to distinguish between anemia due to chronic and anemia due to acute blood loss because the two conditions have entirely different codes in ICD-9-CM.
True/False? Anemia due to chronic blood loss and anemia due to acute blood loss code to the same category.
Acute blood-loss anemia.
_______ results from a sudden, significant loss of blood over a brief period of time may be due to trauma, laceration, or rupture of abdominal viscera where no external blood loss is noted. A diagnosis of this must be supported by physician documentation.
Do not code unless the doctor specifies “hemorrhage as a complication of surgery.”
Hemorrhage as a complication of surgery can only be coded in the 998.11 (complications of surgery) if _______?
False. Acute blood-loss anemia should not be coded as a post operative complication unless the Physician identifies as such.
True/False? Acute blood-loss anemia that occurs following surgery implies that it is a complication of the procedure.
1.) 285.9 (anemia, unspecified).
2.) 285.1 (acute post-hemorrhagic anemia).
3.) 280.0
1.) When post operative anemia is documented without specification of acute blood-loss it codes to______?
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_______?
First code for anemia (285.xx) + code for chronic condition e.g.,
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.
Coding/sequencing rule for anemia and chronic conditions:
1.) Anemia and chronic kidney disease.
2.) Anemia and neoplastic disease.
3.) Anemia of other chronic disease.
True. Anemia due to chemotherapy induces changes that are generally short term and not truely aplastic.
True/False? Anemia due to chemotherapy should not be confused with aplastic anemia due to anti-neoplastic chemotherapy.
Pancytopenia (284.19)
When a patient has anemia neutropenia and thrombocytopenia only one code for ________ is assigned?
1.) Cickle-cell anemia/disease (282.6x)
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…).
1.) When a child receives cickle-cell genes from both parents.
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?
1.) Thalassemia (282.4x).
2.) Thalassemia minor
3.) Thalassemia major
1.) A genetic blood disorder resulting from a defect in a gene that controls production of one of the hemoglobin proteins.
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_____?
1.) The physician specifically documents a diagnosis of hemorrhagic disorder due to circulating anti-coagulants.
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.
1.) Subcategory 286.5x to indicate acquired hemophelia or other hemorrhagic disorders due to intrinsic circulating anti-coagulants is only assigned when_______?
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?
First code hematemesis (578.0) + an additional code E 934.2 to indicate Coumadin as the responsible agent. Do not assign code 286.5x.
Code the following:
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.
1.) Whether the WBC count is low or elevated.
2.) False. Physician concurrence regarding the significant of the laboratory results should be confirmed before assigning (288.xx) codes.
1.) Diseases that affect white blood cell counts (WBCs) (288.xx) are classified on the basis of ______?
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?
V22.0, supervision of normal first pregnancy
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:
– The current or primary cancer site should be coded.
-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.
Code original cancer site along with any findings
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 there is a good symptom provided, only that symptom is coded. V71 should not be added as a secondary 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
Coded as?
If there is a good symptom provided, only that symptom is coded. V71 should not be added as a secondary code. If no documentation of signs or symptoms, then assign the V71.xx code
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?
A common follow-up exam is for fracture aftercare
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
Code V54.x (other orthopedic aftercare)
Indication for test: Follow-up fracture
Findings: Normal x-ray
What to Code:
“Trauma” alone cannot be coded as an injury and should instead assigned as V71.4 (observation following other accident)
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?
These are probable or suspected conditions that cannot be coded in the outpatient setting. Coders should code to the highest degree of certainty for the particular encounter, using indicators such as signs or symptoms or other positive findings in the medical report (Vol. 22, No. 3, third quarter, 2005)
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?
Code that diagnosis. The signs and/or symptoms that prompted ordering the test may be reported as additional diagnoses if they are not fully explained or related to the confirmed diagnosis
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 ___________?
Dx code: diverticulitis 562.11
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 sign(s) or symptom(s) that prompted the treating physician to order the study should be coded.
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.
Do not code that diagnosis but instead, report the sign or symptom/s that prompted the study.
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?
Incidental findings would not be coded. Refer back to the reason for the test at the top of the radiology report or the physician order. The reason for the testing would be the primary diagnosis.
If the Impression or Conclusion of the radiology report is an incidental finding and the radiologist states “incidental” then how would this be coded?
The reason for the test should be coded, such as if it was a screening or what kind of testing it is being performed. If there are findings, then those would be coded as additional diagnoses
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?
Look closely at the order to see if this is an order for a Screening Mammogram or a Diagnostic Mammogram.Orders for Screening Mammograms will be documented as “Screening” or it will be checked marked off as Screening. Orders for Diagnostic Mammograms will be documented as “Diagnostic and there will usually be a dx on that order for the reason for the test. Mammograms will be identified as either Screening or Diagnostic at the top of the report- be sure to look for this.
Screening Mammograms
Codes V76.12, V76.11
Diagnostic Mammograms
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
Screening Mammogram:
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?
CMS considers the following patients to be high risk:
-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”?
Screening mammogram with known fibrocystic disease
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?
False. Diagnostic mammograms differ from screening mammograms. Screening mammograms are for patients without apparent problems. Diagnostic mammograms are performed when there IS a problem identified, such as a breast mass, pain, discharge, etc. Diagnostic mammograms should have a diagnosis, sign, symptom or other problem documented
Diagnostic mammograms:
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.
Diagnostic mammograms:
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.
Follow-up mammogram
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?
It may be used in conjunction with other codes related to the patient’s health status (V49.81, Postmenopausal status, and V07.4, Postmenopausal hormone replacement therapy). The screening code should be listed before the status codes.
V82 Special screening for other conditions
V82.8X Other specified conditions
V82.81 Osteoporosis
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
Answer: Assign code V82.81, Special screening for osteoporosis. Code V49.81, Postmenopausal status, may be used as an additional diagnosis
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
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
Category V23 (Supervision of high-risk pregnancy)
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?
Use subcategory 648.X for patients who have current conditions when the condition affects the management of the pregnancy, childbirth, or the puerperium. Use additional codes to identify the conditions, as appropriate. e.g.
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) +
496 (COPD)
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?
1.) Situations when the initial treatment of a disease or injury has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.
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.
4.) True
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.
Code: V54.19 aftercare for healing traumatic fx of bone.
Example: X-ray done after definitive fracture treatment of ankle. Dx on X-ray order and Indication of report states “Healing traumatic fx of ankle”. How is this coded?
Answer: Assign code V67.4, Follow-up examination, Following treatment of healed fracture, for the encounter. This is a follow-up visit for a healed fracture.
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?
Search under “admission for, examination”
In these cases, code V70.5, Health examinations would be the first listed diagnosis.
Outpatient Visits:
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
First listed diagnosis in this case would be V58.83 Encounter for therapeutic drug monitoring
of the medication Coumadin
Additional dx code V58.61 would also be used to describe long-term use of the anticoagulant
Outpatient Visits:
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 1: Review the complete outpatient documentation
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
Primary dx code would be V57.1 for Physical therapy, as the reason chiefly responsible for the patient’s visit
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 code from category V72.8 is sequenced first
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”
V22.0, supervision of normal first pregnancy
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 35 yrs or older at expected time of delivery.
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:
V23.41 history of pre-term labor
V23.42 history of ectopic pregnancy
V23.49 other poor obstetric history
V23.3 grand multiparity
Poor obstetric history includes:
For these encounters where they are checking for viability assign code V23.87
“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.
1.) Admission
2.) Examination
3.) History
4.) Observation
5.) Aftercare
6.) Problem
7.) Status
Chapter 8 V Codes:
V codes are included in the alphabetic index under the following 7 key main terms:
When the sole purpose of the encounter is
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.
Chapter 8 V Codes:
V codes are used as the principle (or first-listed) diagnosis in the following four situations:
1.) to indicate that patient has a history, health status, or other problem that is not in itself an illness or injury but may influence patient care.
2.) To indicate the outcome of delivery for obstetric patients.
Chapter 8 V Codes:
V codes are assigned as additional diagnosis codes in the following two situations:
1.) When the patient history itself is the reason for the admission or encounter.
– V10x = personal hx. of malignant neoplasm
– V12.4 = personal hx. of disorders of nervous system and sense organs.
– V16 – V19 = family history
Chapter 8 V Codes:
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?
1.) Aftercare codes.
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
Chapter 8 V Codes:
1.) V51 – V58 are?
2.) For what four purposes are they generally assigned?
3.) How are they generally sequenced?
False. The appropriate code for the complication listed under the main classification is assigned rather than an aftercare V code.
Chapter 8 V Codes:
True/False a V51 – V58 (aftercare V code) is typically assigned when a patient is admitted because of a complication of previous care.
1.) V67.x
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.
Chapter 8 V Codes:
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.) V67.51
2.) V58.xx
Chapter 8 V Codes:
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?
Chapter 8 V Codes:
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
Chapter 8 V Codes:
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.
The condition that provided the original reason for the outpatient observation.
Chapter 8 V Codes:
If a patient is admitted after a period in the outpatient observation unit for further evaluation unrelated to surgery the principle diagnosis is ________?
False. V66.7 can not be a principle (or first listed) diagnosis. The underlying disease/condition is listed first.
Chapter 8 V Codes:
True/False V66.7 designating admission for palliative/hospice/end-of-life care can be a principle (or first listed diagnosis?
Chapter 8 V Codes:
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.
V72.xx + code designating underlying condition for which surgery was planned.
Chapter 8 V Codes:
What is the appropriate sequencing when V72.xx (special investigative examinations) codes are assigned preoperative evaluations?
1.) V73 – 82
2.) These codes are sequenced as:
a.) V code only
b.) V code as 1st or principle + code for condition or pathology.
Chapter 8 V Codes:
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?
Physician has documented in report that patient is high-risk.
Chapter 8 V Codes:
V codes 76.11 (screening for high-risk patient) is only used when________?
1.) a personal history of a previous condition
2.) a family history, are assigned when family history is the reason for examination or treatment.
Chapter 8 V Codes:
1.) personal history codes V10 -V15 are used to indicate____?
2.) Family history codes V16 -V19 are assigned to indicate ______?
1.) Status codes (V40 -V49)
2.) History codes = problem no longer exists
Status codes = problem is present/on-going
1.) These V codes are used to indicate a continuing condition that may influence care (e.g. pt. is a carrier of a disease, has a pacemaker, tracheostomy etc.)
2.) What is the main difference between these (V codes mentioned above) and history V codes?
Problem codes.
Chapter 8 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.
Categories from V10, V12., and some V13s
V16 – V19
Chapter 8 V Codes:
History, Status, and Problem codes ordinarily can not be used as the principle diagnosis except for which exceptions?
1.) Codes from category V84 are used to report genetic susceptibility to disease.
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.
Chapter 8 V Codes:
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______?
Chapter 8 V Codes:
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.
1.) Chapter 1
2.) The organism responsible for the condition.
1.) This Chapter of the ICD-9-CM classifies infectious and parasitic diseases that are easily transmittable.
2.) The primary axis for organization of this chapter is by________?
1.) A single code assigned to designate the organism: e.g. 072.x = mumps
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)
Infectious and parasitic diseases are classified in one of several ways including:
The organism always takes precedence. In the example, Cystitis (bacillary), monilial 112.2x would be the correct selection.
In an index search for an infection where a main term contains indented subterms including those to indicate organism and others to indicate (acute) (chronic) e.g.
For a diagnosis of chronic cystitis due to monilia:
Cystitis (bacillary)
chronic 595.2x
monilial 112.2x
which subterm should be selected?
Refer to the main term “Infection” or to the main term of the organism. e.g. “Infection”, “Cryptococcal = 117.5
When an organism is specified but not indexed under the main term, for example: cryptococcal cystitis when no term for cryptococcal is located under the main term cystitis, the coder should__________?
Code for contact or exposure to SARS-associated coronavirus?
SARS-associated coronavirus infection.
Pneumonia due to SARS-associated coronavirus
1.) 066.4x
2.) Has been expanded to 5th digit to include complications.
1.) Category used to report West Nile Virus? 2.) Expansions?
1st = residual effect, followed by:
2nd = appropriate late effect code
The infection is not coded because it is no longer present.
How should a residual conditiondue to a previous infection or parasitic infestation be coded?
1.) 010 – 018
2.) site or type
3.) method by which the tuberculosis was determined.
1.) Tuberculosis is classified to categories _______?
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 ____________?
False.The examples should be coded with 795.51
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
-Positive PPD
-Abnormal result of Mantoux test
should be interpreted as a positive diagnosis of tuberculosis and coded from the 010 – 018 category.
Bacteremia (790.7)
The presence of bacteria in the bloodstream after trauma or mild infection. The condition is usually transient and ordinarily clears through the actions of the body’s own immune system.
1.) Septicemia
2.) Sepsis
1.) The term used by the ICD-9-CM to designate codes describing a systemic disease associated with pathological microorganisms or toxins in the blood. The old-school term is “Blood Poisoning”.
2.) Physicians may use this term interchangeabley with ________?
Systemic inflamatory response syndrome (SIRS)
__________refers to the systemic response to infection, trauma/burns,or other insult (e.g. cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis.
__________ generally refers to SIRS due to infection.
1.) fever > 101.3
– heartrate > 90 BPM
– respiratory rate > 20 breaths/min
– hypotension
– 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.
1.) The clinical picture for sepsis generally includes two of the following:
2.) if this clinical picture is present in the chart but there is no definitive diagnositc statement regarding “sepsis” or “SIRS” the coder should________ ?
Query the physician as to whether an additional diagnosis of sepsis (095.9x) should be included.
With a diagnosis of Septicemia (038.xx) only listed in the chart the coder should_____________?
True (clarification from physician may be needed in some instances)
True/False a diagnosis statement of “urosepsis” or “urinary tract infection” followed by a diagnosis of septicemia ususally indicates that the condition has progressed to septicemia, in which case the septicemia should be coded.
1st = underlying systemic infection (e.g. 038.xx, 112.5, etc)
2nd = Sepsis (995.91)/Severe sepsis (995.92)
3rd = other localized infection (only if present)
When sepsis or severe sepsis is the condition that, after study, necessitated the admission: How should this be coded?
A.) 1st code principle dx. (reason for admission) followed by systemic infection code (038.xx, 112.5, or 054.5), then sepsis code (995.91/995.92) as secondary dxs.
B.) The physician mus be queried for clarification to select principle dx.
How should the following be coded?
A.) sepsis/severe sepsis develops after admission?
B.) The medical record is not clear regarding whether or not sepsis was present on admission?
False. 995.9x codes are not assigned unless the term “sepsis” or “SIRS” is specifically documented and they are NEVER assigned as a principle diagnosis. (if there is a clinical picture in the chart suggesting sepsis, the physician should be queried for clarification.)
True/False? 995.9x codes are sometimes used as a principle diagnosis to indicate a clinical picture in the chart suggesting the presence of SIRS or sepsis even when these terms are not documented by the physician.
1.) 630 – 339
2.) 659.3x
1.) Sepsis and septic shock associated with abortion, ectopic pregnancy, or molar pregnancy are classified to___________?
2.) If infection occurs during labor code___________?
Code 670.0x. Do not assign 0.38, or 995.91 as systemic septicemia and sepsis(non-severe) is already covered in the 670.0x code. If septic shock is present, add code 995.92 to indicate severe sepsis and also assign codes to indicate any organ dysfunction.
If sepsis/septic shock occurs during the puerperal period how should it be coded?
The provider’s documentation of the relationship between the infection and the procedure.
Sepsis due to postoperative infection is coded based on______?
1st assign complication code (e.g. 998.59 = “Other postoperative infection” or 674.3x = “Other complications of obstetrical wounds”) followed by systemic (038.xx etc.) and sepsis (995.9x) codes. Add any additional codes for organ dysfunction for cases of severe sepsis and for organism if known. Also, if septic shock occurs, assign 998.02 (“postoperative septic shock”) after 995.92 (“severe sepsis”)
How should postoperative sepsis be coded?
1st assign appropriate complication code (e.g. 999.31 = “infection due to central venous catheter” or 996.62 = infection and inflammatory reaction due to vascular device, implant, and graft”) followed by systemic (038.xx etc.) and sepsis (995.9x) codes. Add any additional codes for acute organ dysfunction for cases of severe sepsis, and for organism if known.
How should sepsis due to vascular catheter infection be coded?
1st code the noninfectious process (burn/injury) followed by systemic (038.xx etc.) and sepsis (995.9x) codes. Also code for any acute organ dysfunction for cases of severe sepsis.
How should the following be coded? A non-infectious process (burn/injury) which designated as the principle diagnosis develops infection and progresses to sepsis or severe sepsis.
1st code the systemic (038.xx etc.) and sepsis (995.9x) codes followed by the noninfectious condition (burn/injury).
How should the following be coded? Sepsis or severe sepsis is the principle diagnosis with the initiating event being a non-infectious process (burn/injury).
Either may be sequenced first.
How should the following be coded? Sepsis or severe sepsis and a non-infectious process (burn/injury) both equally meet the definition of principle diagnosis.
True/False? Only one SIRS code from 995.9x should be assigned for patients with sepsis or severe sepsis associated with trauma or other noninfectious conditions.
1.) 038.0
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
systemic (038.xx.112.5 etc.) +
severe sepsis (995.92) +
septic shock (785.52) +
any associated acute organ dysfunction
Septic shock
Other postoperative infection (998.59) +
Systemic (038.xx) +
sepsis (995.91)
Sepsis due to a postoperative infection
Other postoperative infection (998.59) +
systemic (038.xx.112.5 etc.) +
severe sepsis (995.92) +
postoperative septic shock (998.02)
Postoperative septic shock
Toxic shock syndrome (040.82)
Syndrome caused by a bacterial infection and includes symptoms of: sudden onset high fever, vomiting, watery diarrhea, and myalgia, followed by hypotension and sometimes shock.
With gram-negative bacteria sequence as:
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
1.) The physician specifically states in the chart that an infection has become drug resistant.
2.) Condition/infection + V09.xx code (fourth digit indicates the drug to which the organism/infection has become resistant)
1.) V codes (V09.xx) indicating infections with drug resistant organisms can only be assigned when____________?
2.) How are these codes sequenced?
1. False. Colonization means that a patient is a carrier – the infectious organism is present in the body without necessarily causing illness.
2. A patients carrier status is indicated as with V02.5x codes.
1.) True/False. Colonization is the same as infection.
2.) Coding to indicate that a patient is a carrier of an organism is assigned by ________?
1.) 042
2.) False. The diagnostic statement must indicate in positive terms that the patient has an HIV related illness.
1.) Code_________? is assigned for all types of HIV infections include diagnostic statements such as: “AIDS”, “AIDS-like syndrome”, “AIDS-like disease”, “AIDS related conditions”, “Pre-AIDS”, “HIV disease” etc.
2.) True/False? This code (see above) can also be assigned when diagnostic statement indicates that infection is “probable”, “possible”, “likely” or “?”.
1.) V73.89 (Screening for other specified viral disease)
2.) signs, symptoms or diagnosis
1.) When a patient with no prior diagnosis, history, signs, or symptoms of HIV requests testing of HIV status, the screening is coded as __________?
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
1.) V65.44 (HIV counseling)
2.) 795.71
1.) When patients make a return visit to learn the results of an HIV test, the reason for the encounter should be coded as__________?
2.) Inconclusive results of an HIV test are reported as_____?
Positive HIV test results when the patient shows no signs or symptoms are coed as____?
When the term AIDS is used, when a patient is being treated for any HIV related illness, or when the patient is described as having any active HIV-related condition, code ____? is used.
1.) V01.79 (Contact with or exposure to communicable diseases, other viral diseases)
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.
1.) When a patient has had exposure to/contact with the HIV virus but has no diagnosis, signs or symptoms related to HIV assign code_________?
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?
1.) 042 (Human Immunodeficiency Virus HIV) +
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.
1.) When a patient is admitted for treatment of an HIV infection or any related complication the correct coding/sequencing for this encounter is___________?
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_______?
1.) 647.6 (Other viral diseases) + 042 as an additional code.
2.) V08 would be assigned as an additional code.
1.) When an obstetric patient is identified as having any HIV infection, the correct coding/sequencing is_________?
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____________?
1.) underlying condition = Mumps (072.79)
2.) manifestation = Arthritis (711.50)
correct sequence for manditory multiple coding of a manifestation and its undelying condition?
e.g. Arthritis (711.50) due to mumps (072.79)
the conditioned mentioned is documented as being present.
In situations when associated conditions may or may not be documented, the instruction to “use additional code” indicates that multiple codes should be assigned only if_________?
1.) “UTI, site not specified” – 599.0
2.) “Escherichia coli [E. coli]” E.- 041.49
Diagnostic statement indicates urinary tract infection (UTI) due to e-coli. “UTI, site not specified” listed as 599.0 includes the note “Use additional code to identify organism, such as Escherichia coli [E. coli] (E. coli code = 041.49) What is the correct coding/sequencing?
Report unconfirmed diagnosies as if established except in:
1.) Coding of HIV infection/ AIDS, cancer
3.) Outpatient coding
In an inpatient setting, what is the appropriate coding for unconfimed diagnoses ? i.e. when diagnostic statement lists diagnoses: “possible”, “probable”, “suspected” “likely”, “quest-ionable”, “?” , “rule out”,”consistent with”, “compatable with”, “indicative of”, “suggestive of”, “appears to be”, and “comparable with” 2 exceptions?
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.
True/False – In inpatient or outpatient coding,”borderline” diagnoses are covered under the “possible/probable” rule and coded as if confirmed.
Both codes are assigned with acute (subacute) as first listed. e.g. “Acute and chronic Bronchitis.” –
1.) 466.0 – Bronchitis – acute (subacute)
2.) 491.9 – Bronchitis – chronic
Codes for diagnoses listed as both acute (subacute) and chonic when both subterms appear at the same indentation level e.g
acute or subacute … 466.0
chronic …..491.9
are assigned and sequenced?
Only one code is assigned in this case. e.g. “Acute and chronic poliomyelitis”
=; 335.21 chronic poliomyelitis.
Codes for diagnoses listed as both acute (subacute) and chonic when when only one term is indented as a subterm with the other subterm in parenthases as a non-essential modifier. e.g.
Poliomyelitis (acute) (anterior) (epidemic) 045.9
chronic 335.21
Use the combination code. e.g. chronic and acute respiratory failure =; 518.84
Codes for diagnoses listed as both acute (subacute) and chonic when a combination code has been provided for use when a condition is described as both acute (subacute and chronic. e.g.
518.84 includes both acute and chronic respiratory failue.
disregard “acute/subacute, chronic” modifiers and just use the regular code.
Appropriate coding for when a diagnosis has no subentries listed for “acute/subacute” or “chronic”.
The condition is coded as a confirmed diagnosis. e.g. code 644.21 – “early onset of labor delivered”.
Code assignment for “impending” or “threatened” conditions that did occur? e.g. medical record indicates a diagnosis of threatened premature labor at 28 weeks gestation. Review of medical record indicates that a stillborn was delivered during the hospital stay?
1.) Assign code for “threatened” or “impending” condition. e.g. Pt is admitted with dx. of “threatened abortion” but abortion is averted. Assign code 640.0x for “threatened abortion”.
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”
Code assignment for impending or threatened conditions that did not occur? 2 possibilities:
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.
False – There is no set period of time that must elapse before a condition can be considered a late effect. Certain conditions due to trauma including “Malunion”, “Nonunion”, and “Scarring” are inherent late effects no matter how early they occur.
True/False – Set period of time must elapse before a condition can be considered a late effect.
Generally two codes are required:
1.) Residual condition – e.g. “Paralysis” – 344.40,
followed by:
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.
Generally, what is the appropriate coding/sequencing for late effects – e.g. “paralysis of left leg due to old poliomyelitis”?
1.) When the residual effect is not clearly stated the late effect of the causal condition is is used alone.
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)
What are three exceptions to the general guideline for coding of late effects?
False – A late effect code is generally not used with a code for a current illness or injury of the same type, but there is one exception: 438 codes “late effects of cerebrovascular disease (CVA) are assigned as additional code when a pt. with residual effects from a previous CVA is seen for a current CVA. e.g.
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.
True/False a late effect code is never used with a code for a current illness or injury of the same type
1.) Operative approaches, openings, closures that are an integral part of the of the procedure are not coded.
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.
What is the appropriate coding for operative approaches and closures.
1.) Codes have been developed to include these techniques for most procedures (combination codes) No additional code needed.
2.) When conversion to an open procedure is necessary, only code the open procedure followed by a V64.xx code to indicate the conversion.
1.) What is the appropriate coding for laparoscopic, thoracoscopic, and arthroscopic approaches?
2.) What is the appropriate coding for conversion from a laparoscopic, thoracoscopic, or arthroscopic approach to an open approach?
1.) Procedure code + code for endoscopic approach (unless directed otherwise by ICD-9, or endoscopic approach is included as part of the procedure codes description)
2.) When the endoscope is passed through more than one body cavity, the endoscopy code should indicate the most distant site.
How are other (non-laparoscopic, thoracoscopic, and arthroscopic) endoscopic approaches to procedures coded (2 guidelines)?
When a lesion removed for therapeutic/treatment purposes is sent to the lab for examination, a biopsy code is not assigned.
When should a biopsy code not be assigned even if a record uses the term “biopsy” in reporting the procedure?
Closed biopsies
Biopsies performed via needle, brush, or aspiration?
1.) If endoscopy is not included in the biopsy code,
code as: 1st endoscopy code + 2nd biopsy code.
2.) and 3.)
only code “closed biopsy” for brush and aspiration biopsies
How should closed biopsies of the following types be coded?
1.) Closed – endoscopic
2.) Closed – brush
3.) closed – aspiration
1.) no additional code required – “open” biopsy implies incision.
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
How should open biopsies of the following types be coded?
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)
an associated diagnostic code e.g. “retinal detachment”
A report with a code for a diagnosis-related procedure e.g. “repair of retinal detachment” must also contain__________?
1.) V64.xx codes
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.
What are the guidelines for coding the following:
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?
Coder must determine which site is involved in the revision. e.g. if peritoneal only, then code 54.95 “incision of the peritoneum”, if ventricular site revised, then code 02.42 “replacement of ventricular shunt”, if both sites are involved, then both codes should be assigned.
Appropriate coding for ventriculoperitoneal shunt?
Code for the following:
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)
Required types of codes for stent insertion?
1.) 92.3x = stereotactic radiosurgery
2.) 93.59 = immobilization
Required coding for stereotactic radiosurgery?
1.) code for specific procedure performed
2.) code from subcategory 00.3x to indicate CAS.
Required coding for computer assisted surgery (CAS)?
1.) code for specific procedure performed
2.) code from subcategory 17.4x to indicate robotic assisted surgery.
Required coding for robotic assisted procedures?

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