guidelines

Sepsis and severe sepsis as principal diagnosis
If sepsis or severe sepsis is present on admission, and
meets the definition of principal diagnosis, the systemic
infection code (e.g., 038.xx, 112.5, etc) should be
assigned as the principal diagnosis, followed by code
995.91, Sepsis, or 995.92, Severe sepsis, as required by
the sequencing rules in the Tabular List. Codes from
subcategory 995.9 can never be assigned as a principal
diagnosis. A code should also be assigned for any
localized infection, if present.

Sepsis and severe sepsis as secondary diagnoses
When sepsis or severe sepsis develops during the
encounter (it was not present on admission), the
systemic infection code and code 995.91 or 995.92
should be assigned as secondary diagnoses.

Documentation unclear as to whether sepsis or
severe sepsis is present on admission
Sepsis or severe sepsis may be present on admission but
the diagnosis may not be confirmed until sometime
after admission. If the documentation is not clear
whether the sepsis or severe sepsis was present on
admission, the provider should be queried.

Sepsis/SIRS with Localized Infection
If the reason for admission is both sepsis, severe sepsis, or
SIRS and a localized infection, such as pneumonia or cellulitis, a code for the systemic infection (038.xx, 112.5, etc) should be assigned first, then code 995.91 or 995.92, followed by the code for the localized infection.

If the patient is admitted with a localized infection, such as pneumonia, and sepsis/SIRS
doesn’t develop until after admission, see guideline
I.C.1.b.2.b).

If the localized infection is postprocedural, see Section
I.C.1.b.10 for guidelines related to sepsis due to
postprocedural infection.
Note: The term urosepsis is a nonspecific term. If that is the only term documented then only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism if known.

Bacterial Sepsis and Septicemia
In most cases, it will be a code from category 038, Septicemia, that will be used in conjunction with a code from subcategory 995.9 such as the following:

(a) Streptococcal sepsis If the documentation in the record states streptococcal sepsis, codes 038.0, Streptococcal septicemia, and code 995.91 should be used, in that sequence.

(b) Streptococcal septicemia
If the documentation states streptococcal septicemia,
only code 038.0 should be assigned, however, the
provider should be queried whether the patient has
sepsis, an infection with SIRS.

Acute organ dysfunction that is not clearly associated
with the sepsis
If a patient has sepsis and an acute organ dysfunction, but the medical record documentation indicates that the acute organ dysfunction is related to a medical condition other than the sepsis, do not assign code 995.92, Severe sepsis. An acute organ dysfunction must be associated with the sepsis in order to assign the severe sepsis code. If the documentation is not clear as to whether an acute organ dysfunction is related to the sepsis or another medical condition, query the provider.

Sequencing of septic shock and postprocedural
septic shock
Septic shock generally refers to circulatory failure
associated with severe sepsis, and, therefore, it
represents a type of acute organ dysfunction.
For cases of septic shock, the code for the systemic
infection should be sequenced first, followed by codes
995.92, Severe sepsis and 785.52, Septic shock or
998.02, Postoperative septic shock. Any additional
codes for other acute organ dysfunctions should also be
assigned. As noted in the sequencing instructions in the
Tabular List, the code for septic shock cannot be
assigned as a principal diagnosis.
(b) Septic shock and postprocedural septic shock
without documentation of severe sepsis
Since septic shock indicates the presence of severe
sepsis, code 995.92, Severe sepsis, can be assigned
with code 785.52, Septic shock, or code 998.02
Postoperative shock, septic, even if the term severe
sepsis is not documented in the record.

Sepsis and septic shock complicating abortion and
pregnancy 630-639
Sepsis and septic shock complicating abortion, ectopic
pregnancy, and molar pregnancy are classified to category
codes in Chapter 11 (630-639).

Sepsis and Severe Sepsis Associated with Noninfectious
Process
In some cases, a non-infectious process, such as trauma, may lead to an infection which can result in sepsis or severe sepsis. If sepsis or severe sepsis is documented as associated with a non-infectious condition, such as a burn or serious injury, and this condition meets the definition for principal diagnosis, the code for the non-infectious condition should be sequenced first, followed by the code for the systemic infection and either code 995.91, Sepsis, or 995.92, Severe sepsis.

Additional codes for any associated acute organ dysfunction(s) should also be assigned for cases of severe sepsis. If the sepsis or severe sepsis meets the definition of principal diagnosis, the systemic infection and sepsis codes should be sequenced before the noninfectious condition.

When both the associated non-infectious condition and the sepsis or severe sepsis meet the definition of principal diagnosis, either may be assigned as principal diagnosis.
See Section I.C.1.b.2.a. for guidelines pertaining to sepsis or
severe sepsis as the principal diagnosis. Only one code from subcategory 995.9 should be assigned. Therefore, when a non-infectious condition leads to an infection resulting in sepsis or severe sepsis, assign either code 995.91 or 995.92. Do not additionally assign code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction, or 995.94, Systemic inflammatory response syndrome with acute organ dysfunction.

Selection and sequencing of MRSA codes
Combination codes for MRSA infection
When a patient is diagnosed with an infection that is
due to methicillin resistant Staphylococcus aureus
(MRSA), and that infection has a combination code that
includes the causal organism (e.g., septicemia,
pneumonia) assign the appropriate code for the
condition (e.g., code 038.12, Methicillin resistant
Staphylococcus aureus septicemia or code 482.42,
Methicillin resistant pneumonia due to Staphylococcus
aureus). Do not assign code 041.12, Methicillin
resistant Staphylococcus aureus, as an additional code
because the code includes the type of infection and the MRSA organism. Do not assign a code from
subcategory V09.0, Infection with microorganisms
resistant to penicillins, as an additional diagnosis.

Other codes for MRSA infection
When there is documentation of a current infection
(e.g., wound infection, stitch abscess, urinary tract
infection) due to MRSA, and that infection does not
have a combination code that includes the causal
organism, select the appropriate code to identify the
condition along with code 041.12, Methicillin resistant
Staphylococcus aureus, for the MRSA infection. Do
not assign a code from subcategory V09.0, Infection
with microorganisms resistant to penicillins.

Methicillin susceptible Staphylococcus aureus
(MSSA) and MRSA colonization
The condition or state of being colonized or carrying
MSSA or MRSA is called colonization or carriage,
while an individual person is described as being
colonized or being a carrier. Colonization means that
MSSA or MSRA is present on or in the body without
necessarily causing illness. A positive MRSA
colonization test might be documented by the provider
as “MRSA screen positive” or “MRSA nasal swab
positive”.
Assign code V02.54, Carrier or suspected carrier,
Methicillin resistant Staphylococcus aureus, for patients
documented as having MRSA colonization. Assign
code V02.53, Carrier or suspected carrier, Methicillin
susceptible Staphylococcus aureus, for patient
documented as having MSSA colonization.
Colonization is not necessarily indicative of a disease
process or as the cause of a specific condition the
patient may have unless documented as such by the
provider.
Code V02.59, Other specified bacterial diseases, should
be assigned for other types of staphylococcal
colonization (e.g., S. epidermidis, S. saprophyticus).
Code V02.59 should not be assigned for colonization
with any type of Staphylococcus aureus (MRSA,
MSSA)

MRSA colonization and infection
If a patient is documented as having both MRSA
colonization and infection during a hospital admission,
code V02.54, Carrier or suspected carrier, Methicillin
resistant Staphylococcus aureus, and a code for the
MRSA infection may both be assigned.

Anemia associated with malignancy
When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate anemia code (such as code 285.22,
Anemia in neoplastic disease) is designated as the principal
diagnosis and is followed by the appropriate code(s) for the
malignancy.
Code 285.22 may also be used as a secondary code if the
patient suffers from anemia and is being treated for the
malignancy.
If anemia in neoplastic disease and anemia due to
antineoplastic chemotherapy are both documented, assign
codes for both conditions.

Anemia associated with chemotherapy,
immunotherapy and radiation therapy
When the admission/encounter is for management of an anemia
associated with chemotherapy, immunotherapy or radiotherapy
and the only treatment is for the anemia, the anemia is
sequenced first. The appropriate neoplasm code should be
assigned as an additional code.

Management of dehydration due to the malignancy
When the admission/encounter is for management of
dehydration due to the malignancy or the therapy, or a
combination of both, and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy

Treatment of a complication resulting from a surgical
procedure
When the admission/encounter is for treatment of a
complication resulting from a surgical procedure, designate the complication as the principal or first-listed diagnosis if
treatment is directed at resolving the complication.

Primary malignancy previously excised
When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used
to indicate the former site of the malignancy. Any mention of extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the V10 code used as a secondary code.

Episode of care involves surgical removal of neoplasm
When an episode of care involves the surgical removal of a
neoplasm, primary or secondary site, followed by adjunct
chemotherapy or radiation treatment during the same episode of care, the neoplasm code should be assigned as principal or first-listed diagnosis, using codes in the 140-198 series or where appropriate in the 200-203 series.

Patient admission/encounter solely for administration
of chemotherapy, immunotherapy and radiation
therapy
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or radiation therapy assign code V58.0, Encounter for radiation therapy, or V58.11, Encounter for antineoplastic chemotherapy, or V58.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence. The malignancy for which the therapy is being administered should be assigned as a secondary diagnosis.

Patient admitted for radiotherapy/chemotherapy and
immunotherapy and develops complications
When a patient is admitted for the purpose of radiotherapy,
immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is V58.0, Encounter for radiotherapy, or V58.11, Encounter for antineoplastic chemotherapy, or V58.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications.

Admission/encounter to determine extent of malignancy
When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.

Symptoms, signs, and ill-defined conditions listed in
Chapter 16 associated with neoplasms
Symptoms, signs, and ill-defined conditions listed in Chapter 16 characteristic of, or associated with, an existing primary or secondary site malignancy cannot be used to replace the malignancy as principal or first-listed diagnosis, regardless of the number of admissions or encounters for treatment and care of the neoplasm.

Malignant neoplasm associated with transplanted organ
A malignant neoplasm of a transplanted organ should be coded as a transplant complication. Assign first the appropriate code from subcategory 996.8, Complications of transplanted organ, followed by
code 199.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.

Fifth-digits for category 250:
0 – type II or unspecified type, not stated as uncontrolled
1 – type I, [juvenile type], not stated as uncontrolled
2 – type II or unspecified type, uncontrolled
3 – type I, [juvenile type], uncontrolled

Diabetes mellitus and the use of insulin
All type I diabetics must use insulin to replace what their
bodies do not produce. However, the use of insulin does not mean that a patient is a type I diabetic. Some patients with type II diabetes mellitus are unable to control their blood sugar through diet and oral medication alone and do require insulin. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, the appropriate fifth-digit for type II must be used. For type II patients who routinely use insulin, code V58.67, Long-term(current) use of insulin, should also be assigned to indicate that the patient uses insulin. Code V58.67 should not be assigned if insulin is given temporarily to bring a type II patient’s blood
sugar under control during an encounter.

Assigning and sequencing diabetes codes and
associated conditions
When assigning codes for diabetes and its associated
conditions, the code(s) from category 250 must be sequenced before the codes for the associated conditions. The diabetes codes and the secondary codes that correspond to them are paired codes that follow the etiology/manifestation convention of the classification Assign as many codes from category 250 as needed to identify all of the associated conditions that the patient has. The corresponding secondary codes are listed under each of the diabetes codes.

Diabetic retinopathy/diabetic macular edema
250.5x
362.07
Diabetic macular edema, code 362.07, is only present
with diabetic retinopathy. Another code from
subcategory 362.0, Diabetic retinopathy, must be used
with code 362.07. Codes under subcategory 362.0 are
diabetes manifestation codes, so they must be used
following the appropriate diabetes code.

Insulin pump malfunction – under dose of insulin – 996.57
(a) Underdose of insulin due insulin pump failure
should be assigned 996.57, Mechanical complication
due to insulin pump, as the principal or first listed code,
followed by the appropriate diabetes mellitus code
based on documentation.

Insulin pump malfunction – Overdose of insulin
996.57, 962.3
(b) Overdose of insulin due to insulin pump failure
The principal or first listed code for an encounter due to
an insulin pump malfunction resulting in an overdose of
insulin, should also be 996.57, Mechanical
complication due to insulin pump, followed by code
962.3, Poisoning by insulins and antidiabetic agents,
and the appropriate diabetes mellitus code based on
documentation.

Anemia of chronic disease – 285.2
Anemia in chronic illness, has codes for anemia in chronic kidney disease, code 285.21; anemia in neoplastic disease, code 285.22; and anemia in other chronic illness, code 285.29. These codes can be used as the principal/first listed code if the reason for the encounter is to treat the anemia. They may also be used as secondary codes if treatment of the anemia is a component of an encounter, but
not the primary reason for the encounter. When using a code from subcategory 285 it is also necessary to use the code for the chronic condition causing the anemia.

Anemia in chronic kidney disease – 285.21, 585.xx
When assigning code 285.21, Anemia in chronic kidney
disease, it is also necessary to assign a code from category 585, Chronic kidney disease, to indicate the stage of chronic kidney disease.

Anemia in neoplastic disease – 285.22
When assigning code 285.22, Anemia in neoplastic disease, it is also necessary to assign the neoplasm code that is
responsible for the anemia. Code 285.22 is for use for anemia that is due to the malignancy, not for anemia due to
antineoplastic chemotherapy drugs. Assign the appropriate
code for anemia due to antineoplastic chemotherapy.

Pain – Category 338
Codes in category 338 may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain, unless otherwise indicated below.
If the pain is not specified as acute or chronic, do not assign
codes from category 338, except for post-thoracotomy pain, postoperative pain, neoplasm related pain, or central pain syndrome. A code from subcategories 338.1 and 338.2 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition.

Category 338 Codes as Principal or First-Listed
Diagnosis –

Category 338 codes are acceptable as principal
diagnosis or the first-listed code:

• When pain control or pain management is the
reason for the admission/encounter (e.g., a patient
with displaced intervertebral disc, nerve
impingement and severe back pain presents for
injection of steroid into the spinal canal). The
underlying cause of the pain should be reported as
an additional diagnosis, if known.

• When an admission or encounter is for a procedure
aimed at treating the underlying condition (e.g.,
spinal fusion, kyphoplasty), a code for the
underlying condition (e.g., vertebral fracture, spinal
stenosis) should be assigned as the principal
diagnosis. No code from category 338 should be
assigned.

• When a patient is admitted for the insertion of a
neurostimulator for pain control, assign the
appropriate pain code as the principal or first listed
diagnosis.

When an admission or encounter is for a
procedure aimed at treating the underlying
condition and a neurostimulator is inserted for pain
control during the same admission/encounter, a
code for the underlying condition should be
assigned as the principal diagnosis and the
appropriate pain code should be assigned as a
secondary diagnosis.

Assigning Category 338 Codes and Site Specific
Pain Codes
Codes from category 338 may be used in
conjunction with codes that identify the site of
pain (including codes from chapter 16) if the
category 338 code provides additional
information. For example, if the code describes
the site of the pain, but does not fully describe
whether the pain is acute or chronic, then both
codes should be assigned.

Sequencing of Category 338 Codes with Site Specific
Pain Codes
The sequencing of category 338 codes with site specific
pain codes (including chapter 16 codes), is dependent on the circumstances of the encounter/admission as follows:

• If the encounter is for pain control or pain management, assign the code from category 338 followed by the code
identifying the specific site of pain (e.g., encounter for pain management for acute neck pain from trauma is assigned code 338.11, Acute pain due to trauma, followed by code 723.1, Cervicalgia, to identify the site of pain).

• If the encounter is for any other reason except pain control or pain management, and a related definitive diagnosis has not been established (confirmed) by the
provider, assign the code for the specific site of pain first, followed by the appropriate code from category 338.

Pain due to devices, implants and grafts
Pain associated with devices, implants or grafts left in a
surgical site (for example painful hip prosthesis) is assigned to the appropriate code(s) found in Chapter 17, Injury and
Poisoning. Use additional code(s) from category 338 to
identify acute or chronic pain due to presence of the device,
implant or graft (338.18-338.19 or 338.28-338.29).

Postoperative Pain
Post-thoracotomy pain and other postoperative pain are
classified to subcategories 338.1 and 338.2, depending on
whether the pain is acute or chronic. The default for postthoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form.
Routine or expected postoperative pain immediately
after surgery should not be coded

Postoperative pain not associated with specific
postoperative complication
Postoperative pain not associated with a specific
postoperative complication is assigned to the
appropriate postoperative pain code in category 338.

Postoperative pain associated with specific
postoperative complication
Postoperative pain associated with a specific postoperative complication (such as painful wire sutures) is assigned to the appropriate code(s) found in Chapter 17, Injury and Poisoning. If appropriate, use additional code(s) from category 338 to identify acute or chronic pain (338.18 or 338.28). If pain control/management is the reason for the encounter, a code from category 338 should be assigned as the principal or first-listed diagnosis in accordance with
Section I.C.6.a.1.a above

Postoperative pain as principal or first-listed diagnosis
Postoperative pain may be reported as the principal or
first-listed diagnosis when the stated reason for the
admission/encounter is documented as postoperative
pain control/management.

Postoperative pain as secondary diagnosis
Postoperative pain may be reported as a secondary diagnosis code when a patient presents for outpatient
surgery and develops an unusual or inordinate amount
of postoperative pain. The provider’s documentation should be used to guide the coding of postoperative pain.

Chronic pain – 338.2
Chronic pain is classified to subcategory 338.2. There is no
time frame defining when pain becomes chronic pain. The
provider’s documentation should be used to guide use of these codes.

Neoplasm Related Pain – 338.3
Code 338.3 is assigned to pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic.
This code may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. The underlying neoplasm should be reported as an additional diagnosis. When the reason for the admission/encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code 338.3 may be assigned as an additional diagnosis.

Chronic pain syndrome – 338.4
This condition is different than the term “chronic pain,” and therefore this code should only be used when the provider has specifically documented this condition.

Glaucoma – 365.x
For types of glaucoma classified to subcategories 365.1-
365.6, an additional code should be assigned from
subcategory 365.7, Glaucoma stage, to identify the
glaucoma stage. Codes from 365.7, Glaucoma stage, may
not be assigned as a principal or first-listed diagnosis.

2) Bilateral glaucoma with same stage
When a patient has bilateral glaucoma and both are
documented as being the same type and stage, report only
the code for the type of glaucoma and one code for the stage.

3) Bilateral glaucoma stage with different stages
When a patient has bilateral glaucoma and each eye is
documented as having a different stage, assign one code for
the type of glaucoma and one code for the highest glaucoma
stage.

4) Bilateral glaucoma with different types and different
stages
When a patient has bilateral glaucoma and each eye is
documented as having a different type and a different
stage, assign one code for each type of glaucoma and one
code for the highest glaucoma stage.

5) Patient admitted with glaucoma and stage evolves
during the admission
If a patient is admitted with glaucoma and the stage
progresses during the admission, assign the code for highest
stage documented.

6) Indeterminate stage glaucoma
Assignment of code 365.74, Indeterminate stage glaucoma,
should be based on the clinical documentation. Code
365.74 is used for glaucomas whose stage cannot be
clinically determined. This code should not be confused
with code 365.70, Glaucoma stage, unspecified.
365.70 should be assigned when there is no documentation
regarding the stage of the glaucoma.

Hypertension, Essential, or NOS – 401
Assign hypertension (arterial) (essential) (primary) (systemic) (NOS) to category code 401 with the appropriate fourth digit to indicate malignant (.0), benign (.1), or unspecified (.9). Do not use either .0 malignant or .1 benign unless medical record documentation supports such a designation.

Hypertension with Heart Disease – 402
Heart conditions (425.8, 429.0-429.3, 429.8, 429.9) are
assigned to a code from category 402 when a causal
relationship is stated (due to hypertension) or implied
(hypertensive). Use an additional code from category 428 to identify the type of heart failure in those patients with heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and
congestive heart failure.

The same heart conditions (425.8, 429.0-429.3, 429.8, 429.9) with hypertension, but without a stated causal relationship, are coded separately. Sequence according to the circumstances of the admission/encounter.

Hypertensive Chronic Kidney Disease – 403
Assign codes from category 403, Hypertensive chronic kidney disease, when conditions classified to category 585 or code 587 are present with hypertension. Unlike hypertension with heart disease, ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease (CKD) with hypertension as hypertensive chronic kidney disease. Fifth digits for category 403 should be assigned as follows:
• 0 with CKD stage I through stage IV, or unspecified.
• 1 with CKD stage V or end stage renal disease.ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2011
Page 37 of 107 The appropriate code from category 585, Chronic kidney disease, should be used as a secondary code with a code from category 403 to identify the stage of chronic kidney disease.

Hypertensive Heart and Chronic Kidney Disease – 404
Assign codes from combination category 404, Hypertensive heart and chronic kidney disease, when both hypertensive kidney disease and hypertensive heart disease are stated in the diagnosis. Assume a relationship between the hypertension and the chronic kidney disease, whether or not the condition is so designated. Assign an additional code from category 428, to identify the type of heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure. Fifth digits for category 404 should be assigned as follows:
• 0 without heart failure and with chronic kidney disease
(CKD) stage I through stage IV, or unspecified
• 1 with heart failure and with CKD stage I through stage
IV, or unspecified
• 2 without heart failure and with CKD stage V or end
stage renal disease
• 3 with heart failure and with CKD stage V or end stage
renal disease

The appropriate code from category 585, Chronic kidney
disease, should be used as a secondary code with a code from category 404 to identify the stage of kidney disease.

Hypertensive Cerebrovascular Disease
First assign codes from 430-438, Cerebrovascular disease, then the appropriate hypertension code from categories 401-405.

Hypertensive Retinopathy
Two codes are necessary to identify the condition. First assign the code from subcategory 362.11, Hypertensive retinopathy, then the appropriate code from categories 401-405 to indicate the type of hypertension.

Hypertension, Secondary
Two codes are required: one to identify the underlying etiology and one from category 405 to identify the hypertension. Sequencing of codes is determined by the reason for admission/encounter.

Hypertension, Controlled
Assign appropriate code from categories 401-405. This
diagnostic statement usually refers to an existing state of
hypertension under control by therapy.

Hypertension, Uncontrolled
Uncontrolled hypertension may refer to untreated hypertension or hypertension not responding to current therapeutic regimen. In either case, assign the appropriate code from categories 401-405 to designate the stage and type of hypertension. Code to the type of hypertension.

Elevated Blood Pressure
For a statement of elevated blood pressure without further
specificity, assign code 796.2, Elevated blood pressure reading without diagnosis of hypertension, rather than a code from category 401.

Cerebral infarction/stroke/cerebrovascular accident
(CVA)
The terms stroke and CVA are often used interchangeably to refer to a cerebral infarction. The terms stroke, CVA, and cerebral infarction NOS are all indexed to the default code 434.91, Cerebral artery occlusion, unspecified, with infarction. Additional code(s) should be assigned for any neurologic deficits associated with the acute CVA, regardless of whether or not the neurologic deficit resolves prior to discharge.

Postoperative cerebrovascular accident
A cerebrovascular hemorrhage or infarction that occurs as a result of medical intervention is coded to 997.02, Iatrogenic cerebrovascular infarction or hemorrhage. Medical record documentation should clearly specify the cause- and-effect relationship between the medical
intervention and the cerebrovascular accident in order to assign this code. A secondary code from the code range 430-432 or from a code from subcategories 433 or 434 with a fifth digit of “1” should also be used to identify the type of hemorrhage or infarct.

Category 438, Late Effects of Cerebrovascular disease
Category 438 is used to indicate conditions classifiable to
categories 430-437 as the causes of late effects (neurologic
deficits), themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to 430-437. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to 430-437.
Codes in category 438 are only for use for late effects of
cerebrovascular disease, not for neurologic deficits associated with an acute CVA.

Codes from category 438 with codes from 430-437
Codes from category 438 may be assigned on a health care
record with codes from 430-437, if the patient has a current
cerebrovascular accident (CVA) and deficits from an old CVA.

Code V12.54
Assign code V12.54, Transient ischemic attack (TIA), and
cerebral infarction without residual deficits (and not a code
from category 438) as an additional code for history of
cerebrovascular disease when no neurologic deficits are
present.

Acute myocardial infarction (AMI)
1) ST elevation myocardial infarction (STEMI) and non
ST elevation myocardial infarction (NSTEMI)
The ICD-9-CM codes for acute myocardial infarction (AMI)
identify the site, such as anterolateral wall or true posterior
wall. Subcategories 410.0-410.6 and 410.8 are used for ST
elevation myocardial infarction (STEMI). Subcategory 410.7, Subendocardial infarction, is used for non ST elevation myocardial infarction (NSTEMI) and nontransmural MIs.

2) Acute myocardial infarction, unspecified
Subcategory 410.9 is the default for the unspecified term acute myocardial infarction. If only STEMI or transmural MI without the site is documented, query the provider as to the site, or assign a code from subcategory 410.9.

3) AMI documented as nontransmural or subendocardial
but site provided If an AMI is documented as nontransmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI. If NSTEMI evolves to STEMI, assign the STEMI code. If STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.

Chronic Obstructive Pulmonary Disease [COPD] and
Asthma
1) Conditions that comprise COPD and Asthma
The conditions that comprise COPD are obstructive chronic bronchitis, subcategory 491.2, and emphysema, category 492. All asthma codes are under category 493, Asthma. Code 496, Chronic airway obstruction, not elsewhere classified, is a nonspecific code that should only be used when the documentation in a medical record does not specify the type of COPD being treated

Chronic Obstructive Pulmonary Disease [COPD] and
Asthma
2) Acute exacerbation of chronic obstructive bronchitis
and asthma
The codes for chronic obstructive bronchitis and asthma
distinguish between uncomplicated cases and those in acute exacerbation. An acute exacerbation is a worsening or a decompensation of a chronic condition. An acute exacerbation is not equivalent to an infection superimposed on a chronic condition, though an exacerbation may be triggered by an infection.

3) Overlapping nature of the conditions that comprise
COPD and asthma
Due to the overlapping nature of the conditions that make up COPD and asthma, there are many variations in the way these conditions are documented. Code selection must be based on the terms as documented. When selecting the correct code for the documented type of COPD and asthma, it is essential to first review the index, and then verify the code in the tabular list. There are many instructional notes under the different COPD subcategories and codes. It is important that all such notes be reviewed to assure correct code assignment.

4) Acute exacerbation of asthma and status asthmaticus
An acute exacerbation of asthma is an increased severity of the asthma symptoms, such as wheezing and shortness of breath. Status asthmaticus refers to a patient’s failure to respond to therapy administered during an asthmatic episode and is a life threatening complication that requires emergency care. If status asthmaticus is documented by the provider with any type of COPD or with acute bronchitis, the status asthmaticus should be sequenced first. It supersedes any type of COPD including that with acute exacerbation or acute bronchitis. It is inappropriate to assign an asthma code with 5th digit 2, with acute exacerbation, together with an asthma code with 5th digit
1, with status asthmatics. Only the 5th digit 1 should be
assigned.

Chronic Obstructive Pulmonary Disease [COPD] and
Bronchitis
1) Acute bronchitis with COPD
Acute bronchitis, code 466.0, is due to an infectious organism. When acute bronchitis is documented with COPD, code 491.22, Obstructive chronic bronchitis with acute bronchitis, should be assigned. It is not necessary to also assign code 466.0. If a medical record documents acute bronchitis with COPD with acute exacerbation, only code 491.22 should be assigned. The acute bronchitis included in code 491.22 supersedes the acute exacerbation. If a medical record documents COPD with acute exacerbation without mention of acute bronchitis, only code 491.21 should be assigned.

c. Acute Respiratory Failure –

1) Acute respiratory failure as principal diagnosis

Acute respiratory failure, may be assigned as a principal
diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the
hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

2) Acute respiratory failure as secondary diagnosis
Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

3) Sequencing of acute respiratory failure and another
acute condition
When a patient is admitted with respiratory failure and another acute condition, (e.g., myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or nonrespiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.
If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider for clarification.

1) Stages of chronic kidney disease (CKD)
The ICD-9-CM classifies CKD based on severity. The severity of CKD is designated by stages I-V. Stage II, code 585.2, equates to mild CKD; stage III, code 585.3, equates to moderate CKD; and stage IV, code 585.4, equates to severe CKD. Code 585.6, End stage renal disease (ESRD), is
assigned when the provider has documented end-stage-renal disease (ESRD). If both a stage of CKD and ESRD are documented, assign code 585.6 only.

2) Chronic kidney disease and kidney transplant status
Patients who have undergone kidney transplant may still have some form of CKD, because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Assign the appropriate 585 code for the patient’s stage of CKD and code V42.0. If a transplant complication such as failure or rejection is documented, see section I.C.17.f.2.b for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider.

3) Chronic kidney disease with other conditions
Patients with CKD may also suffer from other serious
conditions, most commonly diabetes mellitus and hypertension. The sequencing of the CKD code in relationship to codes for other contributing conditions is based on the conventions in the tabular list.

Codes from chapter 11 and sequencing priority
1) Obstetric cases require codes from chapter 11, codes in the range 630-679, Complications of Pregnancy, Childbirth, and the Puerperium. Chapter 11 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 11 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code V22.2 should be used in place of any chapter 11 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

2) Chapter 11 codes used only on the maternal record
Chapter 11 codes are to be used only on the maternal record,never on the record of the newborn.

Episodes when no delivery occurs
In episodes when no delivery occurs, the principal diagnosis should correspond to the principal complication of the pregnancy, which necessitated the encounter. Should more than one complication exist, all of which are treated or monitored, any of the complications codes may be sequenced first.

When a delivery occurs
When a delivery occurs, the principal diagnosis should
correspond to the main circumstances or complication of the delivery. In cases of cesarean delivery, the selection of the principal diagnosis should be the condition established after study that was responsible for the patient’s admission. If the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission/encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission/encounter should be selected as the principal diagnosis, even if a cesarean was performed.

Fetal Conditions Affecting the Management of the
Mother
1) Codes from categories 655 and 656
Codes from categories 655, Known or suspected fetal
abnormality affecting management of the mother, and 656,
Other known or suspected fetal and placental problems
affecting the management of the mother, are assigned only
when the fetal condition is actually responsible for modifying the management of the mother, i.e., by requiring diagnostic studies, additional observation, special care, or termination of pregnancy. The fact that the fetal condition exists does not justify assigning a code from this series to the mother’s record.

HIV Infection in Pregnancy, Childbirth and the
Puerperium
During pregnancy, childbirth or the puerperium, a patient admitted because of an HIV-related illness should receive a principal diagnosis of 647.6X, Other specified infectious and parasitic diseases in the mother classifiable elsewhere, but complicating the pregnancy, childbirth or the puerperium, followed by 042 and the code(s) for the
HIV-related illness(es). Patients with asymptomatic HIV infection status admitted during pregnancy, childbirth, or the puerperium should receive codes of 647.6X and V08

Current Conditions Complicating Pregnancy
Assign a code from subcategory 648.x for patients that have current conditions when the condition affects the management of the pregnancy, childbirth, or the puerperium. Use additional secondary codes from other chapters to identify the conditions, as appropriate.

Diabetes mellitus in pregnancy
Diabetes mellitus is a significant complicating factor in pregnancy. Pregnant women who are diabetic should be assigned code 648.0x, Diabetes mellitus complicating pregnancy, and a secondary code from category 250, Diabetes mellitus, or category 249, Secondary diabetes
to identify the type of diabetes. Code V58.67, Long-term (current) use of insulin, should also be assigned if the diabetes mellitus is being treated with insulin

Gestational diabetes
Gestational diabetes can occur during the second and third trimester of pregnancy in women who were not diabetic prior to pregnancy. Gestational diabetes can cause complications in the pregnancy similar to those of pre-existing diabetes mellitus. It also puts the woman at
greater risk of developing diabetes after the pregnancy. Gestational diabetes is coded to 648.8x, Abnormal glucose tolerance. Codes 648.0x and 648.8x should never be used together on the same record. Code V58.67, Long-term (current) use of insulin, should also be assigned if the gestational diabetes is being treated with insulin.

Normal Delivery, Code 650
1) Normal delivery
Code 650 is for use in cases when a woman is admitted for a
full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code 650 is always a principal diagnosis. It is not to be used if any other code from chapter 11 is needed to describe a current complication of the antenatal, delivery, or perinatal period. Additional codes from other chapters may be used with code 650 if they are not related to or are in any way complicating the pregnancy.

2) Normal delivery with resolved antepartum
complication Code 650 may be used if the patient had a complication at some point during her pregnancy, but the complication is not present at the time of the admission for delivery.

3) outcome of delivery , V27.0, Single liveborn, is the only outcome of delivery code appropriate for use with 650.

Postpartum and peripartum periods
The postpartum period begins immediately after delivery and continues for six weeks following delivery. The peripartum period is defined as the last month of pregnancy to five months postpartum.

2) Postpartum complication A postpartum complication is any complication occurring within the six-week period.

3) Pregnancy-related complications after 6 week period
Chapter 11 codes may also be used to describe pregnancy-related complications after the six-week period should the provider document that a condition is pregnancy related.

4) Postpartum complications occurring during the same
admission as delivery Postpartum complications that occur during the same admission as the delivery are identified with a fifth digit of “2.”

Subsequent admissions/encounters for postpartum
complications should be identified with a fifth digit of “4.”

Puerperal sepsis
Code 670.2x, Puerperal sepsis, should be assigned with a
secondary code to identify the causal organism (e.g., for a
bacterial infection, assign a code from category 041, Bacterial infections in conditions classified elsewhere and of unspecified site). A code from category 038, Septicemia, should not be used for puerperal sepsis. Do not assign code 995.91, Sepsis, as code 670.2x describes the sepsis. If applicable, use additional codes to identify severe sepsis (995.92) and any associated acute organ dysfunction.

Code 677, Late effect of complication of pregnancy
1) Code 677, Late effect of complication of pregnancy, childbirth, and the puerperium is for use in those cases when an initial complication of a pregnancy develops a sequelae requiring care or treatment at a future date.

2) After the initial postpartum period This code may be used at any time after the initial postpartum period.

3) Sequencing of Code 677: This code, like all late effect codes, is to be sequenced following the code describing the sequelae of the complication.

Abortions
1) Fifth-digits required for abortion categories
Fifth-digits are required for abortion categories 634-637. Fifth digit assignment is based on the status of the patient at the beginning (or start) of the encounter. Fifth-digit 1, incomplete, indicates that all of the products of conception have not been expelled from the uterus. Fifth-digit 2, complete, indicates that all products of conception have been expelled from the uterus.

2) Code from categories 640-649 and 651-659
A code from categories 640-649 and 651-659 may be used as additional codes with an abortion code to indicate the
complication leading to the abortion.
Fifth digit 3 is assigned with codes from these categories when used with an abortion code because the other fifth digits will not apply. Codes from the 660-669 series are not to be used for complications of abortion.

3) Code 639 for complications
Code 639 is to be used for all complications following
abortion. Code 639 cannot be assigned with codes from
categories 634-638.

4) Abortion with Liveborn Fetus
When an attempted termination of pregnancy results in a
liveborn fetus assign code 644.21, Early onset of delivery, with an appropriate code from category V27, Outcome of Delivery. The procedure code for the attempted termination of pregnancy should also be assigned.

Retained Products of Conception following an
abortion
Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from category 634, Spontaneous abortion, or 635 Legally induced abortion, with a fifth digit of “1” (incomplete). This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion.

Chapter 17: Injury and Poisoning (800-999)

a. Coding of Injuries

a. Coding of Injuries
When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Multiple injury codes are provided in ICD-9-CM, but should not be assigned unless information for a more specific code is not available. These traumatic injury codes are not to be used for normal,
healing surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

1) Superficial injuries
Superficial injuries such as abrasions or contusions are not
coded when associated with more severe injuries of the same site.

2) Primary injury with damage to nerves/blood vessels
When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) from categories 950-957, Injury to nerves and spinal cord, and/or 900-904, Injury to blood vessels. When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

Chapter 17: Injury and Poisoning (800-999)

b. Coding of Traumatic Fractures

b. Coding of Traumatic Fractures

The principles of multiple coding of injuries should be followed in coding fractures. Fractures of specified sites are coded individually by site in accordance with both the provisions within categories 800-829 and the level of detail furnished by medical record content. Combination categories for multiple fractures are provided for use
when there is insufficient detail in the medical record (such as trauma cases transferred to another hospital), when the reporting form limits the number of codes that can be used in reporting pertinent clinical data, or when there is insufficient specificity at the fourth-digit or fifth-digit level.

2) Multiple fractures of same limb
Multiple fractures of same limb classifiable to the same
three-digit or four-digit category are coded to that category.

3) Multiple unilateral or bilateral fractures of same bone
Multiple unilateral or bilateral fractures of same bone(s) but classified to different fourth-digit subdivisions (bone part) within the same three-digit category are coded individually by site.

4) Multiple fracture categories 819 and 828
Multiple fracture categories 819 and 828 classify bilateral
fractures of both upper limbs (819) and both lower limbs (828), but without any detail at the fourth-digit level other than open and closed type of fractures.

5) Multiple fractures sequencing
Multiple fractures are sequenced in accordance with the
severity of the fracture. The provider should be asked to list the fracture diagnoses in the order of severity.

1) Acute Fractures vs. Aftercare
1) Acute Fractures vs. Aftercare

Traumatic fractures are coded using the acute fracture codes (800-829) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

Fractures are coded using the aftercare codes (subcategories V54.0, V54.1, V54.8, or V54.9) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow up visits following fracture
treatment. Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
Care of complications of fractures, such as malunion and
nonunion, should be reported with the appropriate codes.

Pathologic fractures are not coded in the 800-829 range, but instead are assigned to subcategory 733.1.

Coding of Burns
Coding of Burns – Current burns (940-948) are classified by depth, extent and by agent (E code). Burns are classified by depth as first degree (erythema), second degree (blistering), and third degree (full-thickness involvement).

1) Sequencing of burn and related condition codes
Sequence first the code that reflects the highest degree of burn when more than one burn is present.

a. When the reason for the admission or encounter is for
treatment of external multiple burns, sequence first the
code that reflects the burn of the highest degree.

b. When a patient has both internal and external burns, the
circumstances of admission govern the selection of the
principal diagnosis or first-listed diagnosis.

c. When a patient is admitted for burn injuries and other
related conditions such as smoke inhalation and/or
respiratory failure, the circumstances of admission govern
the selection of the principal or first-listed diagnosis.

2) Burns of the same local site
Classify burns of the same local site (three-digit category level, 940-947) but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis.

3) Non-healing burns
Non-healing burns are coded as acute burns. Necrosis of burned skin should be coded as a non-healed burn.

4) Code 958.3, Posttraumatic wound infection
Assign code 958.3, Posttraumatic wound infection, not
elsewhere classified, as an additional code for any documented infected burn site.

5) Assign separate codes for each burn site
When coding burns, assign separate codes for each burn site. Category 946 Burns of Multiple specified sites, should only be used if the location of the burns are not documented. Category 949, Burn, unspecified, is extremely vague and should rarely be used.

6) Assign codes from category 948, Burns
Burns classified according to extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data. It is advisable to use category 948 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category 948 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface.

In assigning a code from category 948:
Fourth-digit codes are used to identify the percentage of
total body surface involved in a burn (all degree).
Fifth-digits are assigned to identify the percentage of
body surface involved in third-degree burn.

Fifth-digit zero (0) is assigned when less than 10
percent or when no body surface is involved in a
third-degree burn.

“rule of nines
Category 948 is based on the classic “rule of nines” in
estimating body surface involved: head and neck are
assigned nine percent, each arm nine percent, each leg
18 percent, the anterior trunk 18 percent, posterior trunk
18 percent, and genitalia one percent. Providers may
change these percentage assignments where necessary
to accommodate infants and children who have
proportionately larger heads than adults and patients
who have large buttocks, thighs, or abdomen that
involve burns.

Encounters for treatment of late effects of burns
Encounters for the treatment of the late effects of burns (i.e., scars or joint contractures) should be coded to the residual condition (sequelae) followed by the appropriate late effect code (906.5-906.9). A late effect E code may also be used, if desired.

Sequelae with a late effect code and current burn
When appropriate, both a sequelae with a late effect code, and a current burn code may be assigned on the same record (when both a current burn and sequelae of an old burn exist).

Coding of Debridement of Wound, Infection, or Burn
Excisional debridement involves surgical removal or cutting away, as opposed to a mechanical (brushing, scrubbing, washing) debridement.

For coding purposes, excisional debridement is assigned to code 86.22.

Nonexcisional debridement is assigned to code 86.28.

Adverse Effects, Poisoning and Toxic Effects

1) Adverse Effect

The properties of certain drugs, medicinal and biological substances or combinations of such substances, may cause toxic reactions. The occurrence of drug toxicity is classified in ICD-9-CM as follows:

1) Adverse Effect
When the drug was correctly prescribed and properly
administered, code the reaction plus the appropriate code from the E930-E949 series. Codes from the E930-E949 series must be used to identify the causative substance for an adverse effect of drug, medicinal and biological substances, correctly prescribed and properly administered. The effect, such as tachycardia, delirium, gastrointestinal hemorrhaging, vomiting, hypokalemia, hepatitis, renal failure, or respiratory failure, is
coded and followed by the appropriate code from the
E930-E949 series.

Adverse effects of therapeutic substances correctly prescribed and properly administered (toxicity, synergistic reaction, side effect, and idiosyncratic reaction) may be due to (1) differences among patients, such as age, sex, disease, and genetic factors, and (2) drug-related factors, such as type of drug, route of administration, duration of therapy, dosage, and bioavailability

Adverse Effects, Poisoning and Toxic Effects

2) Poisoning

2) Poisoning

(a) Error was made in drug prescription
Errors made in drug prescription or in the
administration of the drug by provider, nurse, patient,
or other person, use the appropriate poisoning code
from the 960-979 series.

(b) Overdose of a drug intentionally taken
If an overdose of a drug was intentionally taken or
administered and resulted in drug toxicity, it would be
coded as a poisoning (960-979 series).

(c) Nonprescribed drug taken with correctly prescribed
and properly administered drug
If a nonprescribed drug or medicinal agent was taken in
combination with a correctly prescribed and properly
administered drug, any drug toxicity or other reaction
resulting from the interaction of the two drugs would be
classified as a poisoning.

(d) Interaction of drug(s) and alcohol
When a reaction results from the interaction of a
drug(s) and alcohol, this would be classified as
poisoning.

(e) Sequencing of poisoning
When coding a poisoning or reaction to the improper
use of a medication (e.g., wrong dose, wrong substance,
wrong route of administration) the poisoning code is
sequenced first, followed by a code for the
manifestation. If there is also a diagnosis of drug abuse
or dependence to the substance, the abuse or
dependence is coded as an additional code.

Adverse Effects, Poisoning and Toxic Effects

3) Toxic Effects

(a) Toxic effect codes
When a harmful substance is ingested or comes in
contact with a person, this is classified as a toxic effect.
The toxic effect codes are in categories 980-989.

(b) Sequencing toxic effect codes
A toxic effect code should be sequenced first, followed
by the code(s) that identify the result of the toxic effect.

(c) External cause codes for toxic effects
An external cause code from categories E860-E869 for
accidental exposure, codes E950.6 or E950.7 for
intentional self-harm, category E962 for assault, or
categories E980-E982, for undetermined, should also be
assigned to indicate intent.

Ventilator associated pneumonia
Ventilator associated pneumonia
(a) Documentation of Ventilator associated Pneumonia
As with all procedural or postprocedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure.

Code 997.31, Ventilator associated pneumonia, should be assigned only when the provider has documented
ventilator associated pneumonia (VAP). An additional code to identify the organism (e.g., Pseudomonas aeruginosa, code 041.7) should also be assigned. Do
not assign an additional code from categories 480-484 to identify the type of pneumonia.

Code 997.31 should not be assigned for cases where the patient has pneumonia and is on a mechanical ventilator but the provider has not specifically stated that the
pneumonia is ventilator-associated pneumonia. If the documentation is unclear as to whether the patient
has a pneumonia that is a complication attributable to the mechanical ventilator, query the provider.

(b) Patient admitted with pneumonia and develops VAP
A patient may be admitted with one type of pneumonia (e.g., code 481, Pneumococcal pneumonia) and subsequently develop VAP. In this instance, the
principal diagnosis would be the appropriate code from categories 480-484 for the pneumonia diagnosed at the
time of admission. Code 997.31, Ventilator associated pneumonia, would be assigned as an additional diagnosis when the provider has also documented the
presence of ventilator associated pneumonia.

SIRS due to Non-infectious Process
SIRS due to Non-infectious Process
The systemic inflammatory response syndrome (SIRS) can develop as a result of certain non-infectious disease processes, such as trauma, malignant neoplasm, or pancreatitis. When SIRS is documented with a noninfectious condition, and no subsequent infection is documented, the code for the underlying condition, such as an injury, should be assigned, followed by code 995.93, Systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction, or 995.94, Systemic inflammatory response syndrome
due to non-infectious process with acute organ dysfunction. If an acute organ dysfunction is documented, the appropriate code(s) for the associated acute organ dysfunction(s) should be assigned in addition to
code 995.94. If acute organ dysfunction is documented, but it cannot be determined if the acute organ dysfunction is associated with SIRS or due to another condition (e.g., directly due to the trauma), the provider should be queried.

A. Codes for symptoms, signs, and ill-defined conditions
Codes for symptoms, signs, and ill-defined conditions from Chapter 16 are not to be used as principal diagnosis when a related definitive diagnosis has been established.

B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis
when there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain
disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.

C. Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic
workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses
may be sequenced first.

D. Two or more comparative or contrasting conditions.
In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses
were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should
be principal, either diagnosis may be sequenced first.

E. A symptom(s) followed by contrasting/comparative diagnoses
When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom
code is sequenced first. All the contrasting/comparative diagnoses should be coded
as additional diagnoses.

F. Original treatment plan not carried out
Sequence as the principal diagnosis the condition, which after study occasioned the
admission to the hospital, even though treatment may not have been carried out due to
unforeseen circumstances.

G. Complications of surgery and other medical care
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the 996-999 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific
complication should be assigned.

H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other
similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements
for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute,
long-term care and psychiatric hospitals.

I. Admission from Observation Unit
1. Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.

2. Admission Following Post-Operative Observation
When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

J. Admission from Outpatient Surgery
When a patient receives surgery in the hospital’s outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the
following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:

• If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
• If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as the principal diagnosis.
• If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.

Section III. Reporting Additional Diagnoses
GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES
For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring:
clinical evaluation;
or therapeutic treatment;
or diagnostic procedures;
or extended length of hospital stay;
or increased nursing care and/or monitoring.

The UHDDS item #11-b defines Other Diagnoses as “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital
stay are to be excluded.”

A. Previous conditions
If the provider has included a diagnosis in the final diagnostic statement, such as the discharge summary or the face sheet, it should ordinarily be coded. Some
providers include in the diagnostic statement resolved conditions or diagnoses and status-post procedures from previous admission that have no bearing on the
current stay. Such conditions are not to be reported and are coded only if required by hospital policy.

However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment

B. Abnormal findings
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance. If the
findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the
provider whether the abnormal finding should be added.
Please note: This differs from the coding practices in the outpatient setting for coding encounters for diagnostic tests that have been interpreted by a provider.

C. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out” or other
similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements
for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.

Note: This guideline is applicable only to inpatient admissions to short-term, acute,
long-term care and psychiatric hospitals.

Section IV.Diagnostic Coding and Reporting Guidelines for
Outpatient Services
These coding guidelines for outpatient diagnoses have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits.

The terms encounter and visit are often used interchangeably in describing outpatient service
contacts and, therefore, appear together in these guidelines without distinguishing one from the other.

Though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that:
The Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatric hospitals.

Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.

A. Selection of first-listed condition
In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.

In determining the first-listed diagnosis the coding conventions of ICD-9-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines.

Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

1.Outpatient Surgery
When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is
not performed due to a contraindication.

2. Observation Stay
When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications
requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.

Codes that describe symptoms and signs
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the
provider.

code for the diagnosis, condition, problem, or other
reason for encounter/visit
List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason
for encounter/visit shown in the medical record to be chiefly responsible for the
services provided. List additional codes that describe any coexisting conditions. In
some cases the first-listed diagnosis may be a symptom when a diagnosis has not
been established (confirmed) by the physician.

Uncertain diagnosis
Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

Please note: This differs from the coding practices used by short-term, acute care, long-term care and psychiatric hospitals.

Chronic diseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

Code all documented conditions that coexist
Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that
were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact
on current care or influences treatment.

L. Patients receiving diagnostic services only
For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in
the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may
be sequenced as additional diagnoses.

For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign V72.5 and/or a code from subcategory
V72.6. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test.

For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed
or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

Please note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

M.Patients receiving therapeutic services only
For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in
the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may
be sequenced as additional diagnoses.

The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

N. Patients receiving preoperative evaluations only
For patients receiving preoperative evaluations only, sequence first a code from category V72.8, Other specified examinations, to describe the pre-op consultations.
Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.

O. Ambulatory surgery
For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis
at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.

POA
Present on admission is defined as present at the time the order for inpatient admission occurs — conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.

POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury
codes. Issues related to inconsistent, missing, conflicting or unclear documentation must still be
resolved by the provider.

POA Reporting Options
Reporting Options
Y – Yes
N – No
U – Unknown
W – Clinically undetermined
Unreported/Not used (or “1” for Medicare usage) – (Exempt from POA reporting)

Reporting Definitions
Reporting Definitions
Y = present at the time of inpatient admission
N = not present at the time of inpatient admission
U = documentation is insufficient to determine if condition is present on admission
W = provider is unable to clinically determine whether condition was present on
admission or not

Conditions documented as impending or threatened at the time of discharge
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were present on admission, assign “Y”.
If the final diagnosis contains an impending or threatened diagnosis, and this diagnosis is based on symptoms or clinical findings that were not present on admission, assign “N”.

Acute and Chronic Conditions
Assign “Y” for acute conditions that are present at time of admission and N for acute conditions that are not present at time of admission.
Assign “Y” for chronic conditions, even though the condition may not be diagnosed until after admission.
If a single code identifies both an acute and chronic condition, see the POA guidelines for combination codes.

Combination Codes
Assign “N” if any part of the combination code was not present on admission (e.g., obstructive chronic bronchitis with acute exacerbation and the exacerbation
was not present on admission; gastric ulcer that does not start bleeding until after admission; asthma patient develops status asthmaticus after admission)

Assign “Y” if all parts of the combination code were present on admission (e.g., patient with diabetic nephropathy is admitted with uncontrolled diabetes)
If the final diagnosis includes comparative or contrasting diagnoses, and both were present, or suspected, at the time of admission, assign “Y”.

For infection codes that include the causal organism, assign “Y” if the infection (or signs of the infection) was present on admission, even though the culture results may not be known until after admission (e.g., patient is admitted with
pneumonia and the provider documents pseudomonas as the causal organism a few days later).

Same Diagnosis Code for Two or More Conditions
When the same ICD-9-CM diagnosis code applies to two or more conditions during the same encounter (e.g. bilateral condition, or two separate conditions classified to the same ICD-9-CM diagnosis code):

Assign “Y” if all conditions represented by the single ICD-9-CM code were present on admission (e.g. bilateral fracture of the same bone, same site, and both fractures were present on admission)

Assign “N” if any of the conditions represented by the single ICD-9-CM code was not present on admission (e.g. dehydration with hyponatremia is assigned to code 276.1, but only one of these conditions was present on admission).

External cause of injury codes
Assign “Y” for any E code representing an external cause of injury or poisoning that occurred prior to inpatient admission (e.g., patient fell out of bed at home,
patient fell out of bed in emergency room prior to admission)

Assign “N” for any E code representing an external cause of injury or poisoning that occurred during inpatient hospitalization (e.g., patient fell out of hospital bed
during hospital stay, patient experienced an adverse reaction to a medication administered after inpatient admission)

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