ICD-9-CM Official Guidelines For Coding and Reporting Effective October 1, 2002 Narrative changes appear in bold text The Centers for Medicare and Medicaid Services (CMS) formerly the Health Care Financing Administration (HCFA) and the National Center for Health Statistics (NCHS), two departments within the Department of Health and Human Services (DHHS) present the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM. These guidelines for coding and reporting have been developed and approved by the Cooperating Parties for ICD-9-CM: the American Hospital Association, the American Health Information Management Association, CMS, and the NCHS. These guidelines, published by the Department of Health and Human Services have also appeared in the Coding Clinic for ICD-9-CM, published by the American Hospital Association. These guidelines have been developed to assist the user in coding and reporting in situations where the ICD-9-CM does not provide direction. Coding and sequencing instructions in volumes I, II, and III of ICD-9-CM take precedence over any guidelines. The conventions, general guidelines and chapter-specific guidelines apply to the proper use of ICD-9-CM, regardless of the health care setting. A joint effort between the attending physician and coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed and approved by the Cooperating Parties to assist both the physician and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation the application of all coding guidelines is a difficult, if not impossible, task. These guidelines are not exhaustive. The cooperating parties are continuing to conduct reviews of these guidelines and develop new guidelines as needed. Users of the ICD-9-CM should be aware that only guidelines approved by the cooperating parties are official. Revision of these guidelines and new guidelines will be published by the U.S. Department of Health and Human Services when they are approved by the cooperating parties. The term “admitted” is used generally to mean a health care encounter in any setting. The guidelines have been reorganized into several new sections including an enhanced introduction that provides more detail about the structure and conventions of the classification usually found in the classification itself. The other new section, General Guidelines, brings together overarching guidelines that were previously found throughout the various sections of the guidelines. The new format of the guidelines also includes a resequencing of the disease-specific guidelines. They are sequenced in the same order as they appear in the tabular list chapters (Infectious and Parasitic diseases, Neoplasms, etc.) These changes will make it easier for coders, experienced and beginners, to more easily find the specific portion of the coding guideline information they seek. Page 1 of 52 Table of Contents Section I ICD-9-CM Conventions, General Coding Guidelines and Chapter-specific Guidelines A. ICD-9-CM conventions Conventions of the ICD-9-CM Abbreviations Etiology/manifestation convention Format Includes and Excludes Notes and Inclusion Terms Other and Unspecified Codes Punctuation B. General Coding Guidelines Acute and Chronic Conditions Combination Codes Conditions that are integral part of disease Conditions that are not integral part of disease Impending or Threatened Conditions Late Effects Level of Detail in Coding Multiple Coding of Single Conditions Signs and Symptoms Other and Unspecified (NOS) Code Titles Other Multiple Coding for Single Condition Code, if applicable Use additional code Use of Alphabetic Index and Tabular List C. Chapter-specific Guidelines C1.Infectious and Parasitic diseases A. Human Immunodeficiency Virus (HIV) Infections Asymptomatic HIV Infection Confirmed Cases of HIV Infection/Illness HIV Infection in Pregnancy, Childbirth and the Puerperium Inconclusive Lab Test for HIV Previously Diagnosed HIV-related Illness Selection and Sequencing of HIV Code Testing for HIV B. Septicemia and Shock C2.Neoplasms Page 2 of 52 C3.Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders Reserved for future guidelines expansion C4.Diseases of Blood and Blood Forming Organs Reserved for future guideline expansion C5.Mental Disorders Reserved for future guideline expansion C6.Diseases of Nervous System and Sense Organs Reserved for future guideline expansion C7.Diseases of Circulatory System A. Hypertension Controlled Hypertension Elevated Blood Pressure Essential Hypertension Hypertension with Heart Disease Hypertensive Cerebrovascular Disease Hypertensive Heart and Renal Disease Hypertensive Renal Disease with Chronic Renal Failure Hypertensive Retinopathy Secondary Hypertension Transient Hypertension Uncontrolled Hypertension B. Late Effect of Cerebrovascular Accident C8.Diseases of Respiratory System Reserved for future guideline expansion C9.Diseases of Digestive System Reserved for future guideline expansion C10.Diseases of Genitourinary System Reserved for future guideline expansion C11.Complications of Pregnancy, Childbirth, and the Puerperium Abortions Chapter 11 Fifth-digits Fetal Conditions Affecting Management of Mother General Rules HIV Infection in Pregnancy, Childbirth and Puerperium Late Effects of Complications of Pregnancy, Childbirth and the Puerperium Normal Delivery 650 Postpartum Period Selection of Principal Diagnosis Page 3 of 52 C12.Diseases Skin and Subcutaneous Tissue Reserved for future guideline expansion C13.Diseases of Musculoskeletal and Connective Tissue Reserved for future guideline expansion C14.Congenital Anomalies Reserved for future guideline expansion C15. Certain Conditions Originating in the Newborn (Perinatal) Period Clinically Significant Conditions Congenital Anomalies General Perinatal Rule Maternal Causes of Perinatal Morbidity Newborn Transfers Other (Additional) Diagnoses Prematurity and Fetal Growth Retardation Use of Category V29 Use of Codes V30-V39 C16.Signs, Symptoms and Ill-Defined Conditions Reserved for future guideline expansion C17.Injury and Poisoning Adverse Effect Adverse Effects, Poisonings and Toxic Effects Coding of Fractures Coding of Injuries Coding of Burns Coding of Debridement of Wound, Infection or Burn Coding of Adverse Effects, Poisoning and Toxic Effects C18.Supplemental Classification of Factors Influencing Health Status and Contact with Health Service (V-Codes) 1. Contact/Exposure 2. Inoculations and vaccinations 3. Status 4. History (of) 5. Screening 6. Observation 7. Aftercare 8. Follow-up 9. Donor 10. Counseling 11. Obstetrics 12. Newborn, infant and child 13. Routine and administrative examinations Page 4 of 52 14. Miscellaneous V codes 15. Nonspecific V codes C19.Supplemental Classification of External Causes of Injury and Poisoning Child and Adult Abuse General Coding guidelines Late effects Misadventures and complications of care Multiple external causes Place of occurrence Poisonings and adverse effects of drugs Terrorism Undetermined cause Unknown intent Section II Selection of Principal Diagnosis(es) for Inpatient, Short-term, Acute Care Hospital Records Complications of Surgery and Other Medical Care Original Treatment Plan Not Carried Out Symptoms, Signs, and Ill-defined Conditions Symptom Followed by Contrasting/Comparative Diagnoses Two or More Comparative or Contrasting Conditions Two or More Equally Meet Definition Two or More Interrelated Conditions Uncertain Diagnosis Section III Reporting Additional Diagnoses for Inpatient, Short-term, Acute Care Hospital Records Abnormal Findings General Rules Previous Conditions Uncertain Diagnosis Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services Page 5 of 52 Section I Conventions, General Coding Guidelines and Chapter-Specific Guidelines The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. A. Conventions for the ICD-9-CM The conventions for the ICD-9-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the index and tabular of the ICD-9-CM as instructional notes. The conventions are as follows: 1. Format: The ICD-9-CM uses an indented format for ease in reference 2. Abbreviations a. Index Abbreviations NEC “Not elsewhere classifiable” This abbreviation in the index represents “other specified” When a specific code is not available for a condition the index directs the coder to the “other specified” code in the tabular. b. Tabular Abbreviations NEC “Not elsewhere classifiable” This abbreviation in the tabular represents “other specified” When a specific code is not available for a condition the tabular includes an NEC entry under a code to identify the code as the “other specified” code. (see “Other” codes) NOS “Not otherwise specified” This abbreviation is the equivalent of unspecified. (see “Unspecified” codes) 3. Punctuation [ ] Brackets are used in the tabular list to enclose synonyms, alternative wording or explanatory phrases. Brackets are used in the index to identify manifestation codes. (see etiology/manifestations)