ICD-9-CM Professional for Physicians Volumes 1 & 2 International Classification of Diseases 9th Revision Clinical Modification Sixth Edition Edited by: Anita C. Hart, RHIA, CCS, CCS-P Catherine A. Hopkins Beth Ford, RHIT, CCS Ingenix is committed to providing you with the ICD-9-CM code update information you need to code accurately and to be in compliance with HIPAA regulations. In the case of adoption of additional ICD-9-CM code changes effective April 1, 2006, Ingenix will provide these code changes to you at no additional cost! Just check back at http://www.IngenixOnline.com and look for the ICD-9-CM Update icon to review the latest information concerning any new code changes. Codes Valid October 1, 2005, through September 30, 2006 410.5–411.1 CIRCULATORY SYSTEM Acute Myocardial Infarction > f other lateral wall k 410.5 <©O k 410.6 k 410.7 Infarction: Infarction: apical-lateral high lateral basal-lateral posterolateral wST elevation myocardial infarction (STEMI) of other lateral wallx True posterior wall infarction Infarction: Infarction: posterobasal strictly posterior wST elevation myocardial infarction (STEMI) of true posterior wallx Subendocardial infarction wNon-ST elevation myocardial infarction (NSTEMI)x Nontransmural infarction AHA: 1Q, ‘00, 7 > f other specified sites k 410.8 <©O k 410.9 Infarction of: Infarction of: atrium septum alone papillary muscle wST elevation myocardial infarction (STEMI) of other specified sitesx <¥U > nspecified site Acute myocardial infarction NOS Coronary occlusion NOS wMyocardial infarction NOSx AHA: 1Q, ‘96, 17; 1Q, ‘92, 9; For code 410.91: 3Q, ‘02, 5 ' 411 Other acute and subacute forms of ischemic heart disease AHA: 4Q, ‘94, 55; 3Q, ‘91, 24 411.0 411.1 Postmyocardial infarction syndrome Dressler’s syndrome DEF: Complication developing several days/weeks after myocardial infarction; symptoms include fever, leukocytosis, chest pain, evidence of pericarditis, pleurisy, and pneumonitis; tendency to recur. Intermediate coronary syndrome Impending infarction Preinfarction syndrome Preinfarction angina Unstable angina EXCLUDES angina (pectoris) (413.9) decubitus (413.0) AHA: 2Q, ‘04, 3; 1Q, ‘03, 12; 3Q, ‘01, 15; 2Q, ‘01, 7, 9; 4Q, ‘98, 86; 2Q, ‘96, 10; 3Q, ‘91, 24; 1Q, ‘91, 14; 3Q, ‘90, 6; 4Q, ‘89, 10 DEF: A condition representing an intermediate stage between angina of effort and acute myocardial infarction. It is often documented by the physician as "unstable angina." ' k Additional Digit Required MSP Medicare Secondary Payer 2006 ICD•9•CM Unspecified Code wx Revised Text Other Specified Code l New Code Manifestation Code s Revised Code Title October 2005 • Volume 1 — 241 V Codes V27.9–V33 V CODES V27.9 <¥U > nspecified outcome of delivery Single birth Multiple birth    M SDx b outcome to infant unspecified ' V28 Antenatal screening abnormal findings on screening — code to findings routine prenatal care (V22.0-V23.9) EXCLUDES V27.9–V33 AHA: 1Q, ’04, 11 M b V28.0 Screening for chromosomal anomalies by amniocentesis M b V28.1 Screening for raised alpha-fetoprotein levels in amniotic fluid M b V28.2 <©O > ther screening based on amniocentesis V28.3 Screening for malformation using ultrasonics b V28.4 Screening for fetal growth retardation using ultrasonics b V28.5 Screening for isoimmunization b M b V28.6 Screening for Streptococcus B AHA: 4Q, ‘97, 46 > ther specified antenatal screening b V28.8 <©O AHA: 3Q, ‘99, 16 V28.9 <¥U > nspecified antenatal screening b ' V29 Observation and evaluation of newborns and infants for suspected condition not found Note: This category is to be used for newborns, within the neonatal period, (the first 28 days of life) who are suspected of having an abnormal condition resulting from exposure from the mother or the birth process, but without signs or symptoms, and, which after examination and observation, is found not to exist. AHA: 1Q, ‘00, 25; 4Q, ‘94, 47; 1Q, ‘94, 9; 4Q, ‘92, 21 1V29.0 Observation for suspected infectious condition N PDx AHA: 1Q, ‘01, 10 1V29.1 Observation for suspected neurological condition N PDx 1V29.2 Observation for suspected respiratory condition N PDx 1V29.3 Observation for suspected genetic or metabolic condition N PDx AHA: 4Q, ‘98, 59, 68 1V29.8 <©O N PDx > bservation for other specified suspected condition AHA: 2Q, ‘03, 15 1V29.9 <¥O N PDx > bservation for unspecified suspected condition AHA: 1Q, ‘02, 6 LIVEBORN INFANTS ACCORDING TO TYPE OF BIRTH (V30-V39) Note: These categories are intended for the coding of liveborn infants who are consuming health care [e.g., crib or bassinet occupancy]. The following fourth-digit subdivisions are for use with categories V30-V39: N k 0 Born in hospital N 1 Born before admission to hospital 2 Born outside hospital and not hospitalized The following two fifth-digits are for use with the fourth-digit .0, Born in hospital: 0 delivered without mention of cesarean delivery 1 delivered by cesarean delivery AHA: 1Q, ‘01, 10 ' V30 Single liveborn PDx AHA: 2Q, ‘03, 9; 4Q, ‘98, 46, 59; 1Q, ‘94, 9; For code V30.00: 1Q, ’04, 8, 16;4Q, ‘03, 68 ' V31 Twin, mate liveborn AHA: 3Q, ‘92, 10 ' V32 Twin, mate stillborn ' V33 <¥T> win, unspecified 1 PDx PDx PDx A code from the V30-V39 series may be sequenced before the V29 on the newborn medical record. N Newborn Age: 0 P Pediatric Age: 0-17 SDx 616 — Volume 1 Secondary Diagnosis M Maternity Age: 12-55 PDx A Adult Age: 15-124 Primary Diagnosis 2006 ICD•9•CM ICD-9-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING Effective April 1, 2005 Narrative changes appear in bold text The guidelines have been updated to include the V Code Table. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO). These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are included in the official government version of the ICD-9CM and also appear in Coding Clinic for ICD-9CM, published by the AHA. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. These guidelines are based on the coding and sequencing instructions in Volumes 1, 2, and 3 of ICD-9-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all health care settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals. A joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the health care provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the 2006 ICD•9•CM Revised text in bold font specific reason for the encounter and the conditions treated. The term “encounter” is used for all settings, including hospital admissions. In the context of these guidelines, the term “provider” is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the cooperating parties, is official. The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting. Section I. Conventions, general coding guidelines and chapterspecific guidelines A. Conventions for the ICD-9-CM 1. Format 2. Abbreviations a. Index abbreviations b. Tabular abbreviations 3. Punctuation 4. Includes and excludes notes and inclusion terms 5. Other and Unspecified codes a. “Other” codes b. “Unspecified” codes 6. Etiology/manifestation convention (“code first,” “use additional code,” and “in diseases classified elsewhere” notes) 7. “And” 8. “With” 9. “See” and “see also” B. General coding guidelines 1. Use of both Alphabetic Index and Tabular List 2. Locate each term in the Alphabetic Index 3. Level of detail in coding 4. Code or codes from 001.0 through V85.4 5. Selection of codes 001.0 through 999.9 6. Signs and symptoms 7. Conditions that are an integral part of a disease process 8. Conditions that are not an integral part of a disease process October 2005 • Coding Guidelines—1 Coding Guidelines Coding Guidelines Index to Diseases Abnormal, abnormality, abnormalities S Additional Digit Required — Refer to the Tabular List (Numeric Code Section) for Additional Digit Selection wx Revised Text l New Line s Revised Code 2006 ICD-9-CM Volume 2 — 1 AAT – Abnormal, abnormality, abnormalities Aberration — see also Anomaly chromosome — see Anomaly, chromosome(s) distantial 368.9 mental (see also Disorder, mental, nonpsychotic) 300.9 Abetalipoproteinemia 272.5 Abionarce 780.79 Abiotrophy 799.89 Ablatio placentae — see Placenta, ablatio retinae (see also Detachment, retina) 361.9 Ablation pituitary (gland) (with hypofunction) 253.7 placenta — see Placenta, ablatio uterus 621.8 Ablepharia, ablepharon, ablephary 743.62 Ablepsia — see Blindness Ablepsy — see Blindness Ablutomania 300.3 Abnormal, abnormality, abnormalities — see also Anomaly acid-base balance 276.4 fetus or newborn — see Distress, fetal adaptation curve, dark 368.63 alveolar ridge 525.9 amnion 658.9 S affecting fetus or newborn 762.9 anatomical relationship NEC 759.9 apertures, congenital, diaphragm 756.6 auditory perception NEC 388.40 autosomes NEC 758.5 13 758.1 18 758.2 21 or 22 758.0 D1 758.1 E3 758.2 G 758.0 ballistocardiogram 794.39 basal metabolic rate (BMR) 794.7 biosynthesis, testicular androgen 257.2 blood level (of) cobalt 790.6 copper 790.6 iron 790.6 lithium 790.6 magnesium 790.6 mineral 790.6 zinc 790.6 blood pressure elevated (without diagnosis of hypertension) 796.2 low (see also Hypotension) 458.9 reading (incidental) (isolated) (nonspecific) 796.3 bowel sounds 787.5 breathing behavior — see Respiration caloric test 794.19 cervix (acquired) NEC 622.9 congenital 752.40 in pregnancy or childbirth 654.6 S causing obstructed labor 660.2 S affecting fetus or newborn 763.1 chemistry, blood NEC 790.6 chest sounds 786.7 chorion 658.9 S affecting fetus or newborn 762.9 chromosomal NEC 758.89 analysis, nonspecific result 795.2 Index A AAT (alpha-1 antitrypsin) deficiency 273.4 AAV (disease) (illness) (infection) — see Human immunodeficiency virus (disease) (illness) (infection) Abactio — see Abortion, induced Abactus venter — see Abortion, induced Abarognosis 781.99 Abasia (-astasia) 307.9 atactica 781.3 choreic 781.3 hysterical 300.11 paroxysmal trepidant 781.3 spastic 781.3 trembling 781.3 trepidans 781.3 Abderhalden-Kaufmann-Lignac syndrome (cystinosis) 270.0 Abdomen, abdominal — see also condition accordion 306.4 acute 789.0 S angina 557.1 burst 868.00 convulsive equivalent (see also Epilepsy) 345.5 S heart 746.87 muscle deficiency syndrome 756.79 obstipum 756.79 Abdominalgia 789.0 S periodic 277.3 Abduction contracture, hip or other joint — see Contraction, joint Abercrombie’s syndrome (amyloid degeneration) 277.3 Aberrant (congenital) — see also Malposition, congenital adrenal gland 759.1 blood vessel NEC 747.60 arteriovenous NEC 747.60 cerebrovascular 747.81 gastrointestinal 747.61 lower limb 747.64 renal 747.62 spinal 747.82 upper limb 747.63 breast 757.6 endocrine gland NEC 759.2 gastrointestinal vessel (peripheral) 747.61 hepatic duct 751.69 lower limb vessel (peripheral) 747.64 pancreas 751.7 parathyroid gland 759.2 peripheral vascular vessel NEC 747.60 pituitary gland (pharyngeal) 759.2 renal blood vessel 747.62 sebaceous glands, mucous membrane, mouth 750.26 spinal vessel 747.82 spleen 759.0 testis (descent) 752.51 thymus gland 759.2 thyroid gland 759.2 upper limb vessel (peripheral) 747.63 Aberratio lactis 757.6 testis 752.51