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
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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
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Codes Valid October 1, 2005, through September 30, 2006
Acute Myocardial Infarction
> f other lateral wall
k 410.5 <©O
k 410.6
k 410.7
high lateral
wST elevation myocardial infarction (STEMI) of other lateral wallx
True posterior wall infarction
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:
septum alone
papillary muscle
wST elevation myocardial infarction (STEMI) of other specified sitesx
> 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
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
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
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
> nspecified outcome of delivery
Single birth
Multiple birth
outcome to infant
' V28 Antenatal screening
abnormal findings on screening — code to findings
routine prenatal care (V22.0-V23.9)
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
V28.4 Screening for fetal growth retardation using ultrasonics
V28.5 Screening for isoimmunization
M b
V28.6 Screening for Streptococcus B
AHA: 4Q, ‘97, 46
> ther specified antenatal screening
V28.8 <©O
AHA: 3Q, ‘99, 16
V28.9 <¥U
> nspecified antenatal screening
' V29 Observation and evaluation of newborns and infants for suspected condition not
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
AHA: 1Q, ‘01, 10
1V29.1 Observation for suspected neurological condition
1V29.2 Observation for suspected respiratory condition
1V29.3 Observation for suspected genetic or metabolic condition
AHA: 4Q, ‘98, 59, 68
1V29.8 <©O
> bservation for other specified suspected condition
AHA: 2Q, ‘03, 15
1V29.9 <¥O
> bservation for unspecified suspected condition
AHA: 1Q, ‘02, 6
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:
k 0 Born in hospital
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
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
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
616 — Volume 1
Secondary Diagnosis
M Maternity Age: 12-55
A Adult Age: 15-124
Primary Diagnosis
2006 ICD•9•CM
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
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
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
placentae — see Placenta, ablatio
retinae (see also Detachment, retina) 361.9
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)
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
AAT (alpha-1 antitrypsin) deficiency 273.4
AAV (disease) (illness) (infection) — see Human
immunodeficiency virus (disease) (illness)
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)
Aberrant (congenital) — see also Malposition,
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
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
lactis 757.6
testis 752.51