Public Health Nursing Documentation Guidelines - Indian Health ...

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Documentation and Coding Guidelines for Public Health Nurses 250 Diabetes mellitus without complication, type not specified Diabetes mellitus without complication, type II Diabetes mellitus without complication, type I 250.4 Diabetes with renal manifestations 250.10 Diabetes mellitus ketoacidosis 719.4 Pain in joint unspecified 780.9 Other general symptoms 312.23 Socialized conduct disorder 780.39 Seizure disorder 789 Abdominal pain 414.01 Coronary atherosclerosis of native coronary artery 414.9 Chronic ischemic heart disease, unspecified 428.0 Congestive heart failure, unspecified 286.9 Other and unspecified coagulation defects 295.9 Unspecified schizophrenia 295.91 Unspecified type schizophrenia, subchronic state 295.92 Unspecified type schizophrenia, chronic state 295.94 Unspecified type schizophrenia, chronic state with exacerbation 295.95 Unspecified type schizophrenia, in remission 714.0 Rheumatoid arthritis 7.6 Immunizations V07.9 Need for prophylactic measure V05.3 Need for inoculation against viral hepatitis V05.4 Need for inoculation against varicella V05.8 Need for vaccination and inoculation V04.81 Need for flu shot V06.1 Need for inoculation with diphtheria-tetanus-pertussis combined vaccine (DTaP) V06.5 Need for inoculation against tetanus-diphtheria V06.4 Need for inoculation against measles-mumps-rubella V04.89 Need for inoculation against other viral diseases. Use this code for human papillomavirus and meningitis vaccines. V04.0 Need for inoculation against poliomyelitis V03.81 Need for inoculation against hemophilus influenza, type B (Hib) V03.82 Need for inoculation against streptococcus pneumoniae (pneumococcus) Indian Health Service Page 7-2
Documentation and Coding Guidelines for Public Health Nurses V03.5 Need for inoculation against diphtheria alone V03.6 Need for inoculation against pertussis alone V15.81 Personal history of noncompliance with medical treatment, presenting hazards to health V15.83 Personal history of underimmunization status 7.7 Adolescent V20.2 Routine infant or child health check V20.1 Other healthy infant or child receiving care 7.8 Women’s Health 795 Abnormal papanicolaou smear 7.9 Screenings V67.59 Purified protein derivative reading (follow-up exam necessary)—other specified follow-up exam V74.1 Screening examination for pulmonary tuberculosis V74.5 Screening examination for venereal disease V77.1 Screening for diabetes mellitus V81.1 Screening for hypertension V82.9 Screening for unspecified condition V82.89 Special screenings for other specified conditions (foot screening) no loss 7.10 Elder Care or Other V15.41 History of physical abuse V15.42 History of emotional abuse V60.6 Person living in institution V60.3 Person living alone V60.0 Lack of housing V60.1 Inadequate housing V60.2 Inadequate material resources V60.4 No other household member able to render care V60.6 Person living in institution V61.3 Problems with aged parents or in-laws 7.11 Acute 462 Acute pharyngitis (sore throat) 465.9 Acute upper respiratory infections of unspecified site 460 Acute nasopharyngitis (common cold) Indian Health Service Page 7-3
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DOCUMENTATION AND CODING GUIDELINES
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FOREWORD This manual was written by
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