Official ICD-9-CM Guidelines for Coding and Reporting

Official ICD-9-CMGuidelines for Coding and ReportingEffective October 1, 2009Narrative changes appear in bold text. Items underlined have beenmoved within the guidelines since October 1, 2008.The Centers for Medicare and Medicaid Services (CMS) and the NationalCenter 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 usingthe International Classification of Diseases, 9 th Revision, ClinicalModification (ICD-9-CM). These guidelines should be used as acompanion document to the official version of the ICD-9-CM aspublished on CD-ROM by the U.S. Government Printing Office (GPO).These guidelines have been approved by the four organizations thatmake up the Cooperating Parties for the ICD-9-CM: the AmericanHospital Association (AHA), the American Health InformationManagement Association (AHIMA), CMS, and NCHS. These guidelinesare included on the official government version of the ICD-9-CM, andalso appear in “Coding Clinic for ICD-9-CM” published by the AHA.These guidelines are a set of rules that have been developed toaccompany and complement the official conventions and instructionsprovided within the ICD-9-CM itself. The instructions andconventions of the classification take precedence over guidelines.These guidelines are based on the coding and sequencing instructions inVolumes I, II and III of ICD-9-CM, but provide additional instruction.Adherence to these guidelines when assigning ICD-9-CM diagnosis andprocedure codes is required under the Health Insurance Portability andAccountability Act (HIPAA). The diagnosis codes (Volumes 1-2) havebeen adopted under HIPAA for all healthcare settings. Volume 3procedure codes have been adopted for inpatient procedures reported byhospitals. A joint effort between the healthcare provider and the coder isessential to achieve complete and accurate documentation, codeassignment, and reporting of diagnoses and procedures. Theseguidelines have been developed to assist both the healthcare providerand the coder in identifying those diagnoses and procedures that are tobe reported. The importance of consistent, complete documentation inthe medical record cannot be overemphasized. Without suchdocumentation accurate coding cannot be achieved. The entire recordshould be reviewed to determine the specific reason for the encounterand the conditions treated.The term encounter is used for all settings, including hospitaladmissions. In the context of these guidelines, the term provider is usedthroughout the guidelines to mean physician or any qualified health carepractitioner who is legally accountable for establishing the patient’sdiagnosis. Only this set of guidelines, approved by the CooperatingParties, is official.The guidelines are organized into sections. Section I includes thestructure and conventions of the classification and general guidelinesthat apply to the entire classification, and chapter-specific guidelines thatcorrespond to the chapters as they are arranged in the classification.Section II includes guidelines for selection of principal diagnosis fornon-outpatient settings. Section III includes guidelines for reportingadditional diagnoses in non-outpatient settings. Section IV is foroutpatient coding and reporting.Section I. Conventions, general coding guidelines andchapter specific guidelinesA. Conventions for the ICD-9-CM1. Format:2. Abbreviationsa. Index abbreviationsb. Tabular abbreviations3. Punctuation4. Includes and Excludes Notes and Inclusion terms5. Other and Unspecified codesa. “Other” codesb. “Unspecified” codes6. Etiology/manifestation convention (“code first”, “use additionalcode” and “in diseases classified elsewhere” notes)7. “And”8. “With”9. “See” and “See Also”B. General Coding Guidelines1. Use of Both Alphabetic Index and Tabular List2. Locate each term in the Alphabetic Index3. Level of Detail in Coding4. Code or codes from 001.0 through V89.095. Selection of codes 001.0 through 999.96. Signs and symptoms7. Conditions that are an integral part of a disease process8. Conditions that are not an integral part of a disease process9. Multiple coding for a single condition10. Acute and Chronic Conditions11. Combination Code12. Late Effects13. Impending or Threatened Condition14. Reporting Same Diagnosis Code More than Once15. Admissions/Encounters for Rehabilitation16. Documentation for BMI and Pressure Ulcer Stages17. SyndromesC. Chapter-Specific Coding Guidelines1. Chapter 1: Infectious and Parasitic Diseases (001-139)a. Human Immunodeficiency Virus (HIV) Infections© 2009 Ingenix 1

Official ICD-9-CM Guidelines for Coding and Reportingf. Undetermined Causeg. Late Effects of External Cause Guidelinesh. Misadventures and Complications of Care Guidelinesi. Terrorism Guidelinesj. Activity Code Guidelinesk. External Cause StatusSection II. Selection of Principal DiagnosisA. Codes for symptoms, signs, and ill-defined conditionsB. Two or more interrelated conditions, each potentially meeting thedefinition for principal diagnosisC. Two or more diagnoses that equally meet the definition for principaldiagnosisD. Two or more comparative or contrasting conditionsE. A symptom(s) followed by contrasting/comparative diagnosesF. Original treatment plan not carried outG. Complications of surgery and other medical careH. Uncertain DiagnosisI. Admission from Observation Unit1. Admission Following Medical Observation2. Admission Following Post-Operative ObservationJ. Admission from Outpatient SurgerySection III. Reporting Additional DiagnosesA. Previous conditionsB. Abnormal findingsC. Uncertain diagnosisSection IV. Diagnostic Coding and Reporting Guidelinesfor Outpatient ServicesA. Selection of first-listed condition1. Outpatient Surgery2. Observation StayB. Codes from 001.0 through V89.09C. Accurate reporting of ICD-9-CM diagnosis codesD. Selection of codes 001.0 through 999.9E. Codes that describe symptoms and signsF. Encounters for circumstances other than a disease or injuryG. Level of Detail in Coding1. ICD-9-CM codes with 3, 4, or 5 digits2. Use of full number of digits required for a codeH. ICD-9-CM code for the diagnosis, condition, problem, or otherreason for encounter/visitI. Uncertain diagnosisJ. Chronic diseasesK. Code all documented conditions that coexistL. Patients receiving diagnostic services onlyM. Patients receiving therapeutic services onlyN. Patients receiving preoperative evaluations onlyO. Ambulatory surgeryP. Routine outpatient prenatal visitsAppendix I: Present on Admission Reporting GuidelinesSection I. Conventions, General CodingGuidelines and Chapter Specific GuidelinesThe conventions, general guidelines and chapter-specific guidelines areapplicable to all health care settings unless otherwise indicated. Theconventions and instructions of the classification take precedenceover guidelines.A. Conventions for the ICD-9-CMThe conventions for the ICD-9-CM are the general rules for use ofthe classification independent of the guidelines. These conventionsare incorporated within the index and tabular of the ICD-9-CM asinstructional notes. The conventions are as follows:1. Format:The ICD-9-CM uses an indented format for ease in reference2. Abbreviationsa. Index abbreviationsNEC “Not elsewhere classifiable”This abbreviation in the index represents “other specified”when a specific code is not available for a condition theindex directs the coder to the “other specified” code in thetabular.b. Tabular abbreviationsNEC “Not elsewhere classifiable”This abbreviation in the tabular represents “other specified”.When a specific code is not available for a condition thetabular includes an NEC entry under a code to identify thecode as the “other specified” code.See Section I.A.5.a. “Other” codes”NOS “Not otherwise specified”This abbreviation is the equivalent of unspecified.See Section I.A.5.b., “Unspecified” codes3. Punctuation[ ] Brackets are used in the tabular list to enclose synonyms,alternative wording or explanatory phrases. Brackets areused in the index to identify manifestation codes.See Section I.A.6. “Etiology/manifestations”( ) Parentheses are used in both the index and tabular toenclose supplementary words that may be present or absentin the statement of a disease or procedure without affectingthe code number to which it is assigned. The terms withinthe parentheses are referred to as nonessential modifiers.: Colons are used in the Tabular list after an incomplete termwhich needs one or more of the modifiers following thecolon to make it assignable to a given category.4. Includes and Excludes Notes and Inclusion termsIncludes:This note appears immediately under a three-digitcode title to further define, or give examples of, the content ofthe category.Excludes:An excludes note under a code indicates that theterms excluded from the code are to be coded elsewhere. Insome cases the codes for the excluded terms should not be usedin conjunction with the code from which it is excluded. Anexample of this is a congenital condition excluded from anacquired form of the same condition. The congenital andacquired codes should not be used together. In other cases, theexcluded terms may be used together with an excluded code. An© 2009 Ingenix 3

Official ICD-9-CM Guidelines for Coding and Reportingexample of this is when fractures of different bones are coded todifferent codes. Both codes may be used together if both types offractures are present.Inclusion terms: List of terms is included under certain fourand five digit codes. These terms are the conditions for whichthat code number is to be used. The terms may be synonyms ofthe code title, or, in the case of “other specified” codes, the termsare a list of the various conditions assigned to that code. Theinclusion terms are not necessarily exhaustive. Additional termsfound only in the index may also be assigned to a code.5. Other and Unspecified codesa. “Other” codesCodes titled “other” or “other specified” (usually a code witha 4th digit 8 or fifth-digit 9 for diagnosis codes) are for usewhen the information in the medical record provides detailfor which a specific code does not exist. Index entries withNEC in the line designate “other” codes in the tabular. Theseindex entries represent specific disease entities for which nospecific code exists so the term is included within an “other”code.b. “Unspecified” codesCodes (usually a code with a 4th digit 9 or 5th digit 0 fordiagnosis codes) titled “unspecified” are for use when theinformation in the medical record is insufficient to assign amore specific code.6. Etiology/manifestation convention (“Code first,” “Useadditional code” and “In diseases classified elsewhere”notes)Certain conditions have both an underlying etiology andmultiple body system manifestations due to the underlyingetiology. For such conditions, the ICD-9-CM has a codingconvention that requires the underlying condition be sequencedfirst followed by the manifestation. Wherever such acombination exists, there is a “Use additional code” note at theetiology code, and a “Code first” note at the manifestation code.These instructional notes indicate the proper sequencing orderof the codes, etiology followed by manifestation.In most cases the manifestation codes will have in the code title,“In diseases classified elsewhere.” Codes with this title are acomponent of the etiology/ manifestation convention. The codetitle indicates that it is a manifestation code. “In diseasesclassified elsewhere” codes are never permitted to be used as firstlisted or principal diagnosis codes. They must be used inconjunction with an underlying condition code and they mustbe listed following the underlying condition.There are manifestation codes that do not have “In diseasesclassified elsewhere” in the title. For such codes a “Useadditional code” note will still be present and the rules forsequencing apply.In addition to the notes in the tabular, these conditions also havea specific index entry structure. In the index both conditions arelisted together with the etiology code first followed by themanifestation codes in brackets. The code in brackets is alwaysto be sequenced second.The most commonly used etiology/manifestation combinationsare the codes for Diabetes mellitus, category 250. For each codeunder category 250 there is a use additional code note for themanifestation that is specific for that particular diabeticmanifestation. Should a patient have more than onemanifestation of diabetes, more than one code from category250 may be used with as many manifestation codes as areneeded to fully describe the patient’s complete diabeticcondition. The category 250 diabetes codes should besequenced first, followed by the manifestation codes.“Code first” and “Use additional code” notes are also used assequencing rules in the classification for certain codes that arenot part of an etiology/ manifestation combination.See - Section I.B.9. “Multiple coding for a single condition.”7. “And”The word “and” should be interpreted to mean either “and” or“or” when it appears in a title.8. “With”The word “with” in the alphabetic index is sequencedimmediately following the main term, not in alphabetical order.9. “See” and “See Also”The “see” instruction following a main term in the indexindicates that another term should be referenced. It is necessaryto go to the main term referenced with the “see” note to locatethe correct code.A “see also” instruction following a main term in the indexinstructs that there is another main term that may also bereferenced that may provide additional index entries that may beuseful. It is not necessary to follow the “see also” note when theoriginal main term provides the necessary code.B. General Coding Guidelines1. Use of Both Alphabetic Index and Tabular ListUse both the Alphabetic Index and the Tabular List whenlocating and assigning a code. Reliance on only the AlphabeticIndex or the Tabular List leads to errors in code assignments andless specificity in code selection.2. Locate each term in the Alphabetic IndexLocate each term in the Alphabetic Index and verify the codeselected in the Tabular List. Read and be guided by instructionalnotations that appear in both the Alphabetic Index and theTabular List.3. Level of Detail in CodingDiagnosis and procedure codes are to be used at their highestnumber of digits available.ICD-9-CM diagnosis codes are composed of codes with 3, 4, or5 digits. Codes with three digits are included in ICD-9-CM asthe heading of a category of codes that may be furthersubdivided by the use of fourth and/or fifth-digits, whichprovide greater detail.A three-digit code is to be used only if it is not furthersubdivided. Where fourth-digit subcategories and/or fifth-digitsubclassifications are provided, they must be assigned. A code isinvalid if it has not been coded to the full number of digitsrequired for that code. For example, Acute myocardialinfarction, code 410, has fourth-digits that describe the locationof the infarction (e.g., 410.2, Of inferolateral wall), andfifth-digits that identify the episode of care. It would be incorrectto report a code in category 410 without a fourth and fifth-digit.ICD-9-CM Volume 3 procedure codes are composed of codeswith either 3 or 4 digits. Codes with two digits are included inICD-9-CM as the heading of a category of codes that may befurther subdivided by the use of third and/or fourth-digits,which provide greater detail.4. Code or codes from 001.0 through V89.09The appropriate code or codes from 001.0 through V89.09 mustbe used to identify diagnoses, symptoms, conditions, problems,complaints or other reason(s) for the encounter/visit.4 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reporting5. Selection of codes 001.0 through 999.9The selection of codes 001.0 through 999.9 will frequently beused to describe the reason for the admission/encounter. Thesecodes are from the section of ICD-9-CM for the classification ofdiseases and injuries (e.g., infectious and parasitic diseases;neoplasms; symptoms, signs, and ill-defined conditions, etc.).6. Signs and symptomsCodes that describe symptoms and signs, as opposed todiagnoses, are acceptable for reporting purposes when a relateddefinitive diagnosis has not been established (confirmed) by theprovider. Chapter 16 of ICD-9-CM, Symptoms, Signs, andIll-Defined conditions (codes 780.0 - 799.9) contain many, butnot all codes for symptoms.7. Conditions that are an integral part of a disease processSigns and symptoms that are associated routinely with a diseaseprocess should not be assigned as additional codes, unlessotherwise instructed by the classification.8. Conditions that are not an integral part of a disease processAdditional signs and symptoms that may not be associatedroutinely with a disease process should be coded when present.9. Multiple coding for a single conditionIn addition to the etiology/manifestation convention thatrequires two codes to fully describe a single condition thataffects multiple body systems, there are other single conditionsthat also require more than one code. “Use additional code”notes are found in the tabular at codes that are not part of anetiology/manifestation pair where a secondary code is useful tofully describe a condition. The sequencing rule is the same asthe etiology/manifestation pair, the “Use additional code”indicates that a secondary code should be added.For example, for infections that are not included in chapter 1, asecondary code from category 041, Bacterial infection inconditions classified elsewhere and of unspecified site, may berequired to identify the bacterial organism causing the infection.A “Use additional code” note will normally be found at theinfectious disease code, indicating a need for the organism codeto be added as a secondary code.“Code first” notes are also under certain codes that are notspecifically manifestation codes but may be due to anunderlying cause. When a “Code first” note is present and anunderlying condition is present the underlying condition shouldbe sequenced first.“Code, if applicable, any causal condition first”, notes indicatethat this code may be assigned as a principal diagnosis when thecausal condition is unknown or not applicable. If a causalcondition is known, then the code for that condition should besequenced as the principal or first-listed diagnosis.Multiple codes may be needed for late effects, complicationcodes and obstetric codes to more fully describe a condition. Seethe specific guidelines for these conditions for furtherinstruction.10. Acute and Chronic ConditionsIf the same condition is described as both acute (subacute) andchronic, and separate subentries exist in the Alphabetic Index atthe same indentation level, code both and sequence the acute(subacute) code first.11. Combination CodeA combination code is a single code used to classify:- Two diagnoses, or- A diagnosis with an associated secondary process(manifestation)- A diagnosis with an associated complicationCombination codes are identified by referring to subterm entriesin the Alphabetic Index and by reading the inclusion andexclusion notes in the Tabular List.Assign only the combination code when that code fullyidentifies the diagnostic conditions involved or when theAlphabetic Index so directs. Multiple coding should not be usedwhen the classification provides a combination code that clearlyidentifies all of the elements documented in the diagnosis.When the combination code lacks necessary specificity indescribing the manifestation or complication, an additional codeshould be used as a secondary code.12. Late EffectsA late effect is the residual effect (condition produced) after theacute phase of an illness or injury has terminated. There is notime limit on when a late effect code can be used. The residualmay be apparent early, such as in cerebrovascular accident cases,or it may occur months or years later, such as that due to aprevious injury. Coding of late effects generally requires twocodes sequenced in the following order: The condition or natureof the late effect is sequenced first. The late effect code issequenced second.An exception to the above guidelines are those instances wherethe code for late effect is followed by a manifestation codeidentified in the Tabular List and title, or the late effect code hasbeen expanded (at the fourth and fifth-digit levels) to includethe manifestation(s). The code for the acute phase of an illnessor injury that led to the late effect is never used with a code forthe late effect.13. Impending or Threatened ConditionCode any condition described at the time of discharge as“impending” or “threatened” as follows:If it did occur, code as confirmed diagnosis. If it did notoccur, reference the Alphabetic Index to determine if thecondition has a subentry term for “impending” or“threatened” and also reference main term entries for“Impending” and for “Threatened.” If the subterms arelisted, assign the given code. If the subterms are not listed,code the existing underlying condition(s) and not thecondition described as impending or threatened.14. Reporting Same Diagnosis Code More than OnceEach unique ICD-9-CM diagnosis code may be reported onlyonce for an encounter. This applies to bilateral conditions or twodifferent conditions classified to the same ICD-9-CM diagnosiscode.15. Admissions/Encounters for RehabilitationWhen the purpose for the admission/encounter is rehabilitation,sequence the appropriate V code from category V57, Careinvolving use of rehabilitation procedures, as theprincipal/first-listed diagnosis. The code for the condition forwhich the service is being performed should be reported as anadditional diagnosis.Only one code from category V57 is required. Code V57.89,Other specified rehabilitation procedures, should be assigned ifmore than one type of rehabilitation is performed during a singleencounter. A procedure code should be reported to identify eachtype of rehabilitation therapy actually performed.16. Documentation for BMI and Pressure Ulcer StagesFor the Body Mass Index (BMI) and pressure ulcer stage codes,code assignment may be based on medical recorddocumentation from clinicians who are not the patient’s© 2009 Ingenix 5

Official ICD-9-CM Guidelines for Coding and Reportingprovider (i.e., physician or other qualified healthcarepractitioner legally accountable for establishing the patient’sdiagnosis), since this information is typically documented byother clinicians involved in the care of the patient (e.g., adietitian often documents the BMI and nurses often documentsthe pressure ulcer stages). However, the associated diagnosis(such as overweight, obesity, or pressure ulcer) must bedocumented by the patient’s provider. If there is conflictingmedical record documentation, either from the same clinician ordifferent clinicians, the patient’s attending provider should bequeried for clarification.The BMI and pressure ulcer stage codes should only be reportedas secondary diagnoses. As with all other secondary diagnosiscodes, the BMI and pressure ulcer stage codes should only beassigned when they meet the definition of a reportableadditional diagnosis.See Section III, Reporting Additional Diagnoses.17. SyndromesFollow the Alphabetic Index guidance when codingsyndromes. In the absence of index guidance, assign codesfor the documented manifestations of the syndrome.C. Chapter-Specific Coding GuidelinesIn addition to general coding guidelines, there are guidelines forspecific diagnoses and/or conditions in the classification. Unlessotherwise indicated, these guidelines apply to all health caresettings. Please refer to Section II for guidelines on the selection ofprincipal diagnosis.1. Chapter 1: Infectious and Parasitic Diseases (001-139)a. Human Immunodeficiency Virus (HIV) Infections1) Code only confirmed casesCode only confirmed cases of HIV infection/illness. Thisis an exception to the hospital inpatient guidelineSection II, H.In this context, “confirmation” does not requiredocumentation of positive serology or culture for HIV;the provider’s diagnostic statement that the patient isHIV positive, or has an HIV-related illness is sufficient.2) Selection and sequencing of HIV codes(a) Patient admitted for HIV-related conditionIf a patient is admitted for an HIV-related condition,the principal diagnosis should be 042, followed byadditional diagnosis codes for all reportedHIV-related conditions.(b) Patient with HIV disease admitted for unrelatedconditionIf a patient with HIV disease is admitted for anunrelated condition (such as a traumatic injury), thecode for the unrelated condition (e.g., the nature ofinjury code) should be the principal diagnosis.Other diagnoses would be 042 followed byadditional diagnosis codes for all reportedHIV-related conditions.(c) Whether the patient is newly diagnosedWhether the patient is newly diagnosed or has hadprevious admissions/encounters for HIV conditionsis irrelevant to the sequencing decision.(d) Asymptomatic human immunodeficiency virusV08 Asymptomatic human immunodeficiency virus[HIV] infection, is to be applied when the patientwithout any documentation of symptoms is listed asbeing “HIV positive,” “known HIV,” “HIV testpositive,” or similar terminology. Do not use thiscode if the term “AIDS” is used or if the patient istreated for any HIV-related illness or is described ashaving any condition(s) resulting from his/her HIVpositive status; use 042 in these cases.(e) Patients with inconclusive HIV serologyPatients with inconclusive HIV serology, but nodefinitive diagnosis or manifestations of the illness,may be assigned code 795.71, Inconclusiveserologic test for Human Immunodeficiency Virus[HIV].(f) Previously diagnosed HIV-related illnessPatients with any known prior diagnosis of anHIV-related illness should be coded to 042. Once apatient has developed an HIV-related illness, thepatient should always be assigned code 042 on everysubsequent admission/encounter. Patientspreviously diagnosed with any HIV illness (042)should never be assigned to 795.71 or V08.(g) HIV Infection in Pregnancy, Childbirth and thePuerperiumDuring pregnancy, childbirth or the puerperium, apatient admitted (or presenting for a health careencounter) because of an HIV-related illness shouldreceive a principal diagnosis code of 647.6x, Otherspecified infectious and parasitic diseases in themother classifiable elsewhere, but complicating thepregnancy, childbirth or the puerperium, followedby 042 and the code(s) for the HIV-relatedillness(es). Codes from Chapter 15 always takesequencing priority.Patients with asymptomatic HIV infection statusadmitted (or presenting for a health care encounter)during pregnancy, childbirth, or the puerperiumshould receive codes of 647.6x and V08.(h) Encounters for testing for HIV If a patient is beingseen to determine his/her HIV status, use codeV73.89, Screening for other specified viral disease.Use code V69.8, Other problems related to lifestyle,as a secondary code if an asymptomatic patient is ina known high risk group for HIV. Should a patientwith signs or symptoms or illness, or a confirmedHIV related diagnosis be tested for HIV, code thesigns and symptoms or the diagnosis. An additionalcounseling code V65.44 may be used if counselingis provided during the encounter for the test.When a patient returns to be informed of his/herHIV test results use code V65.44, HIV counseling, ifthe results of the test are negative.If the results are positive but the patient isasymptomatic use code V08, Asymptomatic HIVinfection. If the results are positive and the patient issymptomatic use code 042, HIV infection, withcodes for the HIV related symptoms or diagnosis.The HIV counseling code may also be used ifcounseling is provided for patients with positive testresults.b. Septicemia, Systemic Inflammatory Response Syndrome(SIRS), Sepsis, Severe Sepsis, and Septic Shock1) SIRS, Septicemia, and Sepsis6 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reporting(a) The terms septicemia and sepsis are often usedinterchangeably by providers, however they are notconsidered synonymous terms. The followingdescriptions are provided for reference but do notpreclude querying the provider for clarificationabout terms used in the documentation:(i) Septicemia generally refers to a systemicdisease associated with the presence ofpathological microorganisms or toxins in theblood, which can include bacteria, viruses,fungi or other organisms.(ii) Systemic inflammatory response syndrome(SIRS) generally refers to the systemicresponse to infection, trauma/burns, or otherinsult (such as cancer) with symptomsincluding fever, tachycardia, tachypnea, andleukocytosis.(iii)Sepsis generally refers to SIRS due toinfection.(iv)Severe sepsis generally refers to sepsis withassociated acute organ dysfunction.(b) The coding of SIRS, sepsis and severe sepsisThe coding of SIRS, sepsis and severe sepsis requiresa minimum of 2 codes: a code for the underlyingcause (such as infection or trauma) and a code fromsubcategory 995.9 Systemic inflammatory responsesyndrome (SIRS).(i) The code for the underlying cause (such asinfection or trauma) must be sequencedbefore the code from subcategory 995.9Systemic inflammatory response syndrome(SIRS).(ii) Sepsis and severe sepsis require a code forthe systemic infection (038.xx, 112.5, etc.)and either code 995.91, Sepsis, or 995.92,Severe sepsis. If the causal organism is notdocumented, assign code 038.9, Unspecifiedsepticemia.(iii)Severe sepsis requires additional code(s) forthe associated acute organ dysfunction(s).(iv)If a patient has sepsis with multiple organdysfunctions, follow the instructions forcoding severe sepsis.(v) Either the term sepsis or SIRS must bedocumented to assign a code fromsubcategory 995.9.See Section I.C.17.g, Injury and poisoning, forinformation regarding systemic inflammatoryresponse syndrome (SIRS) due to trauma/burns andother non-infectious processes.(c) Due to the complex nature of sepsis and severesepsis, some cases may require querying theprovider prior to assignment of the codes.2) Sequencing sepsis and severe sepsis(a) Sepsis and severe sepsis as principal diagnosisIf sepsis or severe sepsis is present on admission,and meets the definition of principal diagnosis, thesystemic 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, Severesepsis, as required by the sequencing rules in theTabular List. Codes from subcategory 995.9 cannever be assigned as a principal diagnosis. A codeshould also be assigned for any localized infection, ifpresent.If the sepsis or severe sepsis is due to apostprocedural infection, see Section I.C.10 forguidelines related to sepsis due to postproceduralinfection.(b) Sepsis and severe sepsis as secondary diagnosesWhen sepsis or severe sepsis develops during theencounter (it was not present on admission), thesystemic infection code and code 995.91 or 995.92should be assigned as secondary diagnoses.(c) Documentation unclear as to whether sepsis orsevere sepsis is present on admissionSepsis or severe sepsis may be present on admissionbut the diagnosis may not be confirmed untilsometime after admission. If the documentation isnot clear whether the sepsis or severe sepsis waspresent on admission, the provider should bequeried.3) Sepsis/SIRS with Localized InfectionIf the reason for admission is both sepsis, severe sepsis,or SIRS and a localized infection, such as pneumonia orcellulitis, a code for the systemic infection (038.xx,112.5, etc) should be assigned first, then code 995.91 or995.92, followed by the code for the localized infection.If the patient is admitted with a localized infection, suchas pneumonia, and sepsis/SIRS doesn’t develop untilafter admission, see guideline I.C.1.b.2.b).If the localized infection is postprocedural, see SectionI.C.10 for guidelines related to sepsis due to postproceduralinfection.Note: The term urosepsis is a nonspecific term. If that isthe only term documented then only code 599.0 shouldbe assigned based on the default for the term in theICD-9-CM index, in addition to the code for the causalorganism if known.4) Bacterial Sepsis and SepticemiaIn most cases, it will be a code from category 038,Septicemia, that will be used in conjunction with a codefrom subcategory 995.9 such as the following:(a) Streptococcal sepsisIf the documentation in the record statesstreptococcal sepsis, codes 038.0, Streptococcalsepticemia, and code 995.91 should be used, in thatsequence.(b) Streptococcal septicemiaIf the documentation states streptococcalsepticemia, only code 038.0 should be assigned,however, the provider should be queried whetherthe patient has sepsis, an infection with SIRS.5) Acute organ dysfunction that is not clearlyassociated with the sepsisIf a patient has sepsis and an acute organ dysfunction,but the medical record documentation indicates that theacute organ dysfunction is related to a medical conditionother than the sepsis, do not assign code 995.92, Severesepsis. An acute organ dysfunction must be associatedwith the sepsis in order to assign the severe sepsis code.© 2009 Ingenix 7

Official ICD-9-CM Guidelines for Coding and ReportingIf the documentation is not clear as to whether an acuteorgan dysfunction is related to the sepsis or anothermedical condition, query the provider.6) Septic shock(a) Sequencing of septic shockSeptic shock generally refers to circulatory failureassociated with severe sepsis, and, therefore, itrepresents a type of acute organ dysfunction.For all cases of septic shock, the code for thesystemic infection should be sequenced first,followed by codes 995.92 and 785.52. Anyadditional codes for other acute organ dysfunctionsshould also be assigned. As noted in the sequencinginstructions in the Tabular List, the code for septicshock cannot be assigned as a principal diagnosis.(b) Septic Shock without documentation of severesepsisSeptic shock indicates the presence of severe sepsis.Code 995.92, Severe sepsis, must be assigned withcode 785.52, Septic shock, even if the term severesepsis is not documented in the record. The “Useadditional code” note and the “Code first” note inthe tabular support this guideline.7) Sepsis and septic shock complicating abortion andpregnancySepsis and septic shock complicating abortion, ectopicpregnancy, and molar pregnancy are classified tocategory codes in Chapter 11 (630-639).See section I.C.11.i.7. for information on the coding ofpuerperal sepsis.8) Negative or inconclusive blood culturesNegative or inconclusive blood cultures do not precludea diagnosis of septicemia or sepsis in patients withclinical evidence of the condition, however, the providershould be queried.9) Newborn sepsisSee Section I.C.15.j for information on the coding of newbornsepsis.10) Sepsis due to a postprocedural infection(a) Documentation of causal relationshipAs with all postprocedural complications, codeassignment is based on the provider’sdocumentation of the relationship between theinfection and the procedure.(b) Sepsis due to postprocedural infectionIn cases of postprocedural sepsis, the complicationcode, such as code 998.59, Other postoperativeinfection, or 674.3x, Other complications ofobstetrical surgical wounds should be coded firstfollowed by the appropriate sepsis codes (systemicinfection code and either code 995.91or 995.92).An additional code(s) for any acute organdysfunction should also be assigned for cases ofsevere sepsis.11) External cause of injury codes with SIRSRefer to Section I.C.19.a.7 for instruction on the use ofexternal cause of injury codes with codes for SIRS resultingfrom trauma.12) Sepsis and severe sepsis associated withnoninfectious processIn some cases, a non-infectious process, such astrauma, may lead to an infection which can result insepsis or severe sepsis. If sepsis or severe sepsis isdocumented as associated with a non-infectiouscondition, such as a burn or serious injury, and thiscondition meets the definition for principaldiagnosis, the code for the noninfectious conditionshould be sequenced first, followed by the code forthe systemic infection and either code 995.91,Sepsis, or 995.92, Severe sepsis. Additional codesfor any associated acute organ dysfunction(s) shouldalso be assigned for cases of severe sepsis. If thesepsis or severe sepsis meets the definition ofprincipal diagnosis, the systemic infection and sepsiscodes should be sequenced before thenon-infectious condition. When both the associatednon-infectious condition and the sepsis or severesepsis meet the definition of principal diagnosis,either may be assigned as principal diagnosis.See Section I.C.1.b.2) (a) for guidelines pertaining tosepsis or severe sepsis as the principal diagnosis.Only one code from subcategory 995.9 should beassigned. Therefore, when a non-infectiouscondition leads to an infection resulting in sepsis orsevere sepsis, assign either code 995.91 or 995.92.Do not additionally assign code 995.93, Systemicinflammatory response syndrome due tonon-infectious process without acute organdysfunction, or 995.94, Systemic inflammatoryresponse syndrome with acute organ dysfunction.See Section I.C.17.g for information on the coding ofSIRS due to trauma/burns or other non-infectiousdisease processes.c. Methicillin Resistant Staphylococcus aureus(MRSA) Conditions1) Selection and sequencing of MRSA codes(a) Combination codes for MRSA infectionWhen a patient is diagnosed with aninfection that is due to methicillin resistantStaphylococcus aureus (MRSA), and thatinfection has a combination code thatincludes the causal organism (e.g.,septicemia, pneumonia) assign theappropriate code for the condition (e.g.,code 038.12, Methicillin resistantStaphylococcus aureus septicemia or code482.42, Methicillin resistant pneumonia dueto Staphylococcus aureus). Do not assign code041.12, Methicillin resistant Staphylococcusaureus, as an additional code because thecode includes the type of infection and theMRSA organism. Do not assign a code fromsubcategory V09.0, Infection withmicroorganisms resistant to penicillins, asan additional diagnosis.See Section C.1.b.1 for instructions on codingand sequencing of septicemia.(b) Other codes for MRSA infectionWhen there is documentation of a currentinfection (e.g., wound infection, stitchabscess, urinary tract infection) due toMRSA, and that infection does not have a8 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reportingcombination code that includes the causalorganism, select the appropriate code toidentify the condition along with code041.12, Methicillin resistant Staphylococcusaureus, for the MRSA infection. Do notassign a code from subcategory V09.0,Infection with microorganisms resistant topenicillins.(c) Methicillin susceptible Staphylococcusaureus (MSSA) and MRSA colonizationThe condition or state of being colonized orcarrying MSSA or MRSA is calledcolonization or carriage, while an individualperson is described as being colonized orbeing a carrier. Colonization means thatMSSA or MSRA is present on or in the bodywithout necessarily causing illness. Apositive MRSA colonization test might bedocumented by the provider as “MRSAscreen positive” or “MRSA nasal swabpositive”.Assign code V02.54, Carrier or suspectedcarrier, Methicillin resistant Staphylococcusaureus, for patients documented as havingMRSA colonization. Assign code V02.53,Carrier or suspected carrier, Methicillinsusceptible Staphylococcus aureus, for patientdocumented as having MSSA colonization.Colonization is not necessarily indicative ofa disease process or as the cause of a specificcondition the patient may have unlessdocumented as such by the provider.Code V02.59, Other specified bacterialdiseases, should be assigned for other typesof staphylococcal colonization (e.g., S.epidermidis, S. saprophyticus). CodeV02.59 should not be assigned forcolonization with any type of Staphylococcusaureus (MRSA, MSSA).(d) MRSA colonization and infectionIf a patient is documented as having bothMRSA colonization and infection during ahospital admission, code V02.54, Carrier orsuspected carrier, Methicillin resistantStaphylococcus aureus, and a code for theMRSA infection may both be assigned.2. Chapter 2: Neoplasms (140-239)General guidelinesChapter 2 of the ICD-9-CM contains the codes for most benignand all malignant neoplasms. Certain benign neoplasms, such asprostatic adenomas, may be found in the specific body systemchapters. To properly code a neoplasm it is necessary todetermine from the record if the neoplasm is benign, in-situ,malignant, or of uncertain histologic behavior. If malignant, anysecondary (metastatic) sites should also be determined.The neoplasm table in the Alphabetic Index should bereferenced first. However, if the histological term isdocumented, that term should be referenced first, rather thangoing immediately to the Neoplasm Table, in order to determinewhich column in the Neoplasm Table is appropriate. Forexample, if the documentation indicates “adenoma,” refer to theterm in the Alphabetic Index to review the entries under thisterm and the instructional note to “see also neoplasm, by site,benign.” The table provides the proper code based on the type ofneoplasm and the site. It is important to select the propercolumn in the table that corresponds to the type of neoplasm.The tabular should then be referenced to verify that the correctcode has been selected from the table and that a more specificsite code does not exist.See Section I. C. 18.d.4. for information regarding V codes for geneticsusceptibility to cancer.a. Treatment directed at the malignancyIf the treatment is directed at the malignancy, designate themalignancy as the principal diagnosis.The only exception to this guideline is if a patientadmission/encounter is solely for the administration ofchemotherapy, immunotherapy or radiation therapy, assignthe appropriate V58.x code as the first-listed or principaldiagnosis, and the diagnosis or problem for which theservice is being performed as a secondary diagnosis.b. Treatment of secondary siteWhen a patient is admitted because of a primary neoplasmwith metastasis and treatment is directed toward thesecondary site only, the secondary neoplasm is designated asthe principal diagnosis even though the primary malignancyis still present.c. Coding and sequencing of complicationsCoding and sequencing of complications associated with themalignancies or with the therapy thereof are subject to thefollowing guidelines:1) Anemia associated with malignancyWhen admission/encounter is for management of ananemia associated with the malignancy, and thetreatment is only for anemia, the appropriate anemiacode (such as code 285.22, Anemia in neoplasticdisease) is designated as the principal diagnosis and isfollowed by the appropriate code(s) for the malignancy.Code 285.22 may also be used as a secondary code if thepatient suffers from anemia and is being treated for themalignancy.Code 285.22, Anemia in neoplastic disease, and code285.3, Antineoplastic chemotherapy inducedanemia, may both be assigned if anemia in neoplasticdisease and anemia due to antineoplasticchemotherapy are both documented.2) Anemia associated with chemotherapy,immunotherapy and radiation therapyWhen the admission/encounter is for management of ananemia associated with chemotherapy, immunotherapyor radiotherapy and the only treatment is for theanemia, the anemia is sequenced first. The appropriateneoplasm code should be assigned as an additionalcode.3) Management of dehydration due to the malignancyWhen the admission/encounter is for management ofdehydration due to the malignancy or the therapy, or acombination of both, and only the dehydration is beingtreated (intravenous rehydration), the dehydration issequenced first, followed by the code(s) for themalignancy.4) Treatment of a complication resulting from a surgicalprocedureWhen the admission/encounter is for treatment of a© 2009 Ingenix 9

Official ICD-9-CM Guidelines for Coding and Reportingcomplication resulting from a surgical procedure,designate the complication as the principal or first-listeddiagnosis if treatment is directed at resolving thecomplication.d. Primary malignancy previously excisedWhen a primary malignancy has been previously excised oreradicated from its site and there is no further treatmentdirected to that site and there is no evidence of any existingprimary malignancy, a code from category V10, Personalhistory of malignant neoplasm, should be used to indicatethe former site of the malignancy. Any mention of extension,invasion, or metastasis to another site is coded as asecondary malignant neoplasm to that site. The secondarysite may be the principal or first-listed with the V10 codeused as a secondary code.e. Admissions/Encounters involving chemotherapy,immunotherapy and radiation therapy1) Episode of care involves surgical removal ofneoplasmWhen an episode of care involves the surgical removal ofa neoplasm, primary or secondary site, followed byadjunct chemotherapy or radiation treatment during thesame episode of care, the neoplasm code should beassigned as principal or first-listed diagnosis, usingcodes in the 140-198 series or where appropriate in the200-203 series.2) Patient admission/encounter solely foradministration of chemotherapy, immunotherapyand radiation therapyIf a patient admission/encounter is solely for theadministration of chemotherapy, immunotherapy orradiation therapy assign code V58.0, Encounter forradiation therapy, or V58.11, Encounter forantineoplastic chemotherapy, or V58.12, Encounter forantineoplastic immunotherapy as the first-listed orprincipal diagnosis. If a patient receives more than oneof these therapies during the same admission more thanone of these codes may be assigned, in any sequence.The malignancy for which the therapy is beingadministered should be assigned as a secondarydiagnosis.3) Patient admitted for radiotherapy/chemotherapy andimmunotherapy and develops complicationsWhen a patient is admitted for the purpose ofradiotherapy, immunotherapy or chemotherapy anddevelops complications such as uncontrolled nausea andvomiting or dehydration, the principal or first-listeddiagnosis is V58.0, Encounter for radiotherapy, orV58.11, Encounter for antineoplastic chemotherapy, orV58.12, Encounter for antineoplastic immunotherapyfollowed by any codes for the complications.f. Admission/encounter to determine extent of malignancyWhen the reason for admission/encounter is to determinethe extent of the malignancy, or for a procedure such asparacentesis or thoracentesis, the primary malignancy orappropriate metastatic site is designated as the principal orfirst-listed diagnosis, even though chemotherapy orradiotherapy is administered.g. Symptoms, signs, and ill-defined conditions listed inChapter 16 associated with neoplasmsSymptoms, signs, and ill-defined conditions listed inChapter 16 characteristic of, or associated with, an existingprimary or secondary site malignancy cannot be used toreplace the malignancy as principal or first-listed diagnosis,regardless of the number of admissions or encounters fortreatment and care of the neoplasm.h. Admission/encounter for pain control/managementSee Section I.C.6.a.5 for information on codingadmission/encounter for pain control/management.i. Malignant neoplasm associated with transplanted organA malignant neoplasm of a transplanted organ should becoded as a transplant complication. Assign first theappropriate code from subcategory 996.8, Complications oftransplanted organ, followed by code 199.2, Malignantneoplasm associated with transplanted organ. Use anadditional code for the specific malignancy.3. Chapter 3: Endocrine, Nutritional, and Metabolic Diseasesand Immunity Disorders (240-279)a. Diabetes mellitusCodes under category 250, Diabetes mellitus, identifycomplications/manifestations associated with diabetesmellitus. A fifth-digit is required for all category 250 codesto identify the type of diabetes mellitus and whether thediabetes is controlled or uncontrolled.See I.C.3.a.7 for secondary diabetes1) Fifth-digits for category 250:The following are the fifth-digits for the codes undercategory 250:0 type II or unspecified type, not stated asuncontrolled1 type I, [juvenile type], not stated as uncontrolled2 type II or unspecified type, uncontrolled3 type I, [juvenile type], uncontrolledThe age of a patient is not the sole determining factor,though most type I diabetics develop the conditionbefore reaching puberty. For this reason type I diabetesmellitus is also referred to as juvenile diabetes.2) Type of diabetes mellitus not documentedIf the type of diabetes mellitus is not documented in themedical record the default is type II.3) Diabetes mellitus and the use of insulinAll type I diabetics must use insulin to replace what theirbodies do not produce. However, the use of insulin doesnot mean that a patient is a type I diabetic. Somepatients with type II diabetes mellitus are unable tocontrol their blood sugar through diet and oralmedication alone and do require insulin.If the documentation in a medical record does notindicate the type of diabetes but does indicate that thepatient uses insulin, the appropriate fifth-digit for type IImust be used. For type II patients who routinely useinsulin, code V58.67, Long-term (current) use ofinsulin, should also be assigned to indicate that thepatient uses insulin. Code V58.67 should not beassigned if insulin is given temporarily to bring a type IIpatient’s blood sugar under control during an encounter.4) Assigning and sequencing diabetes codes andassociated conditionsWhen assigning codes for diabetes and its associatedconditions, the code(s) from category 250 must besequenced before the codes for the associatedconditions. The diabetes codes and the secondary codes10 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reportingthat correspond to them are paired codes that follow theetiology/manifestation convention of the classification(See Section I.A.6., Etiology/manifestation convention).Assign as many codes from category 250 as needed toidentify all of the associated conditions that the patienthas. The corresponding secondary codes are listedunder each of the diabetes codes.(a) Diabetic retinopathy/ diabetic macular edemaDiabetic macular edema, code 362.07, is onlypresent with diabetic retinopathy. Another codefrom subcategory 362.0, Diabetic retinopathy, mustbe used with code 362.07. Codes under subcategory362.0 are diabetes manifestation codes, so they mustbe used following the appropriate diabetes code.5) Diabetes mellitus in pregnancy and gestationaldiabetes(a) For diabetes mellitus complicating pregnancy, seeSection I.C.11.f., Diabetes mellitus in pregnancy.(b) For gestational diabetes, see Section I.C.11, g.,Gestational diabetes.6) Insulin pump malfunction(a) Underdose of insulin due insulin pump failureAn underdose of insulin due to an insulin pumpfailure should be assigned 996.57, Mechanicalcomplication due to insulin pump, as the principalor first listed code, followed by the appropriatediabetes mellitus code based on documentation.(b) Overdose of insulin due to insulin pump failureThe principal or first listed code for an encounterdue to an insulin pump malfunction resulting in anoverdose of insulin, should also be 996.57,Mechanical complication due to insulin pump,followed by code 962.3, Poisoning by insulins andantidiabetic agents, and the appropriate diabetesmellitus code based on documentation.7) Secondary Diabetes MellitusCodes under category 249, Secondary diabetes mellitus,identify complications/ manifestations associated withsecondary diabetes mellitus. Secondary diabetes isalways caused by another condition or event (e.g., cysticfibrosis, malignant neoplasm of pancreas,pancreatectomy, adverse effect of drug, or poisoning).(a) Fifth-digits for category 249:A fifth-digit is required for all category 249 codes toidentify whether the diabetes is controlled oruncontrolled.(b) Secondary diabetes mellitus and the use ofinsulinFor patients who routinely use insulin, codeV58.67, Long-term (current) use of insulin, shouldalso be assigned. Code V58.67 should not beassigned if insulin is given temporarily to bring apatient’s blood sugar under control during anencounter.(c) Assigning and sequencing secondary diabetescodes and associated conditionsWhen assigning codes for secondary diabetes and itsassociated conditions (e.g. renal manifestations), thecode(s) from category 249 must be sequencedbefore the codes for the associated conditions. Thesecondary diabetes codes and the diabeticmanifestation codes that correspond to them arepaired codes that follow the etiology/manifestationconvention of the classification. Assign as manycodes from category 249 as needed to identify all ofthe associated conditions that the patient has. Thecorresponding codes for the associated conditionsare listed under each of the secondary diabetescodes. For example, secondary diabetes withdiabetic nephrosis is assigned to code 249.40,followed by 581.81.(d) Assigning and sequencing secondary diabetescodes and its causesThe sequencing of the secondary diabetes codes inrelationship to codes for the cause of the diabetes isbased on the reason for the encounter, applicableICD-9-CM sequencing conventions, andchapter-specific guidelines.If a patient is seen for treatment of the secondarydiabetes or one of its associated conditions, a codefrom category 249 is sequenced as the principal orfirst-listed diagnosis, with the cause of thesecondary diabetes (e.g. cystic fibrosis) sequenced asan additional diagnosis.If, however, the patient is seen for the treatment ofthe condition causing the secondary diabetes (e.g.,malignant neoplasm of pancreas), the code for thecause of the secondary diabetes should besequenced as the principal or first-listed diagnosisfollowed by a code from category 249.(i) Secondary diabetes mellitus due topancreatectomyFor postpancreatectomy diabetes mellitus(lack of insulin due to the surgical removal ofall or part of the pancreas), assign code251.3, Postsurgical hypoinsulinemia. Assigna code from subcategory 249 and codeV45.79, Other acquired absence of organ, asadditional codes. Code also any diabeticmanifestations (e.g. diabetic nephrosis581.81).(ii) Secondary diabetes due to drugsSecondary diabetes may be caused by anadverse effect of correctly administeredmedications, poisoning or late effect ofpoisoning.See Section I.C.17.e for coding of adverse effects andpoisoning, and section I.C.19 for E code reporting.4. Chapter 4: Diseases of Blood and Blood Forming Organs(280-289)a. Anemia of chronic diseaseSubcategory 285.2, Anemia in chronic illness, has codes foranemia in chronic kidney disease, code 285.21; anemia inneoplastic disease, code 285.22; and anemia in otherchronic illness, code 285.29. These codes can be used as theprincipal/first listed code if the reason for the encounter is totreat the anemia. They may also be used as secondary codesif treatment of the anemia is a component of an encounter,but not the primary reason for the encounter. When using acode from subcategory 285 it is also necessary to use thecode for the chronic condition causing the anemia.© 2009 Ingenix 11

Official ICD-9-CM Guidelines for Coding and Reporting1) Anemia in chronic kidney diseaseWhen assigning code 285.21, Anemia in chronic kidneydisease, it is also necessary to assign a code fromcategory 585, Chronic kidney disease, to indicate thestage of chronic kidney disease.See I.C.10.a. Chronic kidney disease (CKD).2) Anemia in neoplastic diseaseWhen assigning code 285.22, Anemia in neoplasticdisease, it is also necessary to assign the neoplasm codethat is responsible for the anemia. Code 285.22 is foruse for anemia that is due to the malignancy, not foranemia due to antineoplastic chemotherapy drugs.Assign code 285.3 for anemia due to antineoplasticchemotherapy.See Section I.C.2.c.1 Anemia associated with malignancy. SeeSection I.C.2.c.2 Anemia associated with chemotherapy,immunotherapy and radiation therapy.5. Chapter 5: Mental Disorders (290-319)Reserved for future guideline expansion6. Chapter 6: Diseases of Nervous System and Sense Organs(320-389)a. Pain - Category 3381) General coding informationCodes in category 338 may be used in conjunction withcodes from other categories and chapters to providemore detail about acute or chronic pain and neoplasmrelatedpain, unless otherwise indicated below.If the pain is not specified as acute or chronic, do notassign codes from category 338, except forpost-thoracotomy pain, postoperative pain, neoplasmrelated pain, or central pain syndrome.A code from subcategories 338.1 and 338.2 should notbe assigned if the underlying (definitive) diagnosis isknown, unless the reason for the encounter is paincontrol/ management and not management of theunderlying condition.(a) Category 338 codes as principal or first-listeddiagnosisCategory 338 codes are acceptable as principaldiagnosis or the first-listed code:• When pain control or pain management isthe reason for the admission/encounter (e.g.,a patient with displaced intervertebral disc,nerve impingement and severe back painpresents for injection of steroid into thespinal canal). The underlying cause of thepain should be reported as an additionaldiagnosis, if known.• When an admission or encounter is for aprocedure aimed at treating the underlyingcondition (e.g., spinal fusion, kyphoplasty), acode for the underlying condition (e.g.,vertebral fracture, spinal stenosis) should beassigned as the principal diagnosis. No codefrom category 338 should be assigned.• When a patient is admitted for the insertionof a neurostimulator for pain control, assignthe appropriate pain code as the principal orfirst listed diagnosis. When an admission orencounter is for a procedure aimed at treatingthe underlying condition and aneurostimulator is inserted for pain controlduring the same admission/encounter, a codefor the underlying condition should beassigned as the principal diagnosis and theappropriate pain code should be assigned asa secondary diagnosis.(b) Use of category 338 codes in conjunction withsite specific pain codes(i) Assigning category 338 codes andsite-specific pain codesCodes from category 338 may be used inconjunction with codes that identify the siteof pain (including codes from chapter 16) ifthe category 338 code provides additionalinformation. For example, if the codedescribes the site of the pain, but does notfully describe whether the pain is acute orchronic, then both codes should be assigned.(ii) Sequencing of category 338 codes withsite-specific pain codesThe sequencing of category 338 codes withsite-specific pain codes (including chapter 16codes), is dependent on the circumstances ofthe encounter/admission as follows:• If the encounter is for pain control or painmanagement, assign the code from category338 followed by the code identifying thespecific site of pain (e.g., encounter for painmanagement for acute neck pain fromtrauma is assigned code 338.11, Acute paindue to trauma, followed by code 723.1,Cervicalgia, to identify the site of pain).• If the encounter is for any other reasonexcept pain control or pain management,and a related definitive diagnosis has notbeen established (confirmed) by theprovider, assign the code for the specific siteof pain first, followed by the appropriatecode from category 338.2) Pain due to devices, implants and graftsPain associated with devices, implants or grafts left in asurgical site (for example painful hip prosthesis) isassigned to the appropriate code(s) found in Chapter 17,Injury and Poisoning. Use additional code(s) fromcategory 338 to identify acute or chronic pain due topresence of the device, implant or graft (338.18- 338.19or 338.28-338.29).3) Postoperative painPost-thoracotomy pain and other postoperative pain areclassified to subcategories 338.1 and 338.2, dependingon whether the pain is acute or chronic. The default forpost-thoracotomy and other postoperative pain notspecified as acute or chronic is the code for the acuteform.Routine or expected postoperative pain immediatelyafter surgery should not be coded.(a) Postoperative pain not associated with specificpostoperative complicationPostoperative pain not associated with a specificpostoperative complication is assigned to the12 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reportingappropriate postoperative pain code in category338.(b) Postoperative pain associated with specificpostoperative complicationPostoperative pain associated with a specificpostoperative complication (such as painful wiresutures) is assigned to the appropriate code(s) foundin Chapter 17, Injury and Poisoning. If appropriate,use additional code(s) from category 338 to identifyacute or chronic pain (338.18 or 338.28). If paincontrol/management is the reason for the encounter,a code from category 338 should be assigned as theprincipal or first-listed diagnosis in accordance withSection I.C.6.a.1.a above.(c) Postoperative pain as principal or first-listeddiagnosisPostoperative pain may be reported as the principalor first-listed diagnosis when the stated reason forthe admission/encounter is documented aspostoperative pain control/management.(d) Postoperative pain as secondary diagnosisPostoperative pain may be reported as a secondarydiagnosis code when a patient presents foroutpatient surgery and develops an unusual orinordinate amount of postoperative pain.The provider’s documentation should be used toguide the coding of postoperative pain, as well asSection III. Reporting Additional Diagnoses and SectionIV. Diagnostic Coding and Reporting in the OutpatientSetting.See Section II.I.2 for information on sequencing ofdiagnoses for patients admitted to hospital inpatient carefollowing post-operative observation.See Section II.J for information on sequencing ofdiagnoses for patients admitted to hospital inpatient carefrom outpatient surgery.See Section IV.A.2 for information on sequencing ofdiagnoses for patients admitted for observation.4) Chronic painChronic pain is classified to subcategory 338.2. There isno time frame defining when pain becomes chronicpain. The provider’s documentation should be used toguide use of these codes.5) Neoplasm related painCode 338.3 is assigned to pain documented as beingrelated, associated or due to cancer, primary orsecondary malignancy, or tumor. This code is assignedregardless of whether the pain is acute or chronic.This code may be assigned as the principal or first-listedcode when the stated reason for theadmission/encounter is documented as paincontrol/pain management. The underlying neoplasmshould be reported as an additional diagnosis.When the reason for the admission/encounter ismanagement of the neoplasm and the pain associatedwith the neoplasm is also documented, code 338.3 maybe assigned as an additional diagnosis.See Section I.C.2 for instructions on the sequencing ofneoplasms for all other stated reasons for theadmission/encounter (except for pain control/painmanagement).6) Chronic pain syndromeThis condition is different than the term “chronic pain,”and therefore this code should only be used when theprovider has specifically documented this condition.7. Chapter 7: Diseases of Circulatory System (390-459)a. HypertensionHypertension TableThe Hypertension Table, found under the main term,“Hypertension,” in the Alphabetic Index, contains acomplete listing of all conditions due to or associated withhypertension and classifies them according to malignant,benign, and unspecified.1) Hypertension, essential, or NOSAssign hypertension (arterial) (essential) (primary)(systemic) (NOS) to category code 401 with theappropriate fourth-digit to indicate malignant (.0),benign (.1), or unspecified (.9). Do not use either .0malignant or .1 benign unless medical recorddocumentation supports such a designation.2) Hypertension with heart diseaseHeart conditions (425.8, 429.0-429.3, 429.8, 429.9) areassigned to a code from category 402 when a causalrelationship is stated (due to hypertension) or implied(hypertensive). Use an additional code from category428 to identify the type of heart failure in those patientswith heart failure. More than one code from category428 may be assigned if the patient has systolic ordiastolic 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 causalrelationship, are coded separately. Sequence accordingto the circumstances of the admission/encounter.3) Hypertensive chronic kidney diseaseAssign codes from category 403, Hypertensive chronickidney disease, when conditions classified to categories585 are present. Unlike hypertension with heart disease,ICD-9-CM presumes a cause-and-effect relationship andclassifies chronic kidney disease (CKD) withhypertension as hypertensive chronic kidney disease.Fifth-digits for category 403 should be assigned asfollows:• 0 with CKD stage I through stage IV, orunspecified.• 1 with CKD stage V or end stage renal disease.The appropriate code from category 585, Chronickidney disease, should be used as a secondary code witha code from category 403 to identify the stage of chronickidney disease.See Section I.C.10.a for information on the coding of chronickidney disease.4) Hypertensive heart and chronic kidney diseaseAssign codes from combination category 404,Hypertensive heart and chronic kidney disease, whenboth hypertensive kidney disease and hypertensive heartdisease are stated in the diagnosis. Assume a relationshipbetween the hypertension and the chronic kidneydisease, whether or not the condition is so designated.Assign an additional code from category 428, to identifythe type of heart failure. More than one code fromcategory 428 may be assigned if the patient has systolicor diastolic failure and congestive heart failure.© 2009 Ingenix 13

Official ICD-9-CM Guidelines for Coding and ReportingFifth-digits for category 404 should be assigned asfollows:• 0 without heart failure and with chronic kidneydisease (CKD) stage I through stage IV, orunspecified• 1 with heart failure and withCKD stage I through stage IV,or unspecified• 2 without heart failure and with CKD stage V orend stagerenal disease• 3 with heart failure and withCKD stage V or end stage renaldiseaseThe appropriate code from category 585, Chronickidney disease, should be used as a secondary code witha code from category 404 to identify the stage of kidneydisease.See Section I.C.10.a for information on the coding of chronickidney disease.5) Hypertensive cerebrovascular diseaseFirst assign codes from 430-438, Cerebrovasculardisease, then the appropriate hypertension code fromcategories 401-405.6) Hypertensive retinopathyTwo codes are necessary to identify the condition. Firstassign the code from subcategory 362.11, Hypertensiveretinopathy, then the appropriate code from categories401-405 to indicate the type of hypertension.7) Hypertension, secondaryTwo codes are required: one to identify the underlyingetiology and one from category 405 to identify thehypertension. Sequencing of codes is determined by thereason for admission/encounter.8) Hypertension, transientAssign code 796.2, Elevated blood pressure readingwithout diagnosis of hypertension, unless patient has anestablished diagnosis of hypertension. Assign code642.3x for transient hypertension of pregnancy.9) Hypertension, controlledAssign appropriate code from categories 401-405. Thisdiagnostic statement usually refers to an existing state ofhypertension under control by therapy.10) Hypertension, uncontrolledUncontrolled hypertension may refer to untreatedhypertension or hypertension not responding to currenttherapeutic regimen. In either case, assign theappropriate code from categories 401-405 to designatethe stage and type of hypertension. Code to the type ofhypertension.11) Elevated blood pressureFor a statement of elevated blood pressure withoutfurther specificity, assign code 796.2, Elevated bloodpressure reading without diagnosis of hypertension,rather than a code from category 401.b. Cerebral infarction/stroke/cerebrovascular accident(CVA)The terms stroke and CVA are often used interchangeably torefer to a cerebral infarction. The terms stroke, CVA, andcerebral infarction NOS are all indexed to the default code434.91, Cerebral artery occlusion, unspecified, withinfarction. Code 436, Acute, but ill-defined, cerebrovasculardisease, should not be used when the documentation statesstroke or CVA.See Section I.C.18.d.3 for information on coding status postadministration of tPA in a different facility within the last 24hours.c. Postoperative cerebrovascular accidentA cerebrovascular hemorrhage or infarction that occurs as aresult of medical intervention is coded to 997.02, Iatrogeniccerebrovascular infarction or hemorrhage. Medical recorddocumentation should clearly specify the cause- and-effectrelationship between the medical intervention and thecerebrovascular accident in order to assign this code. Asecondary code from the code range 430-432 or from a codefrom subcategories 433 or 434 with a fifth-digit of “1”should also be used to identify the type of hemorrhage orinfarct.This guideline conforms to the use additional code noteinstruction at category 997. Code 436, Acute, butill-defined, cerebrovascular disease, should not be used as asecondary code with code 997.02.d. Late Effects of cerebrovascular disease1) Category 438, late effects of cerebrovascular diseaseCategory 438 is used to indicate conditions classifiableto categories 430-437 as the causes of late effects(neurologic deficits), themselves classified elsewhere.These “late effects” include neurologic deficits thatpersist after initial onset of conditions classifiable to430-437. The neurologic deficits caused bycerebrovascular disease may be present from the onsetor may arise at any time after the onset of the conditionclassifiable to 430-437.2) Codes from category 438 with codes from 430-437Codes from category 438 may be assigned on a healthcare record with codes from 430-437, if the patient has acurrent cerebrovascular accident (CVA) and deficitsfrom an old CVA.3) Code V12.54Assign code V12.54, Transient ischemic attack (TIA),and cerebral infarction without residual deficits (and nota code from category 438) as an additional code forhistory of cerebrovascular disease when no neurologicdeficits are present.e. Acute myocardial infarction (AMI)1) ST elevation myocardial infarction (STEMI) and nonST elevation myocardial infarction (NSTEMI)The ICD-9-CM codes for acute myocardial infarction(AMI) identify the site, such as anterolateral wall or trueposterior wall. Subcategories 410.0-410.6 and 410.8 areused for ST elevation myocardial infarction (STEMI).Subcategory 410.7, Subendocardial infarction, is usedfor non ST elevation myocardial infarction (NSTEMI)and nontransmural MIs.2) Acute myocardial infarction, unspecifiedSubcategory 410.9 is the default for the unspecifiedterm acute myocardial infarction. If only STEMI ortransmural MI without the site is documented, query theprovider as to the site, or assign a code from subcategory410.9.14 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reporting3) AMI documented as nontransmural orsubendocardial but site providedIf an AMI is documented as nontransmural orsubendocardial, but the site is provided, it is still codedas a subendocardial AMI. If NSTEMI evolves to STEMI,assign the STEMI code. If STEMI converts to NSTEMIdue to thrombolytic therapy, it is still coded as STEMI.See Section I.C.18.d.3 for information on coding status postadministration of tPA in a different facility within the last 24hours.8. Chapter 8: Diseases of Respiratory System (460-519)See I.C.17.f. for ventilator-associated pneumonia.a. Chronic obstructive pulmonary disease [COPD] andasthma1) Conditions that comprise COPD and asthmaThe conditions that comprise COPD are obstructivechronic bronchitis, subcategory 491.2, and emphysema,category 492. All asthma codes are under category 493,Asthma. Code 496, Chronic airway obstruction, notelsewhere classified, is a nonspecific code that shouldonly be used when the documentation in a medicalrecord does not specify the type of COPD being treated.2) Acute exacerbation of chronic obstructive bronchitisand asthmaThe codes for chronic obstructive bronchitis and asthmadistinguish between uncomplicated cases and those inacute exacerbation. An acute exacerbation is aworsening or a decompensation of a chronic condition.An acute exacerbation is not equivalent to an infectionsuperimposed on a chronic condition, though anexacerbation may be triggered by an infection.3) Overlapping nature of the conditions that compriseCOPD and asthmaDue to the overlapping nature of the conditions thatmake up COPD and asthma, there are many variationsin the way these conditions are documented. Codeselection must be based on the terms as documented.When selecting the correct code for the documentedtype of COPD and asthma, it is essential to first reviewthe index, and then verify the code in the tabular list.There are many instructional notes under the differentCOPD subcategories and codes. It is important that allsuch notes be reviewed to assure correct codeassignment.4) Acute exacerbation of asthma and status asthmaticusAn acute exacerbation of asthma is an increased severityof the asthma symptoms, such as wheezing andshortness of breath. Status asthmaticus refers to apatient’s failure to respond to therapy administeredduring an asthmatic episode and is a life threateningcomplication that requires emergency care. If statusasthmaticus is documented by the provider with anytype of COPD or with acute bronchitis, the statusasthmaticus should be sequenced first. It supersedes anytype of COPD including that with acute exacerbation oracute bronchitis. It is inappropriate to assign an asthmacode with 5 th digit 2, with acute exacerbation, togetherwith an asthma code with 5 th digit 1, with statusasthmatics. Only the 5 th digit 1 should be assigned.b. Chronic obstructive pulmonary disease [COPD] andbronchitis1) Acute bronchitis with COPDAcute bronchitis, code 466.0, is due to an infectiousorganism. When acute bronchitis is documented withCOPD, code 491.22, Obstructive chronic bronchitiswith acute bronchitis, should be assigned. It is notnecessary to also assign code 466.0. If a medical recorddocuments acute bronchitis with COPD with acuteexacerbation, only code 491.22 should be assigned. Theacute bronchitis included in code 491.22 supersedes theacute exacerbation. If a medical record documentsCOPD with acute exacerbation without mention ofacute bronchitis, only code 491.21 should be assigned.c. Acute Respiratory Failure1) Acute respiratory failure as principal diagnosisCode 518.81, Acute respiratory failure, may be assignedas a principal diagnosis when it is the conditionestablished after study to be chiefly responsible foroccasioning the admission to the hospital, and theselection is supported by the Alphabetic Index andTabular List. However, chapter-specific codingguidelines (such as obstetrics, poisoning, HIV, newborn)that provide sequencing direction take precedence.2) Acute respiratory failure as secondary diagnosisRespiratory failure may be listed as a secondarydiagnosis if it occurs after admission, or if it is presenton admission, but does not meet the definition ofprincipal diagnosis.3) Sequencing of acute respiratory failure and anotheracute conditionWhen a patient is admitted with respiratory failure andanother acute condition, (e.g., myocardial infarction,cerebrovascular accident, aspiration pneumonia), theprincipal diagnosis will not be the same in everysituation. This applies whether the other acute conditionis a respiratory or nonrespiratory condition. Selection ofthe principal diagnosis will be dependent on thecircumstances of admission. If both the respiratoryfailure and the other acute condition are equallyresponsible for occasioning the admission to thehospital, and there are no chapter-specific sequencingrules, the guideline regarding two or more diagnosesthat 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 acuterespiratory failure and another condition are equallyresponsible for occasioning the admission, query theprovider for clarification.d. Influenza due to certain identified virusesCode only confirmed cases of avian influenza (code 488.0,Influenza due to identified avian influenza virus) ornovel H1N1 influenza virus (H1N1 or swine flu, code488.1). This is an exception to the hospital inpatientguideline Section II, H. (Uncertain Diagnosis).In this context, “confirmation” does not requiredocumentation of positive laboratory testing specific foravian or novel H1N1 influenza. However, coding should bebased on the provider’s diagnostic statement that the patienthas avian or novel H1N1 (H1N1 or swine flu) influenza.© 2009 Ingenix 15

Official ICD-9-CM Guidelines for Coding and ReportingIf the provider records “suspected or possible or probableavian or novel H1N1 influenza (H1N1 or swine flue),” theappropriate influenza code from category 487 should beassigned. A code from category 488, Influenza due tocertain identified viruses, should not be assigned.9. Chapter 9: Diseases of Digestive System (520-579)Reserved for future guideline expansion10. Chapter 10: Diseases of Genitourinary System (580-629)a. Chronic kidney disease1) Stages of chronic kidney disease (CKD)The ICD-9-CM classifies CKD based on severity. Theseverity of CKD is designated by stages I-V. Stage II, code585.2, 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 renaldisease (ESRD), is assigned when the provider hasdocumented 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 statusPatients who have undergone kidney transplant may stillhave some form of CKD, because the kidney transplantmay not fully restore kidney function. Therefore, thepresence of CKD alone does not constitute a transplantcomplication. Assign the appropriate 585 code for thepatient’s stage of CKD and code V42.0. If a transplantcomplication such as failure or rejection is documented,see section I.C.17.f.2.b for information on codingcomplications of a kidney transplant. If thedocumentation is unclear as to whether the patient has acomplication of the transplant, query the provider.3) Chronic kidney disease with other conditionsPatients with CKD may also suffer from other seriousconditions, most commonly diabetes mellitus andhypertension. The sequencing of the CKD code inrelationship to codes for other contributing conditions isbased on the conventions in the tabular list.See Section I.C.3.a.4 for sequencing instructions for diabetes.See Section I.C.4.a.1 for anemia in CKD.See Section I.C.7.a.3 for hypertensive chronic kidney disease.See Section I.C.17.f.2.b, Kidney transplant complications,for instructions on coding of documented rejection or failure.11. Chapter 11: Complications of Pregnancy, Childbirth, andthe Puerperium (630-679)a. General Rules for Obstetric Cases1) Codes from chapter 11 and sequencing priorityObstetric cases require codes from chapter 11, codes inthe range 630-679, Complications of Pregnancy,Childbirth, and the Puerperium. Chapter 11 codes havesequencing priority over codes from other chapters.Additional codes from other chapters may be used inconjunction with chapter 11 codes to further specifyconditions. Should the provider document that thepregnancy is incidental to the encounter, then codeV22.2 should be used in place of any chapter 11 codes.It is the provider’s responsibility to state that thecondition being treated is not affecting the pregnancy.2) Chapter 11 codes used only on the maternal recordChapter 11 codes are to be used only on the maternalrecord, never on the record of the newborn.3) Chapter 11 fifth-digitsCategories 640-648, 651-676 have required fifth-digits,which indicate whether the encounter is antepartum,postpartum and whether a delivery has also occurred.4) Fifth-digits, appropriate for each codeThe fifth-digits, which are appropriate for each codenumber, are listed in brackets under each code. Thefifth-digits on each code should all be consistent witheach other. That is, should a delivery occur all of thefifth-digits should indicate the delivery.b. Selection of OB Principal or First-listed Diagnosis1) Routine outpatient prenatal visitsFor routine outpatient prenatal visits when nocomplications are present codes V22.0, Supervision ofnormal first pregnancy, and V22.1, Supervision of othernormal pregnancy, should be used as the first-listeddiagnoses. These codes should not be used inconjunction with chapter 11 codes.2) Prenatal outpatient visits for high-risk patientsFor prenatal outpatient visits for patients with high-riskpregnancies, a code from category V23, Supervision ofhigh-risk pregnancy, should be used as the first-listeddiagnosis. Secondary Chapter 11 codes may be used inconjunction with these codes if appropriate.3) Episodes when no delivery occursIn episodes when no delivery occurs, the principaldiagnosis should correspond to the principalcomplication of the pregnancy, which necessitated theencounter. Should more than one complication exist, allof which are treated or monitored, any of thecomplications codes may be sequenced first.4) When a delivery occursWhen a delivery occurs, the principal diagnosis shouldcorrespond to the main circumstances or complicationof the delivery. In cases of cesarean delivery, the selectionof the principal diagnosis should be the conditionestablished after study that was responsible for thepatient’s admission. If the patient was admitted witha condition that resulted in the performance of acesarean procedure, that condition should beselected as the principal diagnosis. If the reason forthe admission/encounter was unrelated to the conditionresulting in the cesarean delivery, the condition relatedto the reason for the admission/ encounter should beselected as the principal diagnosis, even if a cesareanwas performed.5) Outcome of deliveryAn outcome of delivery code, V27.0-V27.9, should beincluded on every maternal record when a delivery hasoccurred. These codes are not to be used on subsequentrecords or on the newborn record.c. Fetal conditions affecting the management of the mother1) Codes from category 655Known or suspected fetal abnormality affectingmanagement of the mother, and category 656, Otherfetal and placental problems affecting the managementof the mother, are assigned only when the fetal conditionis actually responsible for modifying the management ofthe mother, i.e., by requiring diagnostic studies,additional observation, special care, or termination of16 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reportingpregnancy. The fact that the fetal condition exists doesnot justify assigning a code from this series to themother’s record.See I.C.18.d. for suspected maternal and fetal conditions notfound2) In utero surgeryIn cases when surgery is performed on the fetus, adiagnosis code from category 655, Known or suspectedfetal abnormalities affecting management of the mother,should be assigned identifying the fetal condition.Procedure code 75.36, Correction of fetal defect, shouldbe assigned on the hospital inpatient record.No code from Chapter 15, the perinatal codes, shouldbe used on the mother’s record to identify fetalconditions. Surgery performed in utero on a fetus is stillto be coded as an obstetric encounter.d. HIV infection in pregnancy, childbirth and thepuerperiumDuring pregnancy, childbirth or the puerperium, a patientadmitted because of an HIV-related illness should receive aprincipal diagnosis of 647.6x, Other specified infectious andparasitic diseases in the mother classifiable elsewhere, butcomplicating the pregnancy, childbirth or the puerperium,followed by 042 and the code(s) for the HIV-relatedillness(es).Patients with asymptomatic HIV infection status admittedduring pregnancy, childbirth, or the puerperium shouldreceive codes of 647.6x and V08.e. Current conditions complicating pregnancyAssign a code from subcategory 648.x for patients that havecurrent conditions when the condition affects themanagement of the pregnancy, childbirth, or thepuerperium. Use additional secondary codes from otherchapters to identify the conditions, as appropriate.f. Diabetes mellitus in pregnancyDiabetes mellitus is a significant complicating factor inpregnancy. Pregnant women who are diabetic should beassigned code 648.0x, Diabetes mellitus complicatingpregnancy, and a secondary code from category 250,Diabetes mellitus, or category 249, Secondary diabetes toidentify the type of diabetes.Code V58.67, Long-term (current) use of insulin, shouldalso be assigned if the diabetes mellitus is being treated withinsulin.g. Gestational diabetesGestational diabetes can occur during the second and thirdtrimester of pregnancy in women who were not diabeticprior to pregnancy. Gestational diabetes can causecomplications in the pregnancy similar to those ofpre-existing diabetes mellitus. It also puts the woman atgreater risk of developing diabetes after the pregnancy.Gestational diabetes is coded to 648.8x, Abnormal glucosetolerance. Codes 648.0x and 648.8x should never be usedtogether on the same record.Code V58.67, Long-term (current) use of insulin, shouldalso be assigned if the gestational diabetes is being treatedwith insulin.h. Normal delivery, Code 6501) Normal deliveryCode 650 is for use in cases when a woman is admittedfor a full-term normal delivery and delivers a single,healthy infant without any complications antepartum,during the delivery, or postpartum during the deliveryepisode. Code 650 is always a principal diagnosis. It isnot to be used if any other code from chapter 11 isneeded to describe a current complication of theantenatal, delivery, or perinatal period. Additional codesfrom other chapters may be used with code 650 if theyare not related to or are in any way complicating thepregnancy.2) Normal delivery with resolved antepartumcomplicationCode 650 may be used if the patient had a complicationat some point during her pregnancy, but thecomplication is not present at the time of the admissionfor delivery.3) V27.0, Single liveborn, outcome of deliveryV27.0, Single liveborn, is the only outcome of deliverycode appropriate for use with 650.i. The postpartum and peripartum periods1) Postpartum and peripartum periodsThe postpartum period begins immediately afterdelivery and continues for six weeks following delivery.The peripartum period is defined as the last month ofpregnancy to five months postpartum.2) Postpartum complicationA postpartum complication is any complicationoccurring within the six-week period.3) Pregnancy-related complications after 6 week periodChapter 11 codes may also be used to describepregnancy-related complications after the six-weekperiod should the provider document that a condition ispregnancy related.4) Postpartum complications occurring during the sameadmission as deliveryPostpartum complications that occur during the sameadmission as the delivery are identified with a fifth-digitof “2.” Subsequent admissions/encounters forpostpartum complications should be identified with afifth-digit of “4.”5) Admission for routine postpartum care followingdelivery outside hospitalWhen the mother delivers outside the hospital prior toadmission and is admitted for routine postpartum careand no complications are noted, code V24.0,Postpartum care and examination immediately afterdelivery, should be assigned as the principal diagnosis.6) Admission following delivery outside hospital withpostpartum conditionsA delivery diagnosis code should not be used for awoman who has delivered prior to admission to thehospital. Any postpartum conditions and/or postpartumprocedures should be coded.7) Puerperal sepsisCode 670.2x, Puerperal sepsis, should be assignedwith a secondary code to identify the causalorganism (e.g., for a bacterial infection, assign a codefrom category 041, Bacterial infections in conditionsclassified elsewhere and of unspecified site). A codefrom category 038, Septicemia, should not be usedfor puerperal sepsis. Do not assign code 995.91,Sepsis, as code 670.2x describes the sepsis. If© 2009 Ingenix 17

Official ICD-9-CM Guidelines for Coding and Reportingapplicable, use additional codes to identify severesepsis (995.92) and any associated acute organdysfunction.j. Code 677, Late effect of complication of pregnancy1) Code 677Code 677, Late effect of complication of pregnancy,childbirth, and the puerperium is for use in those caseswhen an initial complication of a pregnancy develops asequelae requiring care or treatment at a future date.2) After the initial postpartum periodThis code may be used at any time after the initialpostpartum period.3) Sequencing of Code 677This code, like all late effect codes, is to be sequencedfollowing the code describing the sequelae of thecomplication.k. Abortions1) Fifth-digits required for abortion categoriesFifth-digits are required for abortion categories 634-637.Fifth digit assignment is based on the status of thepatient at the beginning (or start) of the encounter.Fifth-digit 1, incomplete, indicates that all of theproducts of conception have not been expelled from theuterus. fifth-digit 2, complete, indicates that all productsof conception have been expelled from the uterus priorto the episode of care.2) Code from categories 640-648 and 651-659A code from categories 640-648 and 651-659 may beused as additional codes with an abortion code toindicate the complication leading to the abortion.Fifth-digit 3 is assigned with codes from these categorieswhen used with an abortion code because the otherfifth-digits will not apply. Codes from the 660-669 seriesare not to be used for complications of abortion.3) Code 639 for complicationsCode 639 is to be used for all complications followingabortion. Code 639 cannot be assigned with codes fromcategories 634-638.4) Abortion with liveborn fetusWhen an attempted termination of pregnancy results ina liveborn fetus assign code 644.21, Early onset ofdelivery, with an appropriate code from category V27,Outcome of Delivery. The procedure code for theattempted termination of pregnancy should also beassigned.5) Retained products of conception following anabortionSubsequent admissions for retained products ofconception following a spontaneous or legally inducedabortion are assigned the appropriate code fromcategory 634, Spontaneous abortion, or 635 Legallyinduced abortion, with a fifth-digit of “1” (incomplete).This advice is appropriate even when the patient wasdischarged previously with a discharge diagnosis ofcomplete abortion.12. Chapter 12: Diseases of Skin and Subcutaneous Tissue(680-709)a. Pressure ulcer stage codes1) Pressure ulcer stagesTwo codes are needed to completely describe a pressureulcer: A code from subcategory 707.0, Pressure ulcer, toidentify the site of the pressure ulcer and a code fromsubcategory 707.2, Pressure ulcer stages.The codes in subcategory 707.2, Pressure ulcer stages,are to be used as an additional diagnosis with a code(s)from subcategory 707.0, Pressure Ulcer. Codes from707.2, Pressure ulcer stages, may not be assigned as aprincipal or first-listed diagnosis. The pressure ulcerstage codes should only be used with pressure ulcersand not with other types of ulcers (e.g., stasis ulcer).The ICD-9-CM classifies pressure ulcer stages based onseverity, which is designated by stages I-IV andunstageable.2) Unstageable pressure ulcersAssignment of code 707.25, Pressure ulcer, unstageable,should be based on the clinical documentation. Code707.25 is used for pressure ulcers whose stage cannot beclinically determined (e.g., the ulcer is covered by escharor has been treated with a skin or muscle graft) andpressure ulcers that are documented as deep tissueinjury but not documented as due to trauma. This codeshould not be confused with code 707.20, Pressureulcer, stage unspecified. Code 707.20 should beassigned when there is no documentation regarding thestage of the pressure ulcer.3) Documented pressure ulcer stageAssignment of the pressure ulcer stage code should beguided by clinical documentation of the stage ordocumentation of the terms found in the index. Forclinical terms describing the stage that are not found inthe index, and there is no documentation of the stage,the provider should be queried.4) Bilateral pressure ulcers with same stageWhen a patient has bilateral pressure ulcers (e.g., bothbuttocks) and both pressure ulcers are documented asbeing the same stage, only the code for the site and onecode for the stage should be reported.5) Bilateral pressure ulcers with different stagesWhen a patient has bilateral pressure ulcers at the samesite (e.g., both buttocks) and each pressure ulcer isdocumented as being at a different stage, assign onecode for the site and the appropriate codes for thepressure ulcer stage.6) Multiple pressure ulcers of different sites and stagesWhen a patient has multiple pressure ulcers at differentsites (e.g., buttock, heel, shoulder) and each pressureulcer is documented as being at different stages (e.g.,stage 3 and stage 4), assign the appropriate codes foreach different site and a code for each different pressureulcer stage.7) Patients admitted with pressure ulcers documentedas healedNo code is assigned if the documentation states that thepressure ulcer is completely healed.8) Patients admitted with pressure ulcers documentedas healingPressure ulcers described as healing should be assignedthe appropriate pressure ulcer stage code based on thedocumentation in the medical record. If the18 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reportingdocumentation does not provide information about thestage of the healing pressure ulcer, assign code 707.20,Pressure ulcer stage, unspecified.If the documentation is unclear as to whether the patienthas a current (new) pressure ulcer or if the patient isbeing treated for a healing pressure ulcer, query theprovider.9) Patient admitted with pressure ulcer evolving intoanother stage during the admissionIf a patient is admitted with a pressure ulcer at one stageand it progresses to a higher stage, assign the code forhighest stage reported for that site.13. Chapter 13: Diseases of Musculoskeletal and ConnectiveTissue (710-739)a. Coding of pathologic fractures1) Acute fractures vs. aftercarePathologic fractures are reported using subcategory733.1, when the fracture is newly diagnosed.Subcategory 733.1 may be used while the patient isreceiving active treatment for the fracture. Examples ofactive treatment are: surgical treatment, emergencydepartment encounter, evaluation and treatment by anew physician.Fractures are coded using the aftercare codes(subcategories V54.0, V54.2, V54.8 or V54.9) forencounters after the patient has completed activetreatment of the fracture and is receiving routine care forthe fracture during the healing or recovery phase.Examples of fracture aftercare are: cast change orremoval, removal of external or internal fixation device,medication adjustment, and follow up visits followingfracture treatment.Care for complications of surgical treatment for fracturerepairs during the healing or recovery phase should becoded with the appropriate complication codes.Care of complications of fractures, such as malunionand nonunion, should be reported with the appropriatecodes.See Section I. C. 17.b for information on the coding oftraumatic fractures.14. Chapter 14: Congenital Anomalies (740-759)a. Codes in categories 740-759, congenital anomaliesAssign an appropriate code(s) from categories 740-759,Congenital Anomalies, when an anomaly is documented. Acongenital anomaly may be the principal/first listeddiagnosis on a record or a secondary diagnosis.When a congenital anomaly does not have a unique codeassignment, assign additional code(s) for any manifestationsthat may be present.When the code assignment specifically identifies thecongenital anomaly, manifestations that are an inherentcomponent of the anomaly should not be coded separately.Additional codes should be assigned for manifestations thatare not an inherent component.Codes from Chapter 14 may be used throughout the life ofthe patient. If a congenital anomaly has been corrected, apersonal history code should be used to identify the historyof the anomaly. Although present at birth, a congenitalanomaly may not be identified until later in life. Wheneverthe condition is diagnosed by the physician, it is appropriateto assign a code from codes 740-759.For the birth admission, the appropriate code from categoryV30, Liveborn infants, according to type of birth should besequenced as the principal diagnosis, followed by anycongenital anomaly codes, 740-759.15. Chapter 15: Newborn (Perinatal) Guidelines (760-779)For coding and reporting purposes the perinatal period isdefined as before birth through the 28th day following birth.The following guidelines are provided for reporting purposes.Hospitals may record other diagnoses as needed for internal datause.a. General perinatal rules1) Chapter 15 CodesThey are never for use on the maternal record. Codesfrom Chapter 11, the obstetric chapter, are neverpermitted on the newborn record. Chapter 15 code maybe used throughout the life of the patient if thecondition is still present.2) Sequencing of perinatal codesGenerally, codes from Chapter 15 should be sequencedas the principal/first-listed diagnosis on the newbornrecord, with the exception of the appropriate V30 codefor the birth episode, followed by codes from any otherchapter that provide additional detail. The “useadditional code” note at the beginning of the chaptersupports this guideline. If the index does not provide aspecific code for a perinatal condition, assign code779.89, Other specified conditions originating in theperinatal period, followed by the code from anotherchapter that specifies the condition. Codes for signs andsymptoms may be assigned when a definitive diagnosishas not been established.3) Birth process or community acquired conditionsIf a newborn has a condition that may be either due tothe birth process or community acquired and thedocumentation does not indicate which it is, the defaultis due to the birth process and the code from Chapter 15should be used. If the condition is community-acquired,a code from Chapter 15 should not be assigned.4) Code all clinically significant conditionsAll clinically significant conditions noted on routinenewborn examination should be coded. A condition isclinically significant if it requires:• clinical evaluation; or• therapeutic treatment; or• diagnostic procedures; or• extended length of hospital stay; or• increased nursing care and/or monitoring; or• has implications for future health care needsNote: The perinatal guidelines listed above are the sameas the general coding guidelines for “additionaldiagnoses”, except for the final point regardingimplications for future health care needs. Codes shouldbe assigned for conditions that have been specified bythe provider as having implications for future healthcare needs. Codes from the perinatal chapter should notbe assigned unless the provider has established adefinitive diagnosis.© 2009 Ingenix 19

Official ICD-9-CM Guidelines for Coding and Reportingb. Use of codes V30-V39When coding the birth of an infant, assign a code fromcategories V30-V39, according to the type of birth. A codefrom this series is assigned as a principal diagnosis, andassigned only once to a newborn at the time of birth.c. Newborn transfersIf the newborn is transferred to another institution, the V30series is not used at the receiving hospital.d. Use of category V291) Assigning a code from category V29Assign a code from category V29, Observation andevaluation of newborns and infants for suspectedconditions not found, to identify those instances when ahealthy newborn is evaluated for a suspected conditionthat is determined after study not to be present. Do notuse a code from category V29 when the patient hasidentified signs or symptoms of a suspected problem; insuch cases, code the sign or symptom.A code from category V29 may also be assigned as aprincipal code for readmissions or encounters when theV30 code no longer applies. Codes from category V29are for use only for healthy newborns and infants forwhich no condition after study is found to be present.2) V29 code on a birth recordA V29 code is to be used as a secondary code after theV30, Outcome of delivery, code.e. Use of other V codes on perinatal recordsV codes other than V30 and V29 may be assigned on aperinatal or newborn record code. The codes may be used asa principal or first-listed diagnosis for specific types ofencounters or for readmissions or encounters when the V30code no longer applies.See Section I.C.18 for information regarding the assignment of Vcodes.f. Maternal causes of perinatal morbidityCodes from categories 760-763, Maternal causes of perinatalmorbidity and mortality, are assigned only when thematernal condition has actually affected the fetus ornewborn. The fact that the mother has an associated medicalcondition or experiences some complication of pregnancy,labor or delivery does not justify the routine assignment ofcodes from these categories to the newborn record.g. Congenital anomalies in newbornsFor the birth admission, the appropriate code from categoryV30, Liveborn infants according to type of birth, should beused, followed by any congenital anomaly codes, categories740-759. Use additional secondary codes from otherchapters to specify conditions associated with the anomaly, ifapplicable.Also, see Section I.C.14 for information on the coding ofcongenital anomalies.h. Coding additional perinatal diagnoses1) Assigning codes for conditions that requiretreatmentAssign codes for conditions that require treatment orfurther investigation, prolong the length of stay, orrequire resource utilization.2) Codes for conditions specified as havingimplications for future health care needsAssign codes for conditions that have been specified bythe provider as having implications for future health careneeds.Note: This guideline should not be used for adultpatients.3) Codes for newborn conditions originating in theperinatal periodAssign a code for newborn conditions originating in theperinatal period (categories 760-779), as well ascomplications arising during the current episode of careclassified in other chapters, only if the diagnoses havebeen documented by the responsible provider at thetime of transfer or discharge as having affected the fetusor newborn.i. Prematurity and fetal growth retardationProviders utilize different criteria in determiningprematurity. A code for prematurity should not be assignedunless it is documented. The 5th digit assignment for codesfrom category 764 and subcategories 765.0 and 765.1should be based on the recorded birth weight and estimatedgestational age.A code from subcategory 765.2, Weeks of gestation, shouldbe assigned as an additional code with category 764 andcodes from 765.0 and 765.1 to specify weeks of gestation asdocumented by the provider in the record.j. Newborn sepsisCode 771.81, Septicemia [sepsis] of newborn, should beassigned with a secondary code from category 041, Bacterialinfections in conditions classified elsewhere and ofunspecified site, to identify the organism. A code fromcategory 038, Septicemia, should not be recorded on anewborn record. Do not assign code 995.91, Sepsis, as code771.81 describes the sepsis. If applicable, use additionalcodes to identify severe sepsis (995.92) and any associatedacute organ dysfunction.16. Chapter 16: Signs, Symptoms and Ill-Defined Conditions(780-799)Reserved for future guideline expansion17. Chapter 17: Injury and Poisoning (800-999)a. Coding of injuriesWhen coding injuries, assign separate codes for each injuryunless a combination code is provided, in which case thecombination code is assigned. Multiple injury codes areprovided in ICD-9-CM, but should not be assigned unlessinformation for a more specific code is not available. Thesetraumatic injury codes are not to be used for normal,healing surgical wounds or to identify complications ofsurgical wounds.The code for the most serious injury, as determined by theprovider and the focus of treatment, is sequenced first.1) Superficial injuriesSuperficial injuries such as abrasions or contusions arenot coded when associated with more severe injuries ofthe same site.20 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reporting2) Primary injury with damage to nerves/blood vesselsWhen a primary injury results in minor damage toperipheral nerves or blood vessels, the primary injury issequenced first with additional code(s) from categories950-957, Injury to nerves and spinal cord, and/or900-904, Injury to blood vessels. When the primaryinjury is to the blood vessels or nerves, that injuryshould be sequenced first.b. Coding of traumatic fracturesThe principles of multiple coding of injuries should befollowed in coding fractures. Fractures of specified sites arecoded individually by site in accordance with both theprovisions within categories 800-829 and the level of detailfurnished by medical record content. Combinationcategories for multiple fractures are provided for use whenthere is insufficient detail in the medical record (such astrauma cases transferred to another hospital), when thereporting form limits the number of codes that can be usedin reporting pertinent clinical data, or when there isinsufficient specificity at the fourth-digit or fifth-digit level.More specific guidelines are as follows:1) Acute fractures vs. aftercareTraumatic fractures are coded using the acute fracturecodes (800-829) while the patient is receiving activetreatment for the fracture. Examples of active treatmentare: surgical treatment, emergency departmentencounter, and evaluation and treatment by a newphysician.Fractures are coded using the aftercare codes(subcategories V54.0, V54.1, V54.8, or V54.9) forencounters after the patient has completed activetreatment of the fracture and is receiving routine care forthe fracture during the healing or recovery phase.Examples of fracture aftercare are: cast change orremoval, removal of external or internal fixation device,medication adjustment, and follow up visits followingfracture treatment.Care for complications of surgical treatment for fracturerepairs during the healing or recovery phase should becoded with the appropriate complication codes.Care of complications of fractures, such as malunionand nonunion, should be reported with the appropriatecodes.Pathologic fractures are not coded in the 800-829 range,but instead are assigned to subcategory 733.1. SeeSection I.C.13.a for additional information.2) Multiple fractures of same limbMultiple fractures of same limb classifiable to the samethree-digit or four-digit category are coded to thatcategory.3) Multiple unilateral or bilateral fractures of sameboneMultiple unilateral or bilateral fractures of same bone(s)but classified to different fourth-digit subdivisions (bonepart) within the same three-digit category are codedindividually by site.4) Multiple fracture categories 819 and 828Multiple fracture categories 819 and 828 classifybilateral fractures of both upper limbs (819) and bothlower limbs (828), but without any detail at thefourth-digit level other than open and closed type offractures.5) Multiple fractures sequencingMultiple fractures are sequenced in accordance with theseverity of the fracture. The provider should be asked tolist the fracture diagnoses in the order of severity.c. Coding of burnsCurrent burns (940-948) are classified by depth, extent andby agent (E code). Burns are classified by depth as firstdegree (erythema), second degree (blistering), and thirddegree (full-thickness involvement).1) Sequencing of burn and related condition codesSequence first the code that reflects the highest degree ofburn when more than one burn is present.a. When the reason for the admission or encounter isfor treatment of external multiple burns, sequencefirst the code that reflects the burn of the highestdegree.b. When a patient has both internal and externalburns, the circumstances of admission govern theselection of the principal diagnosis or first-listeddiagnosis.c. When a patient is admitted for burn injuries andother related conditions such as smoke inhalationand/or respiratory failure, the circumstances ofadmission govern the selection of the principal orfirst-listed diagnosis.2) Burns of the same local siteClassify burns of the same local site (three-digit categorylevel, 940-947) but of different degrees to thesubcategory identifying the highest degree recorded inthe diagnosis.3) Non-healing burnsNon-healing burns are coded as acute burns.Necrosis of burned skin should be coded as anon-healed burn.4) Code 958.3, posttraumatic wound infectionAssign code 958.3, Posttraumatic wound infection, notelsewhere classified, as an additional code for anydocumented infected burn site.5) Assign separate codes for each burn siteWhen coding burns, assign separate codes for each burnsite. Category 946, Burns of Multiple specified sites,should only be used if the location of the burns are notdocumented.Category 949, Burn, unspecified, is extremely vague andshould rarely be used.6) Assign codes from category 948, burnsBurns classified according to extent of body surfaceinvolved, when the site of the burn is not specified orwhen there is a need for additional data. It is advisableto use category 948 as additional coding when neededto provide data for evaluating burn mortality, such asthat needed by burn units. It is also advisable to usecategory 948 as an additional code for reportingpurposes when there is mention of a third-degree burninvolving 20 percent or more of the body surface.In assigning a code from category 948:Fourth-digit codes are used to identify thepercentage of total body surface involved in a burn(all degree).© 2009 Ingenix 21

Official ICD-9-CM Guidelines for Coding and ReportingFifth-digits are assigned to identify the percentage ofbody surface involved in third-degree burn.Fifth-digit zero (0) is assigned when less than 10percent or when no body surface is involved in athird-degree burn.Category 948 is based on the classic “rule of nines”in estimating body surface involved: head and neckare assigned nine percent, each arm nine percent,each leg 18 percent, the anterior trunk 18 percent,posterior trunk 18 percent, and genitalia onepercent. Providers may change these percentageassignments where necessary to accommodateinfants and children who have proportionatelylarger heads than adults and patients who have largebuttocks, thighs, or abdomen that involve burns.7) Encounters for treatment of late effects of burnsEncounters for the treatment of the late effects of burns(i.e., scars or joint contractures) should be coded to theresidual condition (sequelae) followed by theappropriate late effect code (906.5-906.9). A late effect Ecode may also be used, if desired.8) Sequelae with a late effect code and current burnWhen appropriate, both a sequelae with a late effectcode, and a current burn code may be assigned on thesame record (when both a current burn and sequelae ofan old burn exist).d. Coding of debridement of wound, infection, or burnExcisional debridement involves surgical removal or cuttingaway, as opposed to a mechanical (brushing, scrubbing,washing) debridement.For coding purposes, excisional debridement is assigned tocode 86.22.Nonexcisional debridement is assigned to code 86.28.e. Adverse effects, poisoning and toxic effectsThe properties of certain drugs, medicinal and biologicalsubstances or combinations of such substances, may causetoxic reactions. The occurrence of drug toxicity is classifiedin ICD-9-CM as follows:1) Adverse effectWhen the drug was correctly prescribed and properlyadministered, code the reaction plus the appropriatecode from the E930-E949 series. Codes from theE930-E949 series must be used to identify the causativesubstance for an adverse effect of drug, medicinal andbiological substances, correctly prescribed and properlyadministered. The effect, such as tachycardia, delirium,gastrointestinal hemorrhaging, vomiting, hypokalemia,hepatitis, renal failure, or respiratory failure, is codedand followed by the appropriate code from theE930-E949 series.Adverse effects of therapeutic substances correctlyprescribed and properly administered (toxicity,synergistic reaction, side effect, and idiosyncraticreaction) 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 ofadministration, duration of therapy, dosage, andbioavailability.2) Poisoning(a) Error was made in drug prescriptionErrors made in drug prescription or in theadministration of the drug by provider, nurse,patient, or other person, use the appropriatepoisoning code from the 960-979 series.(b) Overdose of a drug intentionally takenIf an overdose of a drug was intentionally taken oradministered and resulted in drug toxicity, it wouldbe coded as a poisoning (960-979 series).(c) Nonprescribed drug taken with correctlyprescribed and properly administered drugIf a nonprescribed drug or medicinal agent wastaken in combination with a correctly prescribedand properly administered drug, any drug toxicityor other reaction resulting from the interaction ofthe two drugs would be classified as a poisoning.(d) Interaction of drug(s) and alcoholWhen a reaction results from the interaction of adrug(s) and alcohol, this would be classified aspoisoning.(e) Sequencing of poisoningWhen coding a poisoning or reaction to theimproper use of a medication (e.g., wrong dose,wrong substance, wrong route of administration) thepoisoning code is sequenced first, followed by acode for the manifestation. If there is also adiagnosis of drug abuse or dependence to thesubstance, the abuse or dependence is coded as anadditional code.See Section I.C.3.a.6.b. if poisoning is the result ofinsulin pump malfunctions and Section I.C.19 forgeneral use of E-codes.3) Toxic effects(a) Toxic effect codesWhen a harmful substance is ingested or comes incontact with a person, this is classified as a toxiceffect. The toxic effect codes are in categories980-989.(b) Sequencing toxic effect codesA toxic effect code should be sequenced first,followed by the code(s) that identify the result of thetoxic effect.(c) External cause codes for toxic effectsAn external cause code from categories E860-E869for accidental exposure, codes E950.6 or E950.7 forintentional self-harm, category E962 for assault, orcategories E980-E982, for undetermined, shouldalso be assigned to indicate intent.f. Complications of care1) Complications of care(a) Documentation of complications of careAs with all procedural or postproceduralcomplications, code assignment is based on theprovider’s documentation of the relationshipbetween the condition and the procedure.2) Transplant complications(a) Transplant complications other than kidneyCodes under subcategory 996.8, Complications oftransplanted organ, are for use for bothcomplications and rejection of transplanted organs.A transplant complication code is only assigned ifthe complication affects the function of the22 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reportingtransplanted organ. Two codes are required to fullydescribe a transplant complication, the appropriatecode from subcategory 996.8 and a secondary codethat identifies the complication.Pre-existing conditions or conditions that developafter the transplant are not coded as complicationsunless they affect the function of the transplantedorgans.See I.C.18.d.3) for transplant organ removal statusSee I.C.2.i for malignant neoplasm associated withtransplanted organ.(b) Chronic kidney disease and kidney transplantcomplicationsPatients who have undergone kidney transplant maystill have some form of chronic kidney disease(CKD) because the kidney transplant may not fullyrestore kidney function. Code 996.81 should beassigned for documented complications of a kidneytransplant, such as transplant failure or rejection orother transplant complication. Code 996.81 shouldnot be assigned for post kidney transplant patientswho have chronic kidney (CKD) unless a transplantcomplication such as transplant failure or rejectionis documented. If the documentation is unclear as towhether the patient has a complication of thetransplant, query the provider.For patients with CKD following a kidneytransplant, but who do not have a complicationsuch as failure or rejection, see section I.C.10.a.2,Chronic kidney disease and kidney transplant status.3) Ventilator associated pneumonia(a) Documentation of Ventilator associatedPneumoniaAs with all procedural or postproceduralcomplications, code assignment is based on theprovider’s documentation of the relationshipbetween the condition and the procedure.Code 997.31, Ventilator associated pneumonia,should be assigned only when the provider hasdocumented ventilator associated pneumonia(VAP). An additional code to identify the organism(e.g., Pseudomonas aeruginosa, code 041.7) shouldalso be assigned. Do not assign an additional codefrom categories 480-484 to identify the type ofpneumonia.Code 997.31 should not be assigned for cases wherethe patient has pneumonia and is on a mechanicalventilator but the provider has not specifically statedthat the pneumonia is ventilator-associatedpneumonia.If the documentation is unclear as to whether thepatient has a pneumonia that is a complicationattributable to the mechanical ventilator, query theprovider.(b) Patient admitted with pneumonia and developsVAPA patient may be admitted with one type ofpneumonia (e.g., code 481, Pneumococcalpneumonia) and subsequently develop VAP. In thisinstance, the principal diagnosis would be theappropriate code from categories 480-484 for thepneumonia diagnosed at the time of admission.Code 997.31, Ventilator associated pneumonia,would be assigned as an additional diagnosis whenthe provider has also documented the presence ofventilator associated pneumonia.g. SIRS due to non-infectious processThe systemic inflammatory response syndrome (SIRS) candevelop as a result of certain non-infectious diseaseprocesses, such as trauma, malignant neoplasm, orpancreatitis. When SIRS is documented with a noninfectiouscondition, and no subsequent infection is documented, thecode for the underlying condition, such as an injury, shouldbe assigned, followed by code 995.93, Systemicinflammatory response syndrome due to noninfectiousprocess without acute organ dysfunction, or 995.94,Systemic inflammatory response syndrome due tonon-infectious process with acute organ dysfunction. If anacute organ dysfunction is documented, the appropriatecode(s) for the associated acute organ dysfunction(s) shouldbe assigned in addition to code 995.94. If acute organdysfunction is documented, but it cannot be determined ifthe acute organ dysfunction is associated with SIRS or dueto another condition (e.g., directly due to the trauma), theprovider should be queried.When the non-infectious condition has led to an infectionthat results in SIRS, see Section I.C.1.b.12 for the guideline forsepsis and severe sepsis associated with a non-infectious process.18. Classification of Factors Influencing Health Status andContact with Health Service (Supplemental V01-V89)Note: The chapter specific guidelines provide additionalinformation about the use of V codes for specified encounters.a. IntroductionICD-9-CM provides codes to deal with encounters forcircumstances other than a disease or injury. TheSupplementary Classification of Factors Influencing HealthStatus and Contact with Health Services (V01.0 - V89.09) isprovided to deal with occasions when circumstances otherthan a disease or injury (codes 001-999) are recorded as adiagnosis or problem.There are four primary circumstances for the use of V codes:1) A person who is not currently sick encounters the healthservices for some specific reason, such as to act as anorgan donor, to receive prophylactic care, such asinoculations or health screenings, or to receivecounseling on health related issues.2) A person with a resolving disease or injury, or a chronic,long-term condition requiring continuous care,encounters the health care system for specific aftercareof that disease or injury (e.g., dialysis for renal disease;chemotherapy for malignancy; cast change). Adiagnosis/symptom code should be used whenever acurrent, acute, diagnosis is being treated or a sign orsymptom is being studied.3) Circumstances or problems influence a person’s healthstatus but are not in themselves a current illness orinjury.4) Newborns, to indicate birth statusb. V codes use in any healthcare settingV codes are for use in any healthcare setting. V codes may beused as either a first listed (principal diagnosis code in the© 2009 Ingenix 23

Official ICD-9-CM Guidelines for Coding and Reportinginpatient setting) or secondary code, depending on thecircumstances of the encounter. Certain V codes may onlybe used as first listed, others only as secondary codes.See Section I.C.18.e, V Codes That May Only bePrincipal/First-Listed Diagnosis.c. V Codes indicate a reason for an encounterThey are not procedure codes. A corresponding procedurecode must accompany a V code to describe the procedureperformed.d. Categories of V codes1) Contact/exposureCategory V01 indicates contact with or exposure tocommunicable diseases. These codes are for patientswho do not show any sign or symptom of a disease buthave been exposed to it by close personal contact withan infected individual or are in an area where a disease isepidemic. These codes may be used as a first listed codeto explain an encounter for testing, or, more commonly,as a secondary code to identify a potential risk.2) Inoculations and vaccinationsCategories V03-V06 are for encounters for inoculationsand vaccinations. They indicate that a patient is beingseen to receive a prophylactic inoculation against adisease. The injection itself must be represented by theappropriate procedure code. A code from V03-V06 maybe used as a secondary code if the inoculation is given asa routine part of preventive health care, such as awell-baby visit.3) StatusStatus codes indicate that a patient is either a carrier of adisease or has the sequelae or residual of a past diseaseor condition. This includes such things as the presenceof prosthetic or mechanical devices resulting from pasttreatment. A status code is informative, because thestatus may affect the course of treatment and itsoutcome. A status code is distinct from a history code.The history code indicates that the patient no longer hasthe condition.A status code should not be used with a diagnosis codefrom one of the body system chapters, if the diagnosiscode includes the information provided by the statuscode. For example, code V42.1, Heart transplant status,should not be used with code 996.83, Complications oftransplanted heart. The status code does not provideadditional information. The complication code indicatesthat the patient is a heart transplant patient.The status V codes/categories are:V02 Carrier or suspected carrier of infectiousdiseasesCarrier status indicates that a person harborsthe specific organisms of a disease withoutmanifest symptoms and is capable oftransmitting the infection.V07.5x Prophylactic use of agents affecting estrogenreceptors and estrogen levelThis code indicates when a patient is receivinga drug that affects estrogen receptors andestrogen levels for prevention of cancer.V08 Asymptomatic HIV infection statusThis code indicates that a patient has testedpositive for HIV but has manifested no signs orsymptoms of the disease.V09 Infection with drug-resistant microorganismsThis category indicates that a patient has aninfection that is resistant to drug treatment.Sequence the infection code first.V21 Constitutional states in developmentV22.2 Pregnant state, incidentalThis code is a secondary code only for usewhen the pregnancy is in no way complicatingthe reason for visit. Otherwise, a code from theobstetric chapter is required.V26.5x Sterilization statusV42 Organ or tissue replaced by transplantV43 Organ or tissue replaced by other meansV44 Artificial opening statusV45 Other postsurgical statesAssign code V45.87, Transplant organ removalstatus, to indicate that a transplanted organ hasbeen previously removed. This code should notbe assigned for the encounter in which thetransplanted organ is removed. Thecomplication necessitating removal of thetransplant organ should be assigned for thatencounter.See section I.C17.f.2. for information on the codingof organ transplant complications.Assign code V45.88, Status post administrationof tPA (rtPA) in a different facility within thelast 24 hours prior to admission to the currentfacility, as a secondary diagnosis when a patientis received by transfer into a facility anddocumentation indicates they wereadministered tissue plasminogen activator (tPA)within the last 24 hours prior to admission tothe current facility.This guideline applies even if the patient is stillreceiving the tPA at the time they are receivedinto the current facility.The appropriate code for the condition forwhich the tPA was administered (such ascerebrovascular disease or myocardialinfarction) should be assigned first.Code V45.88 is only applicable to the receivingfacility record and not to the transferringfacility record.V46 Other dependence on machinesV49.6 Upper limb amputation statusV49.7 Lower limb amputation statusNote: Categories V42-V46, and subcategoriesV49.6, V49.7 are for use only if there are nocomplications or malfunctions of the organ ortissue replaced, the amputation site or theequipment on which the patient is dependent.V49.81 Postmenopausal statusV49.82 Dental sealant statusV49.83 Awaiting organ transplant status24 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and ReportingV58.6x Long-term (current) drug useCodes from this subcategory indicate a patient’scontinuous use of a prescribed drug (includingsuch things as aspirin therapy) for thelong-term treatment of a condition or forprophylactic use. It is not for use for patientswho have addictions to drugs. Thissubcategory is not for use of medications fordetoxification or maintenance programs toprevent withdrawal symptoms in patients withdrug dependence (e.g., methadonemaintenance for opiate dependence). Assignthe appropriate code for the drug dependenceinstead.Assign a code from subcategory V58.6,Long-term (current) drug use, if the patient isreceiving a medication for an extended periodas a prophylactic measure (such as for theprevention of deep vein thrombosis) or astreatment of a chronic condition (such asarthritis) or a disease requiring a lengthy courseof treatment (such as cancer). Do not assign acode from subcategory V58.6 for medicationbeing administered for a brief period of time totreat an acute illness or injury (such as a courseof antibiotics to treat acute bronchitis).V83 Genetic carrier statusGenetic carrier status indicates that a personcarries a gene, associated with a particulardisease, which may be passed to offspring whomay develop that disease. The person does nothave the disease and is not at risk of developingthe disease.V84 Genetic susceptibility statusGenetic susceptibility indicates that a personhas a gene that increases the risk of that persondeveloping the disease.Codes from category V84, Geneticsusceptibility to disease, should not be used asprincipal or first-listed codes. If the patient hasthe condition to which he/she is susceptible,and that condition is the reason for theencounter, the code for the current conditionshould be sequenced first. If the patient isbeing seen for follow-up after completedtreatment for this condition, and the conditionno longer exists, a follow-up code should besequenced first, followed by the appropriatepersonal history and genetic susceptibilitycodes. If the purpose of the encounter isgenetic counseling associated with procreativemanagement, a code from subcategory V26.3,Genetic counseling and testing, should beassigned as the first-listed code, followed by acode from category V84. Additional codesshould be assigned for any applicable family orpersonal history.See Section I.C. 18.d.14 for information onprophylactic organ removal due to a geneticsusceptibility.V85 Body Mass Index (BMI)V86 Estrogen receptor statusV88 Acquired absence of other organs and tissue4) History (of)There are two types of history V codes, personal andfamily. Personal history codes explain a patient’s pastmedical condition that no longer exists and is notreceiving any treatment, but that has the potential forrecurrence, and therefore may require continuedmonitoring. The exceptions to this general rule arecategory V14, Personal history of allergy to medicinalagents, and subcategory V15.0, Allergy, other than tomedicinal agents. A person who has had an allergicepisode to a substance or food in the past should alwaysbe considered allergic to the substance.Family history codes are for use when a patient has afamily member(s) who has had a particular disease thatcauses the patient to be at higher risk of also contractingthe disease.Personal history codes may be used in conjunction withfollow-up codes and family history codes may be usedin conjunction with screening codes to explain the needfor a test or procedure. History codes are also acceptableon any medical record regardless of the reason for visit.A history of an illness, even if no longer present, isimportant information that may alter the type oftreatment ordered.The history V code categories are:V10 Personal history of malignant neoplasmV12 Personal history of certain other diseasesV13 Personal history of other diseasesExcept: V13.4, Personal history of arthritis, andV13.6, Personal history of congenitalmalformations. These conditions are life-longso are not true history codes.V14 Personal history of allergy to medicinal agentsV15 Other personal history presenting hazards tohealthExcept: V15.7, Personal history ofcontraception.V16 Family history of malignant neoplasmV17 Family history of certain chronic disablingdiseasesV18 Family history of certain other specific diseasesV19 Family history of other conditionsV87 Other specified personal exposures and historypresenting hazards to health5) ScreeningScreening is the testing for disease or disease precursorsin seemingly well individuals so that early detection andtreatment can be provided for those who test positive forthe disease. Screenings that are recommended for manysubgroups in a population include: routinemammograms for women over 40, a fecal occult bloodtest for everyone over 50, an amniocentesis to rule out afetal anomaly for pregnant women over 35, because theincidence of breast cancer and colon cancer in thesesubgroups is higher than in the general population, as isthe incidence of Down’s syndrome in older mothers.© 2009 Ingenix 25

Official ICD-9-CM Guidelines for Coding and ReportingThe testing of a person to rule out or confirm asuspected diagnosis because the patient has some sign orsymptom is a diagnostic examination, not a screening.In these cases, the sign or symptom is used to explainthe reason for the test.A screening code may be a first listed code if the reasonfor the visit is specifically the screening exam. It mayalso be used as an additional code if the screening isdone during an office visit for other health problems. Ascreening code is not necessary if the screening isinherent to a routine examination, such as a pap smeardone during a routine pelvic examination.Should a condition be discovered during the screeningthen the code for the condition may be assigned as anadditional diagnosis.The V code indicates that a screening exam is planned. Aprocedure code is required to confirm that the screeningwas performed.The screening V code categories:V28 Antenatal screeningV73-V82 Special screening examinations6) ObservationThere are three observation V code categories. They arefor use in very limited circumstances when a person isbeing observed for a suspected condition that is ruledout. The observation codes are not for use if an injury orillness or any signs or symptoms related to the suspectedcondition are present. In such cases thediagnosis/symptom code is used with the correspondingE code to identify any external cause.The observation codes are to be used as principaldiagnosis only. The only exception to this is when theprincipal diagnosis is required to be a code from theV30, Live born infant, category. Then the V29observation code is sequenced after the V30 code.Additional codes may be used in addition to theobservation code but only if they are unrelated to thesuspected condition being observed.Codes from subcategory V89.0, Suspected maternal andfetal conditions not found, may either be used as a firstlisted or as an additional code assignment depending onthe case. They are for use in very limited circumstanceson a maternal record when an encounter is for asuspected maternal or fetal condition that is ruled outduring that encounter (for example, a maternal or fetalcondition may be suspected due to an abnormal testresult). These codes should not be used when thecondition is confirmed. In those cases, the confirmedcondition should be coded. In addition, these codes arenot for use if an illness or any signs or symptoms relatedto the suspected condition or problem are present. Insuch cases the diagnosis/symptom code is used.Additional codes may be used in addition to the codefrom subcategory V89.0, but only if they are unrelatedto the suspected condition being evaluated.Codes from subcategory V89.0 may not be used forencounters for antenatal screening of mother.See Section I.C.18.d., Screening.For encounters for suspected fetal condition that areinconclusive following testing and evaluation, assign theappropriate code from category 655, 656, 657 or 658.The observation V code categories:V29 Observation and evaluation of newborns forsuspected condition not foundFor the birth encounter, a code from categoryV30 should be sequenced before the V29 code.V71 Observation and evaluation for suspectedcondition not foundV89 Suspected maternal and fetal conditions notfound7) AftercareAftercare visit codes cover situations when the initialtreatment of a disease or injury has been performed andthe patient requires continued care during the healing orrecovery phase, or for the long-term consequences of thedisease. The aftercare V code should not be used iftreatment is directed at a current, acute disease or injury.The diagnosis code is to be used in these cases.Exceptions to this rule are codes V58.0, Radiotherapy,and codes from subcategory V58.1, Encounter forchemotherapy and immunotherapy for neoplasticconditions. These codes are to be first listed, followed bythe diagnosis code when a patient’s encounter is solely toreceive radiation therapy or chemotherapy for thetreatment of a neoplasm. Should a patient receive bothchemotherapy and radiation therapy during the sameencounter code V58.0 and V58.1 may be used togetheron a record with either one being sequenced first.The aftercare codes are generally first listed to explainthe specific reason for the encounter. An aftercare codemay be used as an additional code when some type ofaftercare is provided in addition to the reason foradmission and no diagnosis code is applicable. Anexample of this would be the closure of a colostomyduring an encounter for treatment of another condition.Aftercare codes should be used in conjunction with anyother aftercare codes or other diagnosis codes to providebetter detail on the specifics of an aftercare encountervisit, unless otherwise directed by the classification. Thesequencing of multiple aftercare codes is discretionary.Certain aftercare V code categories need a secondarydiagnosis code to describe the resolving condition orsequelae, for others, the condition is inherent in thecode title.Additional V code aftercare category terms include,fitting and adjustment, and attention to artificialopenings.Status V codes may be used with aftercare V codes toindicate the nature of the aftercare. For example codeV45.81, Aortocoronary bypass status, may be used withcode V58.73, Aftercare following surgery of thecirculatory system, NEC, to indicate the surgery forwhich the aftercare is being performed. Also, atransplant status code may be used following codeV58.44, Aftercare following organ transplant, to identifythe organ transplanted. A status code should not be usedwhen the aftercare code indicates the type of status, suchas using V55.0, Attention to tracheostomy with V44.0,Tracheostomy status.See Section I. B.16 Admissions/Encounter for RehabilitationThe aftercare V category/codes:V51.0 Encounter for breast reconstruction followingmastectomy26 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and ReportingV52 Fitting and adjustment of prosthetic device andimplantV53 Fitting and adjustment of other deviceV54 Other orthopedic aftercareV55 Attention to artificial openingsV56 Encounter for dialysis and dialysis catheter careV57 Care involving the use of rehabilitationproceduresV58.0 RadiotherapyV58.11 Encounter for antineoplastic chemotherapyV58.12 Encounter for antineoplastic immunotherapyV58.3x Attention to dressings and suturesV58.41 Encounter for planned post-operative woundclosureV58.42 Aftercare, surgery, neoplasmV58.43 Aftercare, surgery, traumaV58.44 Aftercare involving organ transplantV58.49 Other specified aftercare following surgeryV58.7x Aftercare following surgeryV58.81 Fitting and adjustment of vascular catheterV58.82 Fitting and adjustment of non-vascular catheterV58.83 Monitoring therapeutic drugV58.89 Other specified aftercare8) Follow-upThe follow-up codes are used to explain continuingsurveillance following completed treatment of a disease,condition, or injury. They imply that the condition hasbeen fully treated and no longer exists. They should notbe confused with aftercare codes that explain currenttreatment for a healing condition or its sequelae.Follow-up codes may be used in conjunction withhistory codes to provide the full picture of the healedcondition and its treatment. The follow-up code issequenced first, followed by the history code.A follow-up code may be used to explain repeated visits.Should a condition be found to have recurred on thefollow-up visit, then the diagnosis code should be usedin place of the follow-up code.The follow-up V code categories:V24 Postpartum care and evaluationV67 Follow-up examination9) DonorCategory V59 is the donor codes. They are used forliving individuals who are donating blood or other bodytissue. These codes are only for individuals donating forothers, not for self donations. They are not for use toidentify cadaveric donations.10) CounselingCounseling V codes are used when a patient or familymember receives assistance in the aftermath of an illnessor injury, or when support is required in coping withfamily or social problems. They are not necessary for usein conjunction with a diagnosis code when thecounseling component of care is considered integral tostandard treatment.The counseling V categories/codes:V25.0 General counseling and advice forcontraceptive managementV26.3 Genetic counselingV26.4 General counseling and advice for procreativemanagementV61.x Other family circumstancesV65.1 Person consulted on behalf of another personV65.3 Dietary surveillance and counselingV65.4 Other counseling, not elsewhere classified11) Obstetrics and related conditionsSee Section I.C.11., the Obstetrics guidelines for furtherinstruction on the use of these codes.V codes for pregnancy are for use in those circumstanceswhen none of the problems or complications includedin the codes from the Obstetrics chapter exist (a routineprenatal visit or postpartum care). Codes V22.0,Supervision of normal first pregnancy, and V22.1,Supervision of other normal pregnancy, are always firstlisted and are not to be used with any other code fromthe OB chapter.The outcome of delivery, category V27, should beincluded on all maternal delivery records. It is always asecondary code.V codes for family planning (contraceptive) orprocreative management and counseling should beincluded on an obstetric record either during thepregnancy or the postpartum stage, if applicable.Obstetrics and related conditions V code categories:V22 Normal pregnancyV23 Supervision of high-risk pregnancyExcept: V23.2, Pregnancy with history ofabortion. Code 646.3, Habitual aborter, fromthe OB chapter is required to indicate a historyof abortion during a pregnancy.V24 Postpartum care and evaluationV25 Encounter for contraceptive managementExcept V25.0xSee Section I.C.18.d.11, CounselingV26 Procreative managementExcept V26.5x, Sterilization status, V26.3 andV26.4See Section I.C.18.d.11., CounselingV27 Outcome of deliveryV28 Antenatal screeningSee Section I.C.18.d.6., Screening12) Newborn, infant and childSee Section I.C.15, the Newborn guidelines for furtherinstruction on the use of these codes.Newborn V code categories:V20 Health supervision of infant or childV29 Observation and evaluation of newborns forsuspected condition not foundSee Section I.C.18.d.7, ObservationV30-V39Liveborn infant according to type of birth13) Routine and administrative examinationsThe V codes allow for the description of encounters forroutine examinations, such as, a general check-up, or,examinations for administrative purposes, such as, a© 2009 Ingenix 27

Official ICD-9-CM Guidelines for Coding and Reportingpre-employment physical. The codes are not to be usedif the examination is for diagnosis of a suspectedcondition or for treatment purposes. In such cases thediagnosis code is used. During a routine exam, should adiagnosis or condition be discovered, it should be codedas an additional code. Pre-existing and chronicconditions and history codes may also be included asadditional codes as long as the examination is foradministrative purposes and not focused on anyparticular condition.Pre-operative examination and pre-procedurallaboratory examination V codes are for use only inthose situations when a patient is being cleared for aprocedure or surgery and no treatment is given.The V codes categories/code for routine andadministrative examinations:V20.2 Routine infant or child health checkAny injections given should have acorresponding procedure code.V70 General medical examinationV72 Special investigations and examinationsCodes V72.5 and V72.62 may be used if thereason for the patient encounter is for routinelaboratory/radiology testing in the absence ofany signs, symptoms, or associated diagnosis. Ifroutine testing is performed during the sameencounter as a test to evaluate a sign, symptom,or diagnosis, it is appropriate to assign both theV code and the code describing the reason forthe non-routine test.14) Miscellaneous V codesThe miscellaneous V codes capture a number of otherhealth care encounters that do not fall into one of theother categories. Certain of these codes identify thereason for the encounter, others are for use as additionalcodes that provide useful information on circumstancesthat may affect a patient’s care and treatment.Prophylactic organ removalFor encounters specifically for prophylactic removal ofbreasts, ovaries, or another organ due to a geneticsusceptibility to cancer or a family history of cancer, theprincipal or first listed code should be a code fromsubcategory V50.4, Prophylactic organ removal,followed by the appropriate genetic susceptibility codeand the appropriate family history code.If the patient has a malignancy of one site and is havingprophylactic removal at another site to prevent either anew primary malignancy or metastatic disease, a codefor the malignancy should also be assigned in additionto a code from subcategory V50.4. A V50.4 code shouldnot be assigned if the patient is having organ removal fortreatment of a malignancy, such as the removal of thetestes for the treatment of prostate cancer.Miscellaneous V code categories/codes:V07 Need for isolation and other prophylacticmeasuresExcept V07.5, Prophylactic use of agentsaffecting estrogen receptors and estrogen levelsV50 Elective surgery for purposes other thanremedying health statesV58.5 OrthodonticsV60 Housing, household, and economiccircumstancesV62 Other psychosocial circumstancesV63 Unavailability of other medical facilities for careV64 Persons encountering health services forspecific procedures, not carried outV66 Convalescence and palliative careV68 Encounters for administrative purposesV69 Problems related to lifestyle15) Nonspecific V codesCertain V codes are so non-specific, or potentiallyredundant with other codes in the classification, thatthere can be little justification for their use in theinpatient setting. Their use in the outpatient settingshould be limited to those instances when there is nofurther documentation to permit more precise coding.Otherwise, any sign or symptom or any other reason forvisit that is captured in another code should be used.Nonspecific V code categories/codes:V11 Personal history of mental disorder A codefrom the mental disorders chapter, with an inremission fifth-digit, should be used.V13.4 Personal history of arthritisV13.6 Personal history of congenital malformationsV15.7 Personal history of contraceptionV23.2 Pregnancy with history of abortionV40 Mental and behavioral problemsV41 Problems with special senses and other specialfunctionsV47 Other problems with internal organsV48 Problems with head, neck, and trunkV49 Problems with limbs and other problemsException:V49.6 Upper limb amputation statusV49.7 Lower limb amputation statusV49.81 Postmenopausal statusV49.82 Dental sealant statusV49.83 Awaiting organ transplant statusV51.8 Other aftercare involving the use of plasticsurgeryV58.2 Blood transfusion, without reported diagnosisV58.9 Unspecified aftercareSee Section IV.K. and Section IV.L. of theOutpatient guidelines.e. V Codes That May Only be Principal/First-ListedDiagnosisThe list of V codes/categories below may only bereported as the principal/first-listed diagnosis, exceptwhen there are multiple encounters on the same day andthe medical records for the encounters are combined orwhen there is more than one V code that meets thedefinition of principal diagnosis (e.g., a patient isadmitted to home healthcare for both aftercare andrehabilitation and they equally meet the definition ofprincipal diagnosis). These codes should not be reportedif they do not meet the definition of principal orfirst-listed diagnosis.28 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and ReportingSee Section II and Section IV.A for information on selection ofprincipal and first-listed diagnosis.See Section II.C for information on two or more diagnoses thatequally meet the definition for principal diagnosis.V20.x Health supervision of infant or childV22.0 Supervision of normal first pregnancyV22.1 Supervision of other normal pregnancyV24.x Postpartum care and examinationV26.81 Encounter for assisted reproductive fertilityprocedure cycleV26.82 Encounter for fertility preservationprocedureV30.x Single livebornV31.x Twin, mate livebornV32.x Twin, mate stillbornV33.x Twin, unspecifiedV34.x Other multiple, mates all livebornV35.x Other multiple, mates all stillbornV36.x Other multiple, mates live- and stillbornV37.x Other multiple, unspecifiedV39.x UnspecifiedV46.12 Encounter for respirator dependence duringpower failureV46.13 Encounter for weaning from respirator[ventilator]V51.0 Encounter for breast reconstruction followingmastectomyV56.0 Extracorporeal dialysisV57.x Care involving use of rehabilitation proceduresV58.0 RadiotherapyV58.11 Encounter for antineoplastic chemotherapyV58.12 Encounter for antineoplastic immunotherapyV59.x DonorsV66.0 Convalescence and palliative care followingsurgeryV66.1 Convalescence and palliative care followingradiotherapyV66.2 Convalescence and palliative care followingchemotherapyV66.3 Convalescence and palliative care followingpsychotherapy and other treatment for mentaldisorderV66.4 Convalescence and palliative care followingtreatment of fractureV66.5 Convalescence and palliative care followingother treatmentV66.6 Convalescence and palliative care followingcombined treatmentV66.9 Unspecified convalescenceV68.x Encounters for administrative purposesV70.0 Routine general medical examination at ahealth care facilityV70.1 General psychiatric examination, requested bythe authorityV70.2 General psychiatric examination, other andunspecifiedV70.3 Other medical examination for administrativepurposesV70.4 Examination for medicolegal reasonsV70.5 Health examination of defined subpopulationsV70.6 Health examination in population surveysV70.8 Other specified general medical examinationsV70.9 Unspecified general medical examinationV71.x Observation and evaluation for suspectedconditions not found19. Supplemental Classification of External Causes of Injuryand Poisoning (E codes, E000-E999)Introduction: These guidelines are provided for those who arecurrently collecting E codes in order that there will bestandardization in the process. If your institution plans to begincollecting E codes, these guidelines are to be applied. The use ofE codes is supplemental to the application of ICD-9-CMdiagnosis codes.External causes of injury and poisoning codes (categories E000and E800-E999) are intended to provide data for injuryresearch and evaluation of injury prevention strategies. Activitycodes (categories E001-E030) are intended to be used todescribe the activity of a person seeking care for injuries aswell as other health conditions, when the injury or otherhealth condition resulted from an activity or the activitycontributed to a condition. E codes capture how the injury,poisoning, or adverse effect happened (cause), the intent(unintentional or accidental; or intentional, such as suicide orassault), the person’s status (e.g. civilian, military), theassociated activity and the place where the event occurred.Some major categories of E codes include:• transport accidents• poisoning and adverse effects of drugs, medicinalsubstances and biologicals• accidental falls• accidents caused by fire and flames• accidents due to natural and environmental factors• late effects of accidents, assaults or self injury• assaults or purposely inflicted injury• suicide or self inflicted injuryThese guidelines apply for the coding and collection of E codesfrom records in hospitals, outpatient clinics, emergencydepartments, other ambulatory care settings and provideroffices, and nonacute care settings, except when other specificguidelines apply.a. General E code coding guidelines1) Used with any code in the range of 001-V89An E code from categories E800-E999 may be usedwith any code in the range of 001-V89, which indicatesan injury, poisoning, or adverse effect due to an externalcause.An activity E code (categories E001-E030) may beused with any code in the range of 001-V89 thatindicates an injury, or other health condition thatresulted from an activity, or the activity contributedto a condition.© 2009 Ingenix 29

Official ICD-9-CM Guidelines for Coding and Reporting2) Assign the appropriate E code for all initialtreatmentsAssign the appropriate E code for the initial encounter ofan injury, poisoning, or adverse effect of drugs, not forsubsequent treatment.External cause of injury codes (E-codes) may beassigned while the acute fracture codes are stillapplicable.See Section I.C.17.b.1 for coding of acute fractures.3) Use the full range of E codesUse the full range of E codes (E800-E999) to completelydescribe the cause, the intent and the place ofoccurrence, if applicable, for all injuries, poisonings, andadverse effects of drugs.See a.1.), j.), and k.) in this section for information on the useof status and activity E codes.4) Assign as many E codes as necessaryAssign as many E codes as necessary to fully explaineach cause.5) The selection of the appropriate E codeThe selection of the appropriate E code is guided by theIndex to External Causes, which is located after thealphabetical index to diseases and by Inclusion andExclusion notes in the Tabular List.6) E code can never be a principal diagnosisAn E code can never be a principal (first listed)diagnosis.7) External cause code(s) with systemic inflammatoryresponse syndrome (SIRS)An external cause code is not appropriate with a codefrom subcategory 995.9, unless the patient also hasanother condition for which an E code would beappropriate (such as an injury, poisoning, or adverseeffect of drugs).8. Multiple Cause E Code Coding GuidelinesMore than one E-code is required to fully describe theexternal cause of an illness, injury or poisoning. Theassignment of E-codes should be sequenced in thefollowing priority:If two or more events cause separate injuries, an E codeshould be assigned for each cause. The first listed E codewill be selected in the following order:E codes for child and adult abuse take priority overall other E codes.See Section I.C.19.e., Child and Adult abuse guidelines.E codes for terrorism events take priority over allother E codes except child and adult abuse.E codes for cataclysmic events take priority over allother E codes except child and adult abuse andterrorism.E codes for transport accidents take priority over allother E codes except cataclysmic events, child andadult abuse and terrorism.Activity and external cause status codes areassigned following all causal (intent) E codes.The first-listed E code should correspond to thecause of the most serious diagnosis due to anassault, accident, or self-harm, following the orderof hierarchy listed above.9. If the reporting format limits the number of E codesIf the reporting format limits the number of E codesthat can be used in reporting clinical data, report thecode for the cause/intent most related to theprincipal diagnosis. If the format permits capture ofadditional E codes, the cause/intent, includingmedical misadventures, of the additional eventsshould be reported rather than the codes for place,activity or external status.b. Place of occurrence guidelineUse an additional code from category E849 to indicate thePlace of Occurrence for injuries and poisonings. The Place ofOccurrence describes the place where the event occurredand not the patient’s activity at the time of the event.Do not use E849.9 if the place of occurrence is not stated.c. Adverse effects of drugs, medicinal and biologicalsubstances guidelines1) Do not code directly from the Table of DrugsDo not code directly from the Table of Drugs andChemicals. Always refer back to the Tabular List.2) Use as many codes as necessary to describeUse as many codes as necessary to describe completelyall drugs, medicinal or biological substances.If the reporting format limits the number of E codes, andthere are different fourth digit codes in the same threedigit category, use the code for “Other specified” of thatcategory of drugs, medicinal or biological substances. Ifthere is no “Other specified” code in that category, usethe appropriate “Unspecified” code in that category.If the reporting format limits the number of E codes, andthe codes are in different three digit categories, assignthe appropriate E code for other multiple drugs andmedicinal substances.3) If the same E code would describe the causativeagentIf the same E code would describe the causative agentfor more than one adverse reaction, assign the code onlyonce.4) If two or more drugs, medicinal or biologicalsubstancesIf two or more drugs, medicinal or biological substancesare reported, code each individually unless thecombination code is listed in the Table of Drugs andChemicals. In that case, assign the E code for thecombination.5) When a reaction results from the interaction of adrug(s)When a reaction results from the interaction of a drug(s)and alcohol, use poisoning codes and E codes for both.6) Codes from the E930-E949 seriesCodes from the E930-E949 series must be used toidentify the causative substance for an adverse effect ofdrug, medicinal and biological substances, correctlyprescribed and properly administered. The effect, suchas tachycardia, delirium, gastrointestinal hemorrhaging,vomiting, hypokalemia, hepatitis, renal failure, orrespiratory failure, is coded and followed by theappropriate code from the E930-E949 series.d. Child and adult abuse guideline30 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and Reporting1) Intentional injuryWhen the cause of an injury or neglect is intentionalchild or adult abuse, the first listed E code should beassigned from categories E960-E968, Homicide andinjury purposely inflicted by other persons, (exceptcategory E967). An E code from category E967, Childand adult battering and other maltreatment, should beadded as an additional code to identify the perpetrator,if known.2) Accidental intentIn cases of neglect when the intent is determined to beaccidental E code E904.0, Abandonment or neglect ofinfant and helpless person, should be the first listed Ecode.e. Unknown or suspected intent guideline1) If the intent (accident, self-harm, assault) of thecause of an injury or poisoning is unknownIf the intent (accident, self-harm, assault) of the cause ofan injury or poisoning is unknown or unspecified, codethe intent as undetermined E980-E989.2) If the intent (accident, self-harm, assault) of thecause of an injury or poisoning is questionableIf the intent (accident, self-harm, assault) of the cause ofan injury or poisoning is questionable, probable orsuspected, code the intent as undetermined E980-E989.f. Undetermined causeWhen the intent of an injury or poisoning is known, but thecause is unknown, use codes: E928.9, Unspecified accident,E958.9, Suicide and self-inflicted injury by unspecifiedmeans, and E968.9, Assault by unspecified means.These E codes should rarely be used, as the documentationin the medical record, in both the inpatient, outpatient andother settings, should normally provide sufficient detail todetermine the cause of the injury.g. Late effects of external cause guidelines1) Late effect E codesLate effect E codes exist for injuries and poisonings butnot for adverse effects of drugs, misadventures andsurgical complications.2) Late effect E codes (E929, E959, E969, E977, E989,or E999.1)A late effect E code (E929, E959, E969, E977, E989, orE999.1) should be used with any report of a late effector sequela resulting from a previous injury or poisoning(905-909).3) Late effect E code with a related current injuryA late effect E code should never be used with a relatedcurrent nature of injury code.4) Use of late effect E codes for subsequent visitsUse a late effect E code for subsequent visits when a lateeffect of the initial injury or poisoning is being treated.There is no late effect E code for adverse effects of drugs.Do not use a late effect E code for subsequent visits forfollow-up care (e.g., to assess healing, to receiverehabilitative therapy) of the injury or poisoning whenno late effect of the injury has been documented.h. Misadventures and complications of care guidelines1) Code range E870-E876Assign a code in the range of E870-E876 ifmisadventures are stated by the provider. Whenapplying the E code guidelines pertaining tosequencing, these E codes are considered causalcodes.2) Code range E878-E879Assign a code in the range of E878-E879 if the providerattributes an abnormal reaction or later complication toa surgical or medical procedure, but does not mentionmisadventure at the time of the procedure as the causeof the reaction.i. Terrorism guidelines1) Cause of injury identified by the FederalGovernment (FBI) as terrorismWhen the cause of an injury is identified by the FederalGovernment (FBI) as terrorism, the first-listed E-codeshould be a code from category E979, Terrorism. Thedefinition of terrorism employed by the FBI is found atthe inclusion note at E979. The terrorism E-code is theonly E-code that should be assigned. Additional E codesfrom the assault categories should not be assigned.2) Cause of an injury is suspected to be the result ofterrorismWhen the cause of an injury is suspected to be the resultof terrorism a code from category E979 should not beassigned. Assign a code in the range of E codes basedcircumstances on the documentation of intent andmechanism.3) Code E979.9, Terrorism, secondary effectsAssign code E979.9, Terrorism, secondary effects, forconditions occurring subsequent to the terrorist event.This code should not be assigned for conditions that aredue to the initial terrorist act.4) Statistical tabulation of terrorism codesFor statistical purposes these codes will be tabulatedwithin the category for assault, expanding the currentcategory from E960-E969 to include E979 and E999.1.j. Activity Code GuidelinesAssign a code from category E001-E030 to describe theactivity that caused or contributed to the injury or otherhealth condition.Unlike other E codes, activity E codes may be assignedto indicate a health condition (not just injuries) resultedfrom an activity, or the activity contributed to thecondition.The activity codes are not applicable to poisonings,adverse effects, misadventures or late effects.k. External cause statusA code from category E000, External cause status,should be assigned whenever any other E code isassigned for an encounter, including an Activity E code,except for the events noted below. Assign a code fromcategory E000, External cause status, to indicate thework status of the person at the time the event occurred.The status code indicates whether the event occurredduring military activity, whether a non-military personwas at work, whether an individual including a studentor volunteer was involved in a non-work activity at thetime of the causal event.A code from E000, External cause status, should beassigned, when applicable, with other external causecodes, such as transport accidents and falls. The© 2009 Ingenix 31

Official ICD-9-CM Guidelines for Coding and Reportingexternal cause status codes are not applicable topoisonings, adverse effects, misadventures or lateeffects.Do not assign a code from category E000 if no other Ecodes (cause, activity) are applicable for the encounter.Do not assign code E000.9, Unspecified external causestatus, if the status is not stated.Section II. Selection of Principal DiagnosisThe circumstances of inpatient admission always govern the selection ofprincipal diagnosis. The principal diagnosis is defined in the UniformHospital Discharge Data Set (UHDDS) as “that condition establishedafter study to be chiefly responsible for occasioning the admission of thepatient to the hospital for care.”The UHDDS definitions are used by hospitals to report inpatient dataelements in a standardized manner. These data elements and theirdefinitions can be found in the July 31, 1985, Federal Register (Vol. 50,No, 147), pp. 31038-40.Since that time the application of the UHDDS definitions has beenexpanded to include all non-outpatient settings (acute care, short term,long term care and psychiatric hospitals; home health agencies; rehabfacilities; nursing homes, etc).In determining principal diagnosis the coding conventions in theICD-9-CM, Volumes I and II take precedence over these official codingguidelines.(See Section I.A., Conventions for the ICD-9-CM)The importance of consistent, complete documentation in the medicalrecord cannot be overemphasized. Without such documentation theapplication of all coding guidelines is a difficult, if not impossible, task.A. Codes for symptoms, signs, and ill-defined conditionsCodes for symptoms, signs, and ill-defined conditions from Chapter16 are not to be used as principal diagnosis when a related definitivediagnosis has been established.B. Two or more interrelated conditions, each potentially meetingthe definition for principal diagnosisWhen there are two or more interrelated conditions (such asdiseases in the same ICD-9-CM chapter or manifestationscharacteristically associated with a certain disease) potentiallymeeting the definition of principal diagnosis, either condition maybe sequenced first, unless the circumstances of the admission, thetherapy provided, the Tabular List, or the Alphabetic Index indicateotherwise.C. Two or more diagnoses that equally meet the definition forprincipal diagnosisIn the unusual instance when two or more diagnoses equally meetthe criteria for principal diagnosis as determined by thecircumstances of admission, diagnostic workup and/or therapyprovided, and the Alphabetic Index, Tabular List, or another codingguidelines does not provide sequencing direction, any one of thediagnoses may be sequenced first.D. Two or more comparative or contrasting conditionsIn those rare instances when two or more contrasting or comparativediagnoses are documented as “either/or” (or similar terminology),they are coded as if the diagnoses were confirmed and the diagnosesare sequenced according to the circumstances of the admission. If nofurther determination can be made as to which diagnosis should beprincipal, either diagnosis may be sequenced first.E. A symptom(s) followed by contrasting/comparative diagnosesWhen a symptom(s) is followed by contrasting/comparativediagnoses, the symptom code is sequenced first. All thecontrasting/comparative diagnoses should be coded as additionaldiagnoses.F. Original treatment plan not carried outSequence as the principal diagnosis the condition, which after studyoccasioned the admission to the hospital, even though treatmentmay not have been carried out due to unforeseen circumstances.G. Complications of surgery and other medical careWhen the admission is for treatment of a complication resultingfrom surgery or other medical care, the complication code issequenced as the principal diagnosis. If the complication is classifiedto the 996-999 series and the code lacks the necessary specificity indescribing the complication, an additional code for the specificcomplication should be assigned.H. Uncertain diagnosisIf the diagnosis documented at the time of discharge is qualified as“probable”, “suspected”, “likely”, “questionable”, “possible”, or “stillto be ruled out”, or other similar terms indicating uncertainty, codethe condition as if it existed or was established. The bases for theseguidelines are the diagnostic workup, arrangements for furtherworkup or observation, and initial therapeutic approach thatcorrespond most closely with the established diagnosis.Note: This guideline is applicable only to inpatient admissions toshort-term, acute, long-term care and psychiatric hospitals.I. Admission from observation unit1. Admission following medical observationWhen a patient is admitted to an observation unit for a medicalcondition, which either worsens or does not improve, and issubsequently admitted as an inpatient of the same hospital forthis same medical condition, the principal diagnosis would bethe medical condition which led to the hospital admission.2. Admission following post-operative observationWhen a patient is admitted to an observation unit to monitor acondition (or complication) that develops following outpatientsurgery, and then is subsequently admitted as an inpatient of thesame hospital, hospitals should apply the Uniform HospitalDischarge Data Set (UHDDS) definition of principal diagnosis as"that condition established after study to be chiefly responsiblefor occasioning the admission of the patient to the hospital forcare."J. Admission from outpatient surgeryWhen a patient receives surgery in the hospital's outpatient surgerydepartment and is subsequently admitted for continuing inpatientcare at the same hospital, the following guidelines should befollowed in selecting the principal diagnosis for the inpatientadmission:• If the reason for the inpatient admission is a complication, assignthe complication as the principal diagnosis.• If no complication, or other condition, is documented as thereason for the inpatient admission, assign the reason for theoutpatient surgery as the principal diagnosis.• If the reason for the inpatient admission is another conditionunrelated to the surgery, assign the unrelated condition as theprincipal diagnosis.32 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and ReportingSection III. Reporting Additional DiagnosesGENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSESFor reporting purposes the definition for “other diagnoses” is interpretedas additional conditions that affect patient care in terms of requiring:clinical evaluation; ortherapeutic treatment; ordiagnostic procedures; orextended length of hospital stay; orincreased nursing care and/or monitoring.The UHDDS item #11-b defines Other Diagnoses as “all conditions thatcoexist at the time of admission, that develop subsequently, or that affectthe treatment received and/or the length of stay. Diagnoses that relate toan earlier episode which have no bearing on the current hospital stay areto be excluded.” UHDDS definitions apply to inpatients in acute care,short-term, long term care and psychiatric hospital setting. The UHDDSdefinitions are used by acute care short-term hospitals to reportinpatient data elements in a standardized manner. These data elementsand their definitions can be found in the July 31, 1985, Federal Register(Vol. 50, No, 147), pp. 31038-40.Since that time the application of the UHDDS definitions has beenexpanded to include all non-outpatient settings (acute care, short term,long term care and psychiatric hospitals; home health agencies; rehabfacilities; nursing homes, etc).The following guidelines are to be applied in designating “otherdiagnoses” when neither the Alphabetic Index nor the Tabular List inICD-9-CM provide direction. The listing of the diagnoses in the patientrecord is the responsibility of the attending provider.A. Previous conditionsIf the provider has included a diagnosis in the final diagnosticstatement, such as the discharge summary or the face sheet, itshould ordinarily be coded. Some providers include in thediagnostic statement resolved conditions or diagnoses andstatus-post procedures from previous admission that have nobearing on the current stay. Such conditions are not to be reportedand are coded only if required by hospital policy.However, history codes (V10-V19) may be used as secondary codesif the historical condition or family history has an impact on currentcare or influences treatment.B. Abnormal findingsAbnormal findings (laboratory, x-ray, pathologic, and otherdiagnostic results) are not coded and reported unless the providerindicates their clinical significance. If the findings are outside thenormal range and the attending provider has ordered other tests toevaluate the condition or prescribed treatment, it is appropriate toask the provider whether the abnormal finding should be added.Please note: This differs from the coding practices in the outpatientsetting for coding encounters for diagnostic tests that have beeninterpreted by a provider.C. Uncertain diagnosisIf the diagnosis documented at the time of discharge is qualified as“probable”, “suspected”, “likely”, “questionable”, “possible”, or “stillto be ruled out” or other similar terms indicating uncertainty, codethe condition as if it existed or was established. The bases for theseguidelines are the diagnostic workup, arrangements for furtherworkup or observation, and initial therapeutic approach thatcorrespond most closely with the established diagnosis.Note: This guideline is applicable only to inpatient admissions toshort-term, acute, long-term care and psychiatric hospitals.Section IV. Diagnostic Coding and ReportingGuidelines for Outpatient ServicesThese coding guidelines for outpatient diagnoses have been approvedfor use by hospitals/ providers in coding and reporting hospital-basedoutpatient services and provider-based office visits.Information about the use of certain abbreviations, punctuation,symbols, and other conventions used in the ICD-9-CM Tabular List(code numbers and titles), can be found in Section IA of theseguidelines, under “Conventions Used in the Tabular List.” Informationabout the correct sequence to use in finding a code is also described inSection I.The terms encounter and visit are often used interchangeably indescribing outpatient service contacts and, therefore, appear together inthese 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 willvary in a number of instances from those for inpatient diagnoses,recognizing that:The Uniform Hospital Discharge Data Set (UHDDS) definition ofprincipal 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 notapply to outpatients.A. Selection of first-listed conditionIn the outpatient setting, the term first-listed diagnosis is used in lieuof principal diagnosis.In determining the first-listed diagnosis the coding conventions ofICD-9-CM, as well as the general and disease specific guidelines takeprecedence over the outpatient guidelines.Diagnoses often are not established at the time of the initialencounter/visit. It may take two or more visits before the diagnosis isconfirmed.The most critical rule involves beginning the search for the correctcode assignment through the Alphabetic Index. Never beginsearching initially in the Tabular List as this will lead to codingerrors.1. Outpatient surgeryWhen a patient presents for outpatient surgery, code the reasonfor the surgery as the first-listed diagnosis (reason for theencounter), even if the surgery is not performed due to acontraindication.2. Observation stayWhen a patient is admitted for observation for a medicalcondition, assign a code for the medical condition as thefirst-listed diagnosis.When a patient presents for outpatient surgery and developscomplications requiring admission to observation, code thereason for the surgery as the first reported diagnosis (reason forthe encounter), followed by codes for the complications assecondary diagnoses.B. Codes from 001.0 through V89The appropriate code or codes from 001.0 through V89 must beused to identify diagnoses, symptoms, conditions, problems,complaints, or other reason(s) for the encounter/visit.C. Accurate reporting of ICD-9-CM diagnosis codesFor accurate reporting of ICD-9-CM diagnosis codes, the© 2009 Ingenix 33

Official ICD-9-CM Guidelines for Coding and Reportingdocumentation should describe the patient’s condition, usingterminology which includes specific diagnoses as well as symptoms,problems, or reasons for the encounter. There are ICD-9-CM codesto describe all of these.D. Selection of codes 001.0 through 999.9The selection of codes 001.0 through 999.9 will frequently be usedto describe the reason for the encounter. These codes are from thesection of ICD-9-CM for the classification of diseases and injuries(e.g. infectious and parasitic diseases; neoplasms; symptoms, signs,and ill-defined conditions, etc.).E. Codes that describe symptoms and signsCodes that describe symptoms and signs, as opposed to diagnoses,are acceptable for reporting purposes when a diagnosis has not beenestablished (confirmed) by the provider. Chapter 16 of ICD-9-CM,Symptoms, Signs, and Ill-defined conditions (codes 780.0-799.9)contain many, but not all codes for symptoms.F. Encounters for circumstances other than a disease or injuryICD-9-CM provides codes to deal with encounters for circumstancesother than a disease or injury. The Supplementary Classification offactors Influencing Health Status and Contact with Health Services(V01.0-V89) is provided to deal with occasions when circumstancesother than a disease or injury are recorded as diagnosis or problems.See Section I.C. 18 for information on V-codesG. Level of detail in coding1. ICD-9-CM codes with 3, 4, or 5 digitsICD-9-CM is composed of codes with either 3, 4, or 5 digits.Codes with three digits are included in ICD-9-CM as theheading of a category of codes that may be further subdivided bythe use of fourth and/or fifth-digits, which provide greaterspecificity.2. Use of full number of digits required for a codeA three-digit code is to be used only if it is not furthersubdivided. Where fourth-digit subcategories and/or fifth-digitsubclassifications are provided, they must be assigned. A code isinvalid if it has not been coded to the full number of digitsrequired for that code.See also discussion under Section I.b.3., General Coding Guidelines,Level of Detail in Coding.H. ICD-9-CM code for the diagnosis, condition, problem, or otherreason for encounter/visitList first the ICD-9-CM code for the diagnosis, condition, problem,or other reason for encounter/visit shown in the medical record to bechiefly responsible for the services provided. List additional codesthat describe any coexisting conditions. In some cases the first-listeddiagnosis may be a symptom when a diagnosis has not beenestablished (confirmed) by the physician.I. Uncertain diagnosisDo not code diagnoses documented as “probable”, “suspected,”“questionable,” “rule out,” or “working diagnosis” or other similarterms indicating uncertainty. Rather, code the condition(s) to thehighest degree of certainty for that encounter/visit, such assymptoms, signs, abnormal test results, or other reason for the visit.Please note: This differs from the coding practices used byshort-term, acute care, long-term care and psychiatric hospitals.J. Chronic diseasesChronic diseases treated on an ongoing basis may be coded andreported as many times as the patient receives treatment and care forthe condition(s)K. Code all documented conditions that coexistCode all documented conditions that coexist at the time of theencounter/visit, and require or affect patient care treatment ormanagement. Do not code conditions that were previously treatedand no longer exist. However, history codes (V10-V19) may be usedas secondary codes if the historical condition or family history has animpact on current care or influences treatment.L. Patients receiving diagnostic services onlyFor patients receiving diagnostic services only during anencounter/visit, sequence first the diagnosis, condition, problem, orother reason for encounter/visit shown in the medical record to bechiefly responsible for the outpatient services provided during theencounter/visit. Codes for other diagnoses (e.g., chronic conditions)may be sequenced as additional diagnoses.For encounters for routine laboratory/radiology testing in theabsence of any signs, symptoms, or associated diagnosis, assignV72.5 and a code from the subcategory V72.6. If routine testing isperformed during the same encounter as a test to evaluate a sign,symptom, or diagnosis, it is appropriate to assign both the V codeand the code describing the reason for the non-routine test.For outpatient encounters for diagnostic tests that have beeninterpreted by a physician, and the final report is available at thetime of coding, code any confirmed or definitive diagnosis(es)documented in the interpretation. Do not code related signs andsymptoms as additional diagnoses.Please note: This differs from the coding practice in the hospitalinpatient setting regarding abnormal findings on test results.M. Patients receiving therapeutic services onlyFor patients receiving therapeutic services only during anencounter/visit, sequence first the diagnosis, condition, problem, orother reason for encounter/visit shown in the medical record to bechiefly responsible for the outpatient services provided during theencounter/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 forthe admission/encounter is chemotherapy, radiation therapy, orrehabilitation, the appropriate V code for the service is listed first,and the diagnosis or problem for which the service is beingperformed listed second.N. Patients receiving preoperative evaluations onlyFor patients receiving preoperative evaluations only, sequence first acode from category V72.8, Other specified examinations, to describethe pre-op consultations. Assign a code for the condition to describethe reason for the surgery as an additional diagnosis. Code also anyfindings related to the pre-op evaluation.O. Ambulatory surgeryFor ambulatory surgery, code the diagnosis for which the surgerywas performed. If the postoperative diagnosis is known to bedifferent from the preoperative diagnosis at the time the diagnosis isconfirmed, select the postoperative diagnosis for coding, since it isthe most definitive.P. Routine outpatient prenatal visitsFor routine outpatient prenatal visits when no complications arepresent, codes V22.0, Supervision of normal first pregnancy, orV22.1, Supervision of other normal pregnancy, should be used as theprincipal diagnosis. These codes should not be used in conjunctionwith chapter 11 codes.34 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and ReportingAppendix I. Present on Admission ReportingGuidelinesIntroductionThese guidelines are to be used as a supplement to the ICD-9-CM OfficialGuidelines for Coding and Reporting to facilitate the assignment of thePresent on Admission (POA) indicator for each diagnosis and externalcause of injury code reported on claim forms (UB-04 and 837Institutional).These guidelines are not intended to replace any guidelines in the mainbody of the ICD-9-CM Official Guidelines for Coding and Reporting. ThePOA guidelines are not intended to provide guidance on when acondition should be coded, but rather, how to apply the POA indicatorto the final set of diagnosis codes that have been assigned in accordancewith Sections I, II, and III of the official coding guidelines. Subsequentto the assignment of the ICD-9-CM codes, the POA indicator shouldthen be assigned to those conditions that have been coded.As stated in the Introduction to the ICD-9-CM Official Guidelines forCoding and Reporting, a joint effort between the healthcare providerand the coder is essential to achieve complete and accuratedocumentation, code assignment, and reporting of diagnoses andprocedures. The importance of consistent, complete documentation inthe medical record cannot be overemphasized. Medical recorddocumentation from any provider involved in the care and treatment ofthe patient may be used to support the determination of whether acondition was present on admission or not. In the context of the officialcoding guidelines, the term “provider” means a physician or anyqualified healthcare practitioner who is legally accountable forestablishing the patient’s diagnosis.These guidelines are not a substitute for the provider’s clinical judgmentas to the determination of whether a condition was/was not present onadmission. The provider should be queried regarding issues related tothe linking of signs/symptoms, timing of test results, and the timing offindings.General Reporting RequirementsAll claims involving inpatient admissions to general acute carehospitals or other facilities that are subject to a law or regulationmandating collection of present on admission information.Present on admission is defined as present at the time the order forinpatient admission occurs. Conditions that develop during anoutpatient encounter, including emergency department,observation, or outpatient surgery, are considered as present onadmission.POA indicator is assigned to principal and secondary diagnoses (asdefined in Section II of the Official Guidelines for Coding andReporting) and the external cause of injury codes.Issues related to inconsistent, missing, conflicting or uncleardocumentation must still be resolved by the provider.If a condition would not be coded and reported based on UHDDSdefinitions and current official coding guidelines, then the POAindicator would not be reported.Reporting OptionsY - YesN - NoU - UnknownW – Clinically undeterminedUnreported/Not used (or “1” for Medicare usage) – (Exempt fromPOA reporting)Reporting DefinitionsY = present at the time of inpatient admissionN = not present at the time of inpatient admissionU = documentation is insufficient to determine if condition ispresent on admissionW = provider is unable to clinically determine whether conditionwas present on admission or notTimeframe for POA Identification and DocumentationThere is no required timeframe as to when a provider (per thedefinition of “provider” used in these guidelines) must identify ordocument a condition to be present on admission. In some clinicalsituations, it may not be possible for a provider to make a definitivediagnosis (or a condition may not be recognized or reported by thepatient) for a period of time after admission. In some cases it maybe several days before the provider arrives at a definitive diagnosis.This does not mean that the condition was not present onadmission. Determination of whether the condition was present onadmission or not will be based on the applicable POA guideline asidentified in this document, or on the provider’s best clinicaljudgment.If at the time of code assignment the documentation is unclear as towhether a condition was present on admission or not, it isappropriate to query the provider for clarification.Assigning the POA IndicatorCondition is on the “Exempt from Reporting” listLeave the “present on admission” field blank if the condition ison the list of ICD-9-CM codes for which this field is notapplicable. This is the only circumstance in which the field maybe left blank.POA explicitly documentedAssign Y for any condition the provider explicitly documents asbeing present on admission.Assign N for any condition the provider explicitly documents asnot present at the time of admission.Conditions diagnosed prior to inpatient admissionAssign “Y” for conditions that were diagnosed prior to admission(example: hypertension, diabetes mellitus, asthma)Conditions diagnosed during the admission but clearly presentbefore admissionAssign “Y” for conditions diagnosed during the admission thatwere clearly present but not diagnosed until after admissionoccurred.Diagnoses subsequently confirmed after admission areconsidered present on admission if at the time of admission theyare documented as suspected, possible, rule out, differentialdiagnosis, or constitute an underlying cause of a symptom thatis present at the time of admission.Condition develops during outpatient encounter prior toinpatient admissionAssign Y for any condition that develops during an outpatientencounter prior to a written order for inpatient admission.Documentation does not indicate whether condition waspresent on admissionAssign “U” when the medical record documentation is unclear asto whether the condition was present on admission. “U” should© 2009 Ingenix 35

Official ICD-9-CM Guidelines for Coding and Reportinghospital stay, patient experienced an adverse reaction to amedication administered after inpatient admission)Categories and Codes Exempt from DiagnosisPresent on Admission RequirementNote: “Diagnosis present on admission” for these code categories are exemptbecause they represent circumstances regarding the healthcare encounter orfactors influencing health status that do not represent a current disease orinjury or are always present on admission137-139 Late effects of infectious and parasitic diseases268.1 Rickets, late effect326 Late effects of intracranial abscess or pyogenic infection412 Old myocardial infarction438 Late effects of cerebrovascular disease650 Normal delivery660.7 Failed forceps or vacuum extractor, unspecified677 Late effect of complication of pregnancy, childbirth, andthe puerperium905-909 Late effects of injuries, poisonings, toxic effects, andother external causesV02 Carrier or suspected carrier of infectious diseasesV03 Need for prophylactic vaccination and inoculationagainst bacterial diseasesV04 Need for prophylactic vaccination and inoculationagainst certain viral diseasesV05 Need for other prophylactic vaccination and inoculationagainst single diseasesV06 Need for prophylactic vaccination and inoculationagainst combinations of diseasesV07 Need for isolation and other prophylactic measuresV10 Personal history of malignant neoplasmV11 Personal history of mental disorderV12 Personal history of certain other diseasesV13 Personal history of other diseasesV14 Personal history of allergy to medicinal agentsV15.01-V15.09 Other personal history, Allergy, other than to medicinalagentsV15.1 Other personal history, Surgery to heart and greatvesselsV15.2 Other personal history, Surgery to other major organsV15.3 Other personal history, IrradiationV15.4 Other personal history, Psychological traumaV15.5 Other personal history, InjuryV15.6 Other personal history, PoisoningV15.7 Other personal history, ContraceptionV15.80 Other personal history, History of failed moderatesedationV15.81 Other personal history, Noncompliance with medicaltreatmentV15.82 Other personal history, History of tobacco useV15.83 Other personal history, Underimmunization statusV15.84 Other personal history, Contact with and(suspected) exposure to asbestosV15.85 Other personal history, Contact with and(suspected) exposure to potentially hazardous bodyfluidsV15.86 Other personal history, Contact with and(suspected) exposure to leadV15.88 Other personal history, History of fallV15.89 Other personal history, OtherV15.9 Unspecified personal history presenting hazards tohealthV16 Family history of malignant neoplasmV17 Family history of certain chronic disabling diseasesV18 Family history of certain other specific conditionsV19 Family history of other conditionsV20 Health supervision of infant or childV21 Constitutional states in developmentV22 Normal pregnancyV23 Supervision of high-risk pregnancyV24 Postpartum care and examinationV25 Encounter for contraceptive managementV26 Procreative managementV27 Outcome of deliveryV28 Antenatal screeningV29 Observation and evaluation of newborns for suspectedcondition not foundV30-V39 Liveborn infants according to type of birthV42 Organ or tissue replaced by transplantV43 Organ or tissue replaced by other meansV44 Artificial opening statusV45 Other postprocedural statesV46 Other dependence on machinesV49.60-V49.77 Upper and lower limb amputation statusV49.81-V49.84 Other specified conditions influencing health statusV50 Elective surgery for purposes other than remedyinghealth statesV51 Aftercare involving the use of plastic surgeryV52 Fitting and adjustment of prosthetic device and implant© 2009 Ingenix 37

Official ICD-9-CM Guidelines for Coding and ReportingV53V54V55V56V57V58V59V60V61V62V64V65V66V67V68V69V70V71V72V73V74V75V76V77V78V79V80V81V82V83V84V85V86Fitting and adjustment of other deviceOther orthopedic aftercareAttention to artificial openingsEncounter for dialysis and dialysis catheter careCare involving use of rehabilitation proceduresEncounter for other and unspecified procedures andaftercareDonorsHousing, household, and economic circumstancesOther family circumstancesOther psychosocial circumstancesPersons encountering health services for specificprocedures, not carried outOther persons seeking consultationConvalescence and palliative careFollow-up examinationEncounters for administrative purposesProblems related to lifestyleGeneral medical examinationObservation and evaluation for suspected condition notfoundSpecial investigations and examinationsSpecial screening examination for viral and chlamydialdiseasesSpecial screening examination for bacterial andspirochetal diseasesSpecial screening examination for other infectiousdiseasesSpecial screening for malignant neoplasmsSpecial screening for endocrine, nutritional, metabolic,and immunity disordersSpecial screening for disorders of blood andblood-forming organsSpecial screening for mental disorders anddevelopmental handicapsSpecial screening for neurological, eye, and ear diseasesSpecial screening for cardiovascular, respiratory, andgenitourinary diseasesSpecial screening for other conditionsGenetic carrier statusGenetic susceptibility to diseaseBody Mass IndexEstrogen receptor statusV87.32 Contact with and (suspected) exposure to algaebloomV87.4 Personal history of drug therapyV88 Acquired absence of cervix and uterusV89 Suspected maternal and fetal conditions not foundE000 External cause statusE001-E030 ActivityE800-E807 Railway accidentsE810-E819 Motor vehicle traffic accidentsE820-E825 Motor vehicle nontraffic accidents E826-E829, Otherroad vehicle accidentsE830-E838 Water transport accidentsE840-E845 Air and space transport accidentsE846-E848 Vehicle accidents not elsewhere classifiableE849.0-E849.6 Place of occurrenceE849.8-E849.9 Place of occurrenceE883.1 Accidental fall into wellE883.2 Accidental fall into storm drain or manholeE884.0 Fall from playground equipmentE884.1 Fall from cliffE885.0 Fall from (nonmotorized) scooterE885.1 Fall from roller skatesE885.2 Fall from skateboardE885.3 Fall from skisE885.4 Fall from snowboardE886.0 Fall on same level from collision, pushing, or shoving,by or with other person, In sportsE890.0-E890.9 Conflagration in private dwellingE893.0 Accident caused by ignition of clothing, from controlledfire in private dwellingE893.2 Accident caused by ignition of clothing, from controlledfire not in building or structureE894 Ignition of highly inflammable materialE895 Accident caused by controlled fire in private dwellingE897 Accident caused by controlled fire not in building orstructureE898.0-E898.1 Accident caused by other specified fire and flamesE917.0 Striking against or struck accidentally by objects orpersons, in sports without subsequent fallE917.1 Striking against or struck accidentally by objects orpersons, caused by a crowd, by collective fear or panicwithout subsequent fallE917.2 Striking against or struck accidentally by objects orpersons, in running water without subsequent fallE917.5 Striking against or struck accidentally by objects orpersons, object in sports with subsequent fall38 © 2009 Ingenix

Official ICD-9-CM Guidelines for Coding and ReportingE917.6 Striking against or struck accidentally by objects orpersons, caused by a crowd, by collective fear or panicwith subsequent fallE919.0-E919.1 Accidents caused by machineryE919.3-E919.9 Accidents caused by machineryE921.0-E921.9 Accident caused by explosion of pressure vesselE922.0-E922.9 Accident caused by firearm and air gun missileE924.1 Caustic and corrosive substancesE926.2 Visible and ultraviolet light sourcesE928.0-E928.8 Other and unspecified environmental and accidentalcausesE929.0-E929.9 Late effects of accidental injuryE959 Late effects of self-inflicted injuryE970-E978 Legal interventionE979 TerrorismE981.0-E981.8 Poisoning by gases in domestic use, undeterminedwhether accidentally or purposely inflictedE982.0-E982.9 Poisoning by other gases, undetermined whetheraccidentally or purposely inflictedE985.0-E985.7 Injury by firearms, air guns and explosives,undetermined whether accidentally or purposelyinflictedE987.0 Falling from high place, undetermined whetheraccidentally or purposely inflicted, residential premisesE987.2 Falling from high place, undetermined whetheraccidentally or purposely inflicted, natural sitesE989 Late effects of injury, undetermined whether accidentallyor purposely inflictedE990-E999 Injury resulting from operations of warPOA ExamplesThe POA examples have been removed from the guidelines.© 2009 Ingenix 39