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Chapter 2

Chapter 2. Overview of ICD-9-CM Part 1. An Overview of the ICD-9-CM. Classification System Morbidity (illness) Mortality (death) ICD = International Classification of Diseases WHO’s ICD-9 used globally World Health Organization. Overview. (…Cont’d) 1977: US develops ICD-9-CM version

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Chapter 2

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  1. Chapter 2 Overview of ICD-9-CM Part 1

  2. An Overview of the ICD-9-CM • Classification System • Morbidity (illness) • Mortality (death) • ICD = International Classification of Diseases • WHO’s ICD-9 used globally • World Health Organization

  3. Overview (…Cont’d) • 1977: US develops ICD-9-CM version • ICD-9-CM data comparable to global data in ICD-9 • Updated October 1 of each year • Must use new codes as of October 1 • Also updates April 1 with no grace period

  4. Medicare • Medicare Catastrophic Act of 1988 • Required use of ICD-9-CM codes for diagnosis • Act later repealed, but codes still used • Effective 2003, all claims must have valid diagnosis • Excludes ambulance suppliers

  5. Uses of ICD-9-CM • Facilities track facilityuse through codes • Fiscal entities track health care costs (Cont’d…)

  6. Uses of ICD-9-CM (…Cont’d) • Research • Health care quality • Future needs • Newer cancer center built if patient use warrants

  7. Uses of ICD-9-CM • Use and results evident every day • Newscaster reference to number of AIDS cases • Newspaper article about measles epidemic

  8. ICD-9-CM Principles/Practices Four groups function together to maintain ICD-9-CM • Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA) (Cont’d...)

  9. ICD-9-CM Principles/Practices (...Cont’d) • National Center for Health Statistics (NCHS) • American Health Information Management Association (AHIMA) • American Hospital Association (AHA)

  10. ICD-9-CM Documents Medical Necessity • Diagnoses establish medical necessity • Services and diagnoses must correlate • Correct diagnosis codes allow: • Accurate reimbursement • Fewer rejected claims • Reduced risk of sanctions/fines from audit

  11. CMS-1500 (08/05) in Blocks 21 and 24E (Outpatient) Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.

  12. UB04 in Blocks 66-74 (Inpatient) Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.

  13. Ethics • Documentation must support diagnosis • Example: • Services provided • Diagnosis justifies services • If in doubt, check it out; don’t make assumptions • Ask physician if information is missing or unclear

  14. Ethical Dilemna? • Patient phone calls requesting code change • Reasons • Service covered if preventive • Service applied to deductible • Pre-existing diagnosis not covered • DO NOT CHANGE CODE unless coded wrong originally • Called Coding for Coverage

  15. (con’t) • Unbundling • Billing for multiple individual codes instead of one combination code • In CPT procedural coding • Fraudulent Billing

  16. Out patient Services • Code only confirmed or diagnosed conditions • Symptoms • Do Not Code: • Probable • Rule out • Possible • Suspected

  17. Your Job (Coding) • Translate documentation into ICD-9-CM codes • Legionnaires’ disease = 482.84 • Assign code to highest level specificity • Medical record must substantiate diagnosis code assignment

  18. Format of the ICD-9-CM • Volume 1, Diseases, Tabular List (diagnosis) (17 chapters) • Volume 2, Diseases, Alphabetic Index (diagnosis) (3 sections) • Volume 3, Procedures, Tabular List and Alphabetic Index (inpatient)

  19. Volume 1, Diseases, Tabular List • Contains code numbers • 001.0-999.9 Diagnosis codes describe condition • V and E codes = supplemental information (Cont’d...)

  20. Volume 2, Diseases, Alphabetic Index • Appears first in book (may vary with publishers) • Terms and code numbers verified inVolume 1 • Never code directly from Index! • Read all notes and follow instructions (e.g., see also) • Tables (e.g., Drugs/Chemicals, Hypertension, Neoplasm)

  21. Volume 3, Procedures, Tabular List and Alphabetic Index • Not used for physician services • Index and Tabular List used for procedures and therapies • Inpatient settings only by hospital coders • Procedures and therapies • Maximum 4 digits • 20.41 Simple mastoidectomy

  22. V Codes (V01.0-V89.09) • Patient not ill but encounters health services • e.g., Vaccination • Patient presents for treatment • e.g., Chemotherapy • Some V codes are primary only (e.g., V22.0, supervision of normal first pregnancy) (Cont’d…)

  23. V Codes (V01.0-V89.09) (…Cont’d) • Factors that influence patient’s health status • e.g., Personal history of [PHO] malignant tumor, organ transplant • Birth status and outcome of delivery

  24. Classification of Diseases and Injuries • Main portion of ICD-9-CM • Codes from 001.0-999.9 • Most chapters are organ systems • Digestive System • Respiratory System

  25. Volume 1, Diseases, Format Figure: 2.5 Modified from Buck CJ: 2010 ICD-9-CM, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2010, Saunders.

  26. Category Code • Category: Represent single disease/condition (3 digits) Figure: 2.6 Modified from Buck CJ: 2010 ICD-9-CM, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2010, Saunders.

  27. Subcategory Code • Subcategory: More specific (4th digit) Figure: 2.7 Modified from Buck CJ: 2010 ICD-9-CM, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2010, Saunders.

  28. Subclassification Code • Subclassification: More specific (5th digit) Referenced from Buck CJ: 2010 ICD-9-CM, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2010, Saunders.

  29. Specificity in ICD-9-CM Codes • Each digit adds to the specificity (detail) Figure: 2.9

  30. Remember • Assign to the highest level possible, based on documentation • If 4-digit code exists, do not report 3-digit code • If5-digit code exists, do not report 4-digit code

  31. Chapter 2 Conclusion – Overview ICD-9-CM Part 1

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