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CHAPTER 8

CHAPTER 8. AN OVERVIEW OF ICD-9-CM. 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 ICD-9-CM = 9th Revision; CM, Clinical Modification

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CHAPTER 8

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  1. CHAPTER 8 AN OVERVIEW OF ICD-9-CM

  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 • ICD-9-CM = 9th Revision; CM, Clinical Modification • Continuity of data (Cont’d…)

  3. Overview (…Cont’d) • 1977: US develops ICD-9-CM version • More code subsets define medical care • 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 1with 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 Medicare • Medicare Catastrophic Act of 1988 • Required use of ICD-9-CM codes for diagnosis • Act later repealed, but codes still used • Effective 2003, all claims must have valid diagnosis • Excludes ambulance suppliers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 facility use 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 (…Cont’d)

  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

  14. The Job of a Biller/Coder • Translate documentation into ICD-9-CM codes • Legionnaires’ disease = 482.84 • Assign code to highest level specificity • Medical record must substantiate diagnosis code assignment

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

  16. 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

  17. Volume 1, Tabular List • Two major divisions • Classification of Diseases and Injuries (codes 001.0-999.9) • Supplementary Classification (V codes and E codes)

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

  19. Divisions of Classification of Diseases and Injuries • Chapters: 1 through 17 • Section: A group of related conditions

  20. Volume 1, Diseases, Tabular List (...Cont’d) Divided into: • Chapter • Section • Category • Subcategory • Subclassification

  21. Volume 1, Diseases, Format Figure: 8.5 Modified from Buck CJ: 2012 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2012, Saunders.

  22. Category Code • Category: Represent single disease/condition (3 digits) Figure: 8.6 Modified from Buck CJ: 2012 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2012, Saunders.

  23. Subcategory Code • Subcategory: More specific (4th digit) Figure: 8.7 Modified from Buck CJ: 2012 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2012, Saunders.

  24. Subclassification Code • Subclassification: More specific (5th digit) Referenced from Buck CJ: 2012 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2012, Saunders.

  25. Specificity in ICD-9-CM Codes • Each digit adds to the specificity (detail) Figure: 8.9

  26. Remember • Assign to the highest level possible, based on documentation • If 4-digit code exists, do not report 3-digit code • If 5-digit code exists, do not report 4-digit code

  27. Appendices in Volume 1 • There are five appendices in official ICD-9-CM • Private publishers may have more

  28. Morphology Appendix A, _________of Neoplasms • Used in conjunction with codes from Chapter 2, Neoplasm • Inpatient setting: Cancer registries and claim forms • M codes not placed on a billing claim form (Cont’d…)

  29. Appendix A, Morphology of Neoplasms (…Cont’d) • Begins with M followed by 5 digits • M8400/0, Sweat gland adenoma • First four digits: Histologic type of neoplasm • Fifth digit: Behavior (e.g., 0 = benign)

  30. Appendix B, Glossary of Mental Disorders • Deleted in 2004 • Most psychiatric disorders are classified using: • The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

  31. Appendix C, Drugs American Hospital Formulary Service (AHFS) publishes list of all drugs Tracks drugs nationally; used by pharmacists Each drug coded with up to six-digit code (e.g., 84:04.04) (Cont’d…)

  32. Appendix C, Drugs (…Cont’d) AHFS listing correlated to ICD-9-CM Table of Drugs and Chemicals New drugs not identified by name Rather listed under heading “Drug” in Table of Drugs and Chemicals Example: 84:04.04 antibiotics

  33. Appendix D, Industrial Accidents Three-digit codes that identify occupational hazards Not placed on insurance or billing form Used by state and federal organizations (OSHA) Occupational Safety and Health Administration to summarize industrial accident data

  34. Appendix E, Three-Digit Categories Presented by chapter Categories are labeled 1 through 17, followed by V and E code categories Provides quick overview of ICD-9-CM contents

  35. V Codes (V01.0-V91.9) • 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., V58.11, encounter for chemotherapy) (Cont’d…)

  36. V Codes (V01.0-V91.9) (…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

  37. Volume 2, Sections Section 1, Index to Diseases Section 2, Table of Drugs and Chemicals Section 3, Index to External Causes of Injuries and Poisonings (E Codes) Never primary diagnosis Medicare does not accept for professional billing

  38. 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)

  39. Volume 2, Terms Main terms (bold typeface) Subterms Indented two spaces to right Not bold Example Pain (Main term in bold) orbital region 379.91 (subterm indented)

  40. Volume 2, Alphabetic Index Nonessential modifiers enclosed in parentheses (does not have to be in diagnostic statement) Have no effect on code selection Clarify diagnosis Example: Ileus (adynamic)(bowel)….

  41. Section 1, Index to Diseases Largest part of Volume 2—Index First step in coding, locate main bold term in the Index Subterms indented 2 spaces to the right May have more than one subterm 3 digits = category codes 4 digits = subcategory codes 5 digits = subclassification codes

  42. A Word of Caution About the Alphabetic Index (Section I, Vol. 2) Some words in Index do not appear in Tabular—saves space Exact word may not be in code Tabular description But found in Alphabetic Index That is why you must locate term in Index and then locate Tabular (follow where Index directs)

  43. ICD-9-CM Conventions • Punctuation: [ ] ( ) : } italicized and bold type [ ] • Symbols: §  • Abbreviations: NEC, NOS • Notations: Includes, Excludes, Use Additional Code, And/With, Code if Applicable

  44. Abbreviations • NEC: Not elsewhere classifiable • No more specific code exists • NOS: Not otherwise specified • Unspecified in documentation

  45. [ ] Brackets • Enclose synonyms, alternative wording, or explanatory phrases • Used to identify manifestation codes • Helpful, additional information • Can affect code • Found only in Tabular List (001.0-999.9)

  46. Slanted Brackets [ ] • Enclose manifestations of underlying condition • “Code first underlying disease” • Used in the Alphabetic Index-Volume 2

  47. Etiology and Manifestation of Disease Etiology = cause of disease Manifestation = symptom Etiology + Manifestation = Combination codes

  48. Combination Code Modified from Buck CJ: 2012 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2012, Saunders.

  49. Multiple Coding No combination code, use individual code(s) in this order 250.4x 581.81 Modified from Buck CJ: 2012 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2012, Saunders.

  50. ( ) Parentheses • Contain non-essential modifiers • Take them or leave them • Informational descriptive terms • Found in Tabular List and Index • Does not affect code selection

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