ICD-9-CM Format and Conventions



ICD-9-CM Format and Conventions



Learning Objectives



1. Identify the format of the ICD-9-CM and ICD-10-CM code book


2. Explain and apply the conventions and guidelines


3. Identify the appendices



Abbreviations/Acronyms














ICD-9-CM Official Guidelines for Coding and Reporting


Please refer to the companion Evolve website for the most current guidelines.




Section I. Conventions, general coding guidelines, and chapter-specific guidelines


    The conventions, general guidelines, and chapter-specific guidelines are applicable to all healthcare settings unless otherwise indicated.



A Conventions for the ICD-9-CM


    The conventions for the ICD-9-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the index and tabular of the ICD-9-CM as instructional notes. These conventions are as follows:



1. Format


    The ICD-9-CM uses an indented format for ease in reference


2. Abbreviations



3. Punctuation



4. Includes and Excludes Notes and Inclusion terms



Includes: This note appears immediately under a three-digit code title to further define, or give an example of, the content of the category.


Excludes: An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. In some cases the codes for the excluded terms should not be used in conjunction with the code from which it is excluded. An example of this is a congenital condition excluded from an acquired form of the same condition. The congenital and acquired codes should not be used together. In other cases, the excluded terms may be used together with an excluded code. An example of this is when fractures of different bones are coded to different codes. Both codes may be used together if both types of fractures are present.


Inclusion terms: List of terms is included under certain four and five digit codes. These terms are the conditions for which that code number is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the index may also be assigned a code.


5. Other and Unspecified codes



6. Etiology/manifestation convention (“code first,” “use additional code,” and “in diseases classified elsewhere” notes)


    Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of 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 a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as first listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition.


    There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For such codes, a “use additional code” note will still be present and the rules for sequencing apply.


    In addition to the notes in the Tabular, these conditions also have a specific Index entry structure. In the Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.


    The most commonly used etiology/manifestation combinations are the codes for Diabetes mellitus, category 250. For each code under category 250 there is a use additional code note for the manifestation that is specific for that particular diabetic manifestation. Should a patient have more than one manifestation of diabetes, more than one code from category 250 may be used with as many manifestation codes as are needed to fully describe the patient’s complete diabetic condition. The category 250 diabetes codes should be sequenced first, followed by the manifestation codes.


    “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination.


    See—Section I.B.9. “Multiple coding for 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” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or note in an instructional the Tabular List. The word “with” in the alphabetic index is sequenced immediately following the main term, not in alphabetical order.


9. “See” and “See Also”


    The “see” instruction following a main term in the Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “see” note to locate the correct code.


    A “see also” instruction following a main term in the index instructs that there is another main term that may also be referenced that may provide additional index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.



ICD-10-CM Official Guidelines for Coding and Reporting


Please refer to the companion Evolve website for the most current guidelines.


2012


Narrative changes appear in bold text


Items underlined have been moved within the guidelines since the 2011 version


Italics are used to indicate revisions to heading changes


The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). These guidelines should be used as a companion document to the official version of the ICD-10-CM as published on the NCHS website. The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reason for visits in all health care settings. The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the World Health Organization (WHO).


These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.


These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the health care provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.


The term encounter is used for all settings, including hospital admissions. In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.


The guidelines are organized into sections. Section I includes the structure and conventions of the classification and general guidelines that apply to the entire classification, and chapter-specific guidelines that correspond to the chapters as they are arranged in the classification. Section II includes guidelines for selection of principal diagnosis for non-outpatient settings. Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. Section IV is for outpatient coding and reporting. It is necessary to review all sections of the guidelines to fully understand all of the rules and instructions needed to code properly.




Section I. Conventions, general coding guidelines and chapter-specific guidelines


    The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated. The conventions and instructions of the classification take precedence over guidelines.



A Conventions for the ICD-10-CM


    The conventions for the ICD-10-CM are the general rules for use of the classification independent of the guidelines. These conventions are incorporated within the Alphabetic Index and Tabular List of the ICD-10-CM as instructional notes.



1. The Alphabetic Index and Tabular List


    The ICD-10-CM is divided into the Alphabetic Index, an alphabetical list of terms and their corresponding code, and the Tabular List, a chronological list of codes divided into chapters based on body system or condition (Figures 3-1 and 3-2). The Alphabetic Index consists of the following parts: the Index of Diseases and Injury, the Table of Neoplasms and the Table of Drugs and Chemicals.


image
Figure 3-1 Alphabetic Index entry for Paget’s disease, female breast.

image
Figure 3-2 Tabular List entry for Paget’s disease, female breast.

    See Section I.C2. General guidelines


    See Section I.C.19. Adverse effects, poisoning, underdosing and toxic effects


2. Format and Structure:


    The ICD-10-CM Tabular List contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A three-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3, 4, 5, 6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th characters are still referred to as codes, not subcategories. A code that has an applicable 7th character is considered invalid without the 7th character.


    The ICD-10-CM uses an indented format for ease in reference


3. Use of codes for reporting purposes


    For reporting purposes only codes are permissible, not categories or subcategories, and any applicable 7th character is required.


    In the Alphabetic Index of ICD-10-CM a dash (-) is used to indicate that there are further digits that need to be assigned for a valid code. In Figures 3-1 and 3-2, note that C50.91 would be an invalid code. A sixth digit is necessary to identify left, right, or unspecified breast. All codes must be assigned to the final level of subdivision. A valid code is at least three characters, but could be four, five, six, or seven characters.


4. Placeholder character


    The ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and underdosing codes, categories T36-T50. Where a placeholder exists, the X must be used in order for the code to be considered a valid code (Figure 3-3).


image
Figure 3-3 Placeholder in ICD-10-CM.

5. 7th Characters


    Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters (see Figure 3-3).


6. Abbreviations



a. Alphabetic Index abbreviations


    NEC “Not elsewhere classifiable”


    This abbreviation in the Alphabetic Index represents “other specified”. When a specific code is not available for a condition, the Alphabetic Index directs the coder to the “other specified” code in the Tabular List.


    NOS “Not otherwise specified”


    This abbreviation is the equivalent of unspecified.


b. Tabular List abbreviations


    NEC “Not elsewhere classifiable”


    This abbreviation in the Tabular List represents “other specified”. When a specific code is not available for a condition the Tabular List includes an NEC entry under a code to identify the code as the “other specified” code.


    NOS “Not otherwise specified”


    This abbreviation is the equivalent of unspecified.


7. Punctuation



8. Use of “and”


    When the term “and” is used in a narrative statement it represents and/or.


9. Other and Unspecified codes



10. Includes Notes


    This note appears immediately under a three character code title to further define, or give examples of, the content of the category.


11. Inclusion terms


    List of terms is included under some codes. These terms are the conditions for which that code is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.


12. Excludes Notes


    The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other.



a. Excludes1


    A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition (Figures 3-4 and 3-5).


image
Figure 3-4 Example of Excludes1 note.

image
Figure 3-5 Example of Excludes1 and Excludes2 notes.

b. Excludes2


    A type 2 excludes note represents “Not included here”. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate (see Figure 3-5).


13. Etiology/manifestation convention (“code first”, “use additional code” and “in diseases classified elsewhere” notes)


    Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of 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 a component of the etiology/manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as first-listed or principal diagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. See category F02, Dementia in other diseases classified elsewhere, for an example of this convention.


    There are manifestation codes that do not have “in diseases classified elsewhere” in the title. For such codes a “use additional code” note will still be present and the rules for sequencing apply.


    In addition to the notes in the Tabular List, these conditions also have a specific Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second.


    An example of the etiology/manifestation convention is dementia in Parkinson’s disease. In the Alphabetic Index, code G20 is listed first, followed by code F02.80 or F02.81 in brackets. Code G20 represents the underlying etiology, Parkinson’s disease, and must be sequenced first, whereas codes F02.80 and F02.81 represent the manifestation of dementia in diseases classified elsewhere, with or without behavioral disturbance.


    “Code first” and “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/manifestation combination.


    See Section I.B.7. Multiple coding for a single condition.


14. “And”


    The word “and” should be interpreted to mean either “and” or “or” when it appears in a title.


15. “With”


    The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List.


    The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.


16. “See” and “See Also”


    The “see” instruction following a main term in the Alphabetic Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “see” note to locate the correct code.


    A “see also” instruction following a main term in the Alphabetic Index instructs that there is another main term that may also be referenced that may provide additional Alphabetic Index entries that may be useful. It is not necessary to follow the “see also” note when the original main term provides the necessary code.


17. “Code also note”


    A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.


18. Default codes


    A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned (Figure 3-6).


image
Figure 3-6 Alphabetic Index default code for respiratory failure.


Format of ICD-9-CM and ICD-10-CM Code Books


The ICD-9-CM code book contains three volumes:



Volume 2 (Alphabetic Index) is usually found at the front of the code book and is followed by Volume 1 (Tabular List) and then Volume 3 (Index and Tabular for Procedures).


Several publishers have a variety of ICD-9-CM code books available. Code books are available for use in physician offices that include only Volumes 1 and 2 because ICD-9-CM procedure codes (Volume 3) are not used by physicians. (Physicians use CPT codes to bill for services and procedures.) Expert versions may contain reimbursement edits, color-coded information, Medicare code edits, and age and sex edits. Some books are updated with replacement pages quarterly and may include references to Coding Clinic articles. At the beginning of a code book, information is usually provided that explains the conventions used in that version.


The ICD-10-CM codebook is also divided into two parts: an Alphabetic Index and a Tabular List. The Alphabetic Index lists terms and corresponding codes in alphabetic order. The main index is the Index to Diseases and Injuries, and there is an additional index to External Causes of Injury. There are two tables located in the main index: the Neoplasm table and the Table of Drugs and Chemicals. The Tabular List is an alphanumeric listing of codes that are divided into chapters based on body system or conditions.


There is an additional book for procedures, which is entitled ICD-10-PCS.



Format of Tabular List of Diseases and Injuries


In ICD-9-CM, Volume 1, the Tabular List of Diseases and Injuries (Table 3-1) consists of 17 chapters. Most of these chapters are classified by body system or etiology (cause of disease).



TABLE 3-1


ICD-9-CM TABLE OF CONTENTS FOR TABULAR LIST








Diseases: Tabular List, Volume 1


1. Infectious and Parasitic Diseases (001-139)


2. Neoplasms (140-239)


3. Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders (240-279)


4. Diseases of the Blood and Blood-Forming Organs (280-289)


5. Mental Disorders (290-319)


6. Diseases of the Nervous System and Sense Organs (320-389)


7. Diseases of the Circulatory System (390-459)


8. Diseases of the Respiratory System (460-519)


9. Diseases of the Digestive System (520-579)


10. Diseases of the Genitourinary System (580-629)


11. Complications of Pregnancy, Childbirth, and the Puerperium (630-679)


12. Diseases of the Skin and Subcutaneous Tissue (680-709)


13. Diseases of the Musculoskeletal System and Connective Tissue (710-739)


14. Congenital Anomalies (740-759)


15. Certain Conditions Originating in the Perinatal Period (760-779)


16. Symptoms, Signs, and Ill-Defined Conditions (780-799)


17. Injury and Poisoning (800-999)

Related posts:

  1. Diseases of the Skin and Subcutaneous Tissue: (ICD-9-CM Chapter 12, Codes 680-709, and ICD-10-CM Chapter 12, Codes L00-L99)
  2. Diseases of the Respiratory System: (ICD-9-CM Chapter 8, Codes 460-519, and ICD-10-CM Chapter 10, Codes J00-J99)
  3. Injuries and E Codes: (ICD-9-CM Chapter 17, Codes 800-995, and External Causes, E800-E999, and ICD-10-CM Chapters 19 and 20, Codes S00-Y99)
  4. Introduction to ICD-10-PCS

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on ICD-9-CM Format and Conventions

Full access? Get Clinical Tree

 Get Clinical Tree app for offline access