NYU School of MedicineCoding and Reimbursement Seminar Series

ICD-9 Coding for Physician Practices

Gretchen L. Segado, MS, CPCDirector of Reimbursement ComplianceNYU School of Medicine316 East 30th StreetNew York, NY 10016(212) 263-2446(212) 263-6445 faxGretchen.Segado@med.nyu.edu

Presented by the Office of Reimbursement Compliance

History of ICD-9 CM

Originally developed by the World Health Organization (WHO) to record morbidity and mortality information for statistical purposes

Has been revised and updated to suit a greater variety of needs and to capture additional information.

International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) was issued in 1978

History of ICD-9 CM

In 1988, Medicare Catastrophic Coverage Act required physicians to report medical diagnosis codes on each Medicare payment request.

April 1, 1989, HCFA (now CMS) required diagnosis codes to be reported using ICD-9 CM

Purpose of ICD-9 CM

Classifying morbidity data for reporting; Compiling and comparing health care data; Evaluating the appropriateness and timeliness of

medical care provided, which can be used in determining "medical necessity";

Analyzing payments for health care; and, Conducting epidemiological and clinical research.

Who must use ICD-9 CM?

All physicians and non-physician practitioners are required to use ICD-9 CM diagnosis codes with the exception of– Ambulance providers– Durable medical equipment suppliers– Nonphysician directed

Independently practicing PTs, OTs Independently practicing psychologists Audiologists

Other Coding Systems

Morphology of neoplasms “M Codes” are in ICD-O (International Classification of Disease-Oncology)– not acceptable for Medicare

DSM-IV-R for psychiatric illnesses– Cannot be used for Medicare purposes

Diagnosis coding transforms verbal descriptions into numbers.

In order to utilize the ICD-9-CM to its fullest level, the coder must:

Understand medical terminology

Have a working knowledge of how to use a medical

dictionary; and

Know how the ICD-9-CM text is organized

Three Volumes to ICD-9 CM

Volume 1-DiseasesTabular List

Volume 2-Diseases Alphabetical List Volume 3-Procedures Used for Hospital Inpatient coding

Physicians only use Volumes 1 & 2 Diagnosis codes must be valid for the date of service

reported

Volume 2: The Alphabetical List

Provides detailed instructions which assist the coder in determining if a diagnosis may require the use of additional or alternate codes.

is found in the front half of the ICD-9-CM. It is best to consult the Alphabetic List FIRST

before deciding whether a three-, four- or five-digit code best represents the patient's disease, sign or symptom.

Volume 2: The Alphabetical List

Organized by "main terms" which are printed in bold-faced type for ease of reference. – Diseases–Influenza or Bronchitis– Conditions–Fatigue, Fracture or Injury– Nouns–Disturbance or Syndrome– Adjective–Double, Large or Kink

Volume 2: The Alphabetical List

Anatomical sites are not used for Main terms.

Example: Bronchial asthma will be found under the disease term asthma rather than the anatomical site bronchial. It is located in the Alphabetical Index to Diseases where, in bold-faced type, the entry "Asthma, Asthmatic" appears.

Volume 2: The Alphabetical ListMany conditions can be found in more than one place

Examples: Obstetrical conditions may be found under the name of the condition and under the entries for Delivery, Pregnancy and Puerperal (after delivery.)

Complications of medical and surgical care are indexed under the Name of condition and under Complications.

Eponyms (diseases named for persons) often located alphabetically by the person's name and by the

common name. – For example Vincent's disease (trench mouth) can be found

under Vincent's, Disease and Trench.

Volume 1: The Tabular List

Contains the Classification of Diseases and Injuries.

Contains the three-, four-, and five- digit codes that are used on the claims form to indicate the patient's disease, signs or symptoms.

The Tabular list is arranged in 17 chapters.

Volume 1: The Tabular List

Arranged in numerical sequence. Chapter headings are always in BOLD CAPS.

– Three-digit code numbers always refer to sections. – Four-digit code numbers refer to categories– Five-digit code numbers denote sub-categories.

Note: 5th digits can appear:At the beginning of a chapterAt the beginning of a sectionAt the beginning of a 3-digit

categoryWithin a 4th-digit sub-category

Coding Conventions

Always use the most recent version of the ICD-9-CM, and other coding manuals such as CPT and the HCPCS for the current year.

If you use an old codebook with outdated codes, your payment may be denied, delayed or underpaid.

Coding Conventions

Notes: further define terms, clarify information or list choices of additional diagnosis

Format: Subterms are indented to the right of the term to which they are linked

Excludes: Terms following the excludes instruction are to be coded elsewhere

Coding Conventions

Abbreviations– NEC Not elsewhere classifiable. The category

number for the term including NEC is to be used only when the coder lacks the information necessary to code the term to a more specific category.

– NOS Not otherwise specified. This abbreviation is the equivalent of “unspecified.”

Coding Conventions

Punctuation– [ ] Brackets are used to enclose synonyms, alternative

wordings, or explanatory phrases.– ( ) Parentheses are used to enclose supplementary

words which may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned.

– : Colons are used in the Tabular List after an incomplete term which needs one or more of the modifiers which follow in order to make it assignable to a given category.

Coding Conventions

Format: ICD-9-CM uses an indented format for ease in reference.

Sequencing:Code, if applicable, any causal condition first (A code with this note may be principal if no causal condition is applicable or known)

Instructional Notations

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

– Excludes: Terms following the word “excludes” are to be coded elsewhere. The term excludes means “DO NOT CODE HERE”.

– Use additional code: This instruction is placed in the Tabular List in those categories where the user will need to add further information (by using an additional code) to give a more complete picture of the diagnosis or procedure.

– Code first underlying disease: This instructional note is used for those codes not intended to be used as a principal diagnosis, or not to be sequenced before the underlying disease. The note requires that the underlying disease (etiology) be recorded first and the particular manifestation recorded secondarily. This note appears only in the Tabular List.

The Golden Rule

Always code the primary reason that the patient is interacting with the medical professional

Correct Steps for Choosing a Diagnosis Code

1. Review the medical record to extract the pertinent written description of the disease or symptoms

2. Look up the disease, signs and symptoms or condition in Volume 2, Alphabetic Index and locate the corresponding code

3. Look up corresponding code in Volume 1 and choose most specific code that accurately describes the patient’s condition

Start with the Alphabetic List

Code the disease, sign, or symptom.     There are only 2 circumstances when it

would be appropriate to code directly from the Alphabetic list. – Table of Hypertension – Table of Neoplasms

After Selecting The Appropriate Codes From The Alphabetic List, Go To The Tabular List

Make sure that all appropriate fourth or fifth digits are captured in the code.

This is referred to as "coding to the highest degree of specificity."

If you fail to code to the highest specificity, claims will usually be rejected.

Verify each payer's billing requirements to avoid denied claims.

Coding to the Highest Degree of Specificity means:

   1) Code up to the 5th digit whenever possible, 2) Only use a 4-digit code when no 5-digit code exists and, 3) Only use a 3-digit code when no 4- or 5-digit code exists.

Most ICD-9-CM books have some sort of indicator, for example: a red dot or a "5," that are placed next to codes which are not considered highest degree of specificity.

Often patients cannot be specific about their symptoms or, the physicians are not specific in their documentation. In this situation, do not automatically use a 4-digit code. There may be a 5 digit code where, one of the digits corresponds to the meaning of "unspecified," "without complication," or some other catch-all phrase.

While it may seem that the addition of the fifth digit does not significantly enhance the meaning of the code, the use of a 4-digit code would be considered incorrect where an appropriate five-digit code exists.

Always check the information following a main term, or indented beneath a main term. This may enhance or change the meaning of the main term and therefore play a vital role in determining the final code selected.

Examples

Chronic obstructive pulmonary disease is assigned code 496, chronic airway obstruction, not elsewhere classified.

There is no 4th or 5th digits for 496

Examples

Essential hypertension, 401, has fourth digits that describe the type of hypertension.

It would be incorrect to report code category 401 without a fourth digit

For this code category, there is a 4th digit provided to use when no information about the type of hypertension is available– 401.9 unspecified site

Examples

Gastric Ulcer, 531 has fourth digits assigned to provide information such as whether there is hemorrhage or perforation

A 5th digit is available to describe whether or not there is an obstruction.

It would be incorrect to leave off the fifth digit

DO NOT!!!!!!

Do not code diagnoses documented as “probable”, “suspected”, “questionable” or “rule out’ as if they are established.

Code the condition(s) to the highest degree of specificity known at the time of the encounter – symptoms, signs, abnormal test results or other

reasons for the visit

Diagnosis Coding for Surgical Services

Code the diagnosis for which the surgery was performed

However, when the claim is filed, if the postoperative diagnosis is known to be different from the preoperative diagnosis, select the postoperative diagnosis for coding

Code all exisiting documented conditions that coexist at the time of the encounter and that require or affect patient care

Do not code conditions previously treated and no longer exisiting

Do not code conditions which the patient has unless they are the reason for the service

Coding pre-existing conditions that are no longer being treated may affect medical necessity determinations

The Tabular List Also Contains Two Supplementary Classifications

Supplementary Classification of Factors influencing Health Status and Contact with Health Services, commonly referred to as the "V-codes."

External Causes of Injuries and Poisoning. – These are very rarely used in physician billing as

most payer systems, including Medicare, do not accept them for non-hospital claims. “E-codes”

Supplementary Classification:V-Codes

V01-V82.9 Factors influencing Health Status & Contact with the Health Service

(Circumstances other than a disease of injury classified to categories)

"V-codes" are generally used in three instances:– When a physician identifies a circumstance or problem in a

person who is not currently sick but has, nonetheless, come in contact with health services (to receive a prophylactic vaccination or routine health check, for example).

– When an ill or injured patient requires specific treatment (such as chemotherapy for malignancy or removal of pins or rods).

– When a problem or circumstance that influences the patient's health is not itself a current illness but may affect future medical treatment."

Reporting V-Codes

Usually, V codes should only be reported as supplementary codes and should not be reported as the primary reason for the encounter

Diagnostic tests can be reported with a routine diagnosis code (V70.0-70.9 and V72/0-V72.9) HOWEVER

– When the only diagnosis code listed is one of the codes listed above, the service will be denied as a routine service

V-Codes will be used frequently by radiologists and pathologists

Examples

A specimen is referred to a pathologist A time claim is submitted, if there is an established

dx (eg malignant neoplasm 195.3) this dx code should be reported first to describe the reason for the service

Dx Code V72.6 laboratory examination should be reported as a secondary code

If the diagnosis had not been established, the pathologist should report at least one of the signs or symptoms

A Physician refers a patient to a radiologist…..

For a chest x-ray with the reason for the exam identified a cough and fever, rule-out pneumonia. The x-ray is normal.

The radiologist reports diagnosis code 786.2 (cough) and/or 786.6(fever) as the reason for the service. Dx code V72.5 (radiological exam not elsewhere classified) can be reported as a secondary code

A Physician refers a patient to a radiologist…..

For a chest x-ray with the reason for the exam identified as cough and fever, rule out pneumonia. The x-ray demonstrates bronchopneumonia.

The dx code 485 (bronchopneumonia) should be reported as the reason for the service

V72.5 can be reported as a secondary code

A Physician refers a patient to a radiologist…..

For a chest x-ray with the reason for the exam identified only as rule out pneumonia. The x-ray is normal

The radiologist should use a code for undiagnosed disease (eg 799.9, other unknown and unspecified cause) to indicate the patient has some condition, but it is not clearly defined.

Diagnosis V72.5 can be reported as a secondary code

Supplementary Classification: E-codes"—E800-E999

External causes of Injury and Poisoning (environmental events, circumstances and conditions)

"E-codes" are not normally used on Part B claims. However, check with your carrier to determine which, if any E codes they will allow. – Frequently used for accident and worker’s

compensation claims

USING THE TABLE OF NEOPLASMS

A neoplasm is defined as an abnormal growth of tissue.

– A growth may be a lesion, tumor, cyst or mass. A neoplasm is not always a malignancy.

Growths behave in different ways. Behavior refers to the capacity of the neoplasm to invade surrounding tissue.

– It may remain benign (non-cancerous) or become cancerous but remain in one designated area (malignant, cancer in situ).

Categories Of A Neoplasm Depending On Its Behavior

Malignant Primary:Identifies site of original cancerous neoplasm

Malignant Secondary:Identifies secondary cancerous neoplasm appearing at a body site other than the original site. Malignant, secondary should be used for all secondary cancers, even when the primary malignancy appears to have been arrested.

Malignant Cancer in situ:Identifies cancerous neoplasms that are confined, or "noninvasive" in nature.

Categories Of A Neoplasm Depending On Its Behavior

Benign:Identifies neoplasm that is non-cancerous. Benign neoplasms do not invade normal tissue and remain localized at the primary site.

Uncertain Behavior:This means the tumor cells do not look normal but there are not enough changes to designate malignancy. It is borderline, indicating that the pathologist cannot determine whether this growth is benign or malignant or that this behavior is unpredictable.

Unspecified:So many changes have occurred that it is impossible to tell the origin of the tumor. The nature of the neoplasm is undetermined with no way to tell where the cancer began.

Neoplasm Table—An example

PRIMARY SECONDARY CANCERin Situ

BENIGN UncertainBehavior

174.9 198.81 233.0 217 238.3

Neoplasms are categorized as follows:

140-195.8 Malignant neoplasms of specific sites, stated or presumed to be primary except lymphatic and hematopoietic tissue.  

196-198.89 Malignant neoplasms of specified sites, stated or presumed to be secondary.  

199-199.1 Malignant neoplasms, without specification of site. 200-208.9 Malignant neoplasms of lymphatic and hematopoietic

tissue, stated or presumed to be primary.210-229.9 Benign neoplasms. 230-234.9 Carcinoma – in-situ. 235-238.9 Neoplasms of uncertain behavior 239-239.9 Neoplasms of unspecified nature.

Examples

Metastatic carcinoma of colon to the lungs    Code: Colon as Primary (e.g 153.9) and Lungs as Secondary (e.g.

197.0) depending on the specificity of the documentation in the record.

– If a primary malignant neoplasm previously excised or eradicated by radiation or chemotherapy recurs, code it as primary malignancy of the stated site unless the Index directs otherwise. If you are not sure, check with your payer to see how they would like it coded.

 Recurrence of cancer in Mastectomy site. For example, a cancerous Skin lesion recurs at same site where a lesion has been removed. Code: 173.8 (or 173.9 depending upon the documentation in the record).

You should find the same code for the same diagnosis even if you look it up under different headings on the neoplasm table.

  Example: 230.7 CA in situ of the ileum230.7 CA in the intestines (small)

V – codes Associated with Neoplasms

V10-V10.9 Personal history of malignant neoplasm  V58.0 Radiotherapy  V58.1 Chemotherapy  V66 Convalescence

– V66. 1 following Radiotherapy– V66.2 following Chemotherapy  

V67Follow-up Examination– V67. 1 following Radiotherapy– V67.2 following Chemotherapy

V71. 1Observation for suspected malignant neoplasm

Tips for Coding

Code the condition that brought the patient in today. Some patients present with a complaint of pain. This can be a valid reason for office visits.

The first diagnosis code listed should be the primary diagnosis for that day's service. Do not just depend upon what's in the computer system from the last visit.

Never begin your initial search in the Tabular List (Volume 1) – this leads to errors. The range of code choices should always be explored.

Check all indentations to ensure you have coded the most appropriate code.

Do not code "rule-out" or "suspected" diagnoses, or one that is possible or probable. Code based on the patient's symptom or condition, unless you can document a confirmed diagnosis, which can then be utilized.

Tips for Coding

Do not code a diagnosis for a condition a patient no longer has, unless it has a significant importance relative to the claim being billed. For example, do not code for cancer of the uterus (233.2) if the patient has had a hysterectomy.

It is acceptable to use repeatedly a chronic diagnosis as often as necessary. Do not embellish or modify a valid diagnosis on subsequent visits. If you are unsure if a code applies to a chronic illness that can be used in repeated visits, contact your payer for direction.

When a patient undergoes a surgical procedure, code the diagnosis for the procedure that is being performed (e.g. uterine cancer for hysterectomy).

DO NOT USE a code that is not specifically documented in the record. Do not use mental health diagnosis codes for Medicare when discussing

medical issues. Cancer patients often have complaints of fatigue or insomnia, which are sometimes mistakenly referred to as depression. Symptoms of fatigue or insomnia are valid medical diagnoses.

Tips for Coding

Do not use "E-codes" from the ICD-9-CM for Medicare purposes unless the Carrier's payment policy specifically directs you to do so.

Do not use "history of " when treating the patient for current disease. This term usually refers to patients who are confirmed as 'disease free'. This can mean that the tumor area is confirmed pathologically to be free of disease.

– Some oncologists prefer not use this until the patient has been out of treatment for a specified period (6 months to one year). Check with your doctor and/or payer before using these codes.

Do use a definitive diagnosis for lab tests—for example V58.1 (Encounter for chemotherapy). Chemotherapy is a reason for checking the patient's lab values, in some instances.

Avoid vague terms like "uncertain behavior". Check to see if there is a Pathology Report before using this diagnosis.

Test Your Coding Skills

Using your current ICD-9-CM, assign diagnosis codes for the following statements. Some may require more than one code.

1. Abnormal cervical Pap smear_____2. Metastatic Ca to the lung from the breast (surgery performed

2 years prior with no local recurrence)_____3. Follow-up exam after surgery_____4. Nasopharyngeal polyps_____5. Cancer in situ of the Ovary_____6. Hodgkin's sarcoma of the intra-abdominal lymph node_____

Test Your Coding Skills

7. Breast mass scheduled for biopsy_____8. Abnormal thyroid scan_____ 9. Cancer of the sigmoid colon removed five years ago with no

recurrence_____10.Metastatic carcinoma of the liver originating in the stomach body_____11.Abnormally heavy menstruation and severe abdominal pain -possible

uterine tumor_____12.A 45-year old female patient sees her physician for her annual

mammogram and is found to have bilateral microcalcifications_____13.The physician sees a patient requiring a breast biopsy. The biopsy

results from the pathologist confirm the existence of a malignant tumor. The tumor, a primary cancer, is located within the upper-outer quadrant of the right breast._____

14.A patient with cancer of the upper and lower breast is seen for metastases to the liver._____