2008
Documentation
& Coding Tools
To access these tools and any new tools, go to:
Chronic Kidney Disease Reporting
ICD-9-CM coding for Chronic Renal Failure, Category 585, changed in 2006. The Renal Physicians Foundation along with the National Kidney Foundation promoted code Category 585 being renamed and expanded to reflect the new clinical practice standards for treating Chronic Kidney Disease. (CKD)
Chronic Kidney Disease is defined as either:
Kidney damage - pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.
OR
GFR (Glomerular Filtration Rate) < than 60 mL/min/1.73m for > than 3 months.
The new code assignments, describe the different stages in the progression of Chronic Kidney Disease. The new stag-ing system is based on estimates of the glomerular filtration rate at each stage, with each stage defined by level of kidney function. Higher stages represent lower GFR levels.
1
2
585.1 Chronic Kidney Disease, Stage I
Glomerular Filtration Rate (GFR) 90mL/min or more Healthy kidneys or kidney damage with normal or
high GFR
Plenty of Kidney function but may have protein or albumin in their urine.
585.2 Chronic Kidney Disease, Stage II Mild
Glomerular Filtration Rate (GFR) 60-89mL/min Kidney damage and mild decrease in GFR 585.3 Chronic Kidney Disease, Stage III Moderate
Glomerular Filtration Rate (GFR) 30-59 mL/min Moderate decrease in GFR
585.4 Chronic Kidney Disease, Stage IV Severe Glomerular Filtration Rate (GFR) 15-29 mL/min Severe decrease in GFR
585.5 Chronic Kidney Disease, Stage V Glomerular Filtration Rate (GFR)
less than 15 mL/min or on dialysis Kidney Failure
Append V45.1 if appropriate 585.6 End Stage Renal Disease
End-stage renal disease (ESRD) is an administrative term in the United States, based on the
conditions for payment for health care by Medi-care ESRD Program. ESRD includes patients treated by dialysis or transplantation, irrespective of the level of GFR.
Dialysis Status
Append V45.1 if appropriate
585.9 Chronic Kidney Disease, Unspecified
Includes: Chronic Renal Disease, Chronic Renal Failure NOS, and Chronic Renal Insufficiency ICD-9-CM instructs the coder to use an additional code to identify Kidney Transplant Status if applicable (V42.0). A kidney transplant may not fully restore kidney function, therefore, patients who have undergone a kidney transplant may still have some form of Chronic Kidney Disease. Code V42.0, Kidney replaced by transplant, may be assigned with the appropriate CKD code, based on the patient’s post-transplant stage.
Patients that have had a kidney transplant where documentation indicates the presence of failure or rejection, assign code 996.81 Complication of kidney transplant followed by the appropriate CKD code.
http://kidneynotes.blogspot.com/2005/10/chronic-renal-failure-is-no-more-new.html Sources: Renal Physicians Foundation, National Kidney Foundation
K/DOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification
Chronic Kidney Disease Stages
Codes Valid 10/01/07 to 9/30/08 In addition, for Stage V and ESRD, use code V45.1, if appropriate.
Diagnosis Coding and Documentation
Patient: Jane Doe
Date of Service: 10/30/06
Reason for visit:
S: Voices no complaint except that she wishes she could visit her sister, who is
hospitalized. States she is able to get around, including bathroom and cafeteria,
without difficulty. Denies any pain or shortness of breath. No change in bowel or
bladder habits.
O: Patient alert, oriented to person, disoriented to place and time. No acute distress.
Cardiac: RRR no rubs, gallops or murmurs noted
Lungs CTA bilat. No cough or wheezing noted.
Abd soft non tender to palpitation with Colostomy intact, skin dry and intact
surrounding pink-red stoma, liquid brown feces.
Diminished sensation LE bilaterally, skin cool with rubor.
Old incision for L great toe amputation dry and intact. Able to ambulate to toilet and
cafeteria with walker.
A: 250.70 Diabetes with peripheral circulatory disorders, currently controlled; with
443.81 peripheral vascular disease due to diabetes; and 250.60 diabetes with
neurologic manifestations of 357.2 diabetic polyneuropathy. Finger stick blood
sugar ranges 125-175 in past 2 weeks. Diabetes controlled on current regimen a.c. &
h.s. insulin; sliding scale insulin if needed.
V44.3 Functioning colostomy, no change in plan of care.
V49.71 Old amputated L great toe – stable.
290.40 Mild senile dementia (see notes October 10, 2006)
733.00 Osteoporosis, unspecified
733.13 Osteoporetic vertebral fractures (see notes September 13, 2006).
P: Continue current diet & insulin regimen. Retain sliding scale order for prn with
notification parameters. Continue current activity level.
Authenticated by: Joseph A. Williams MD
Model Progress Note
1
Codes Valid 10/01/07 to 9/30/08
Stroke and Late Effects of Prior Stroke
One of the most common coding errors seen in chart audit is the assignment of a stroke code in the present tense when the coder is actually trying to code for the residual conditions left behind by a prior stroke. Acute stroke is only coded during the initial episode of care.
Cerebrovascular Accidents (Stroke)
In a CVA, there is a decreased supply of blood to the brain that can result in an area of infarction (necrotic cerebral tissue). CVA occurs because of thrombosis, embolism, occlusion (code categories 433 or 434) or hemorrhage (Category 430 to 432). There are codes for each type of CVA. The fourth and fifth digits of these codes indicate either “with” or “without” infarc-tion.
Unless otherwise stated, CVA/stroke is considered an assumed ischemic infarction and is coded 434.91.
The fifth digit of 1 indicates “infarction”.
After the Initial Acute Care
Episode of Stroke
After an initial stroke incident has occurred, generally one of two scenarios will exist. Either the patient will have deficits from the stroke (conditions left behind such as paralysis) or will make a recovery without any long lasting effects.
If the patient recovers without any lingering prob-lems related to the stroke, the code would be V12.54 Stroke NOS without residual deficits.
If the patient has deficits present after the discharge from the initial acute care episode, all deficits are coded to Late Effects (Category 438).
Prior to October 2004, CVA not otherwise speci-fied was coded to Category 436. In the current 2008 ICD-9- CM there is an exclusionary note specifically stating not to use this code for a cerebrovascular ac-cident.
Post-Operative Cerebrovascular
Hemorrhage or Infarction
A post-operative cerebrovascular hemorrhage or in-farction that occurs as a result of medical intervention is coded 997.02 – Complications affecting specified body systems: Iatrogenic cerebrovascular infarction or hemorrhage. In addition, the specific type of infarction must be coded.
The Time Line is Significant
Example 1:
Stroke initial incident
Acute embolic CVA with infarction 434.11
Example 2:
Stroke initial incident; prior stroke with no deficits Acute embolic CVA, prior stroke with no deficits 434.11
V12.54
Example 3:
Stroke initial incident with deficits from prior stroke
Acute embolic CVA with infarction; previous CVA with residual dysphagia
434.11 438.82
Example 4:
Follow-up for evaluation of dysphagia. The dysphagia was due to a stroke.
Office visit to evaluate dysphagia from a stroke one month ago
438.82
Example 5:
The patient suffered a post-operative stroke; acute embolic CVA with infarction
997.02 434.11
“The Mechanics of Chart Documentation”
Documentation validates that services were provided, ensures continuity of care, supports
medical necessity and verifies that services provided are reported with accuracy. Good
documentation supports the level of service billed resulting in appropriate
reimbursement.
* The physician’s signature and credentials must be on each chart entry.
* The patient name and the date of service must be on each page of the patient
chart.
* The medical record must be complete and legible.
* Only standard medical abbreviations should be used.
* Use SOAP format when applicable.
* Note all acute and chronic diagnoses with the current status and treatment
plans in the progress note.
ICD-9-CM Guidelines and Tips
* Current year version of ICD-9-CM 2008 must be used for accurate diagnostic
coding.
* Superbills need to be managed, updated, expanded and revised yearly.
* Diagnosis codes must be accurate and specific. If a code offers 5 digits in
ICD-9-CM, five digits must be used. Each digit adds specificity.
* Avoid unspecified codes .9 unless there is not a more specific code available.
* Code both the etiology (underlying disease) and the manifestation of the
disease. The underlying disease would be coded first, with the manifestation of
the disease in 2
ndplace.
Example:
Kaposi’s sarcoma due to HIV
042 (HIV) underlying disease
176.0 Kaposi’s sarcoma (manifestation)
* When a combination code is offered in ICD-9-CM to classify two diagnoses, it
must be used.
Example:
Malignant Hypertensive Chronic Kidney Disease
Chronic Kidney Disease Stage V
403.01 Hypertensive chronic kidney disease,
malignant, with ckd stage V or end stage
renal disease
Correctly Reporting Cancer Diagnoses:
Current Cancer vs. History of Cancer
To correctly report a diagnosis of cancer, one must determine whether the patient’s cancer has been eradicat-ed or is currently being treateradicat-ed. The neoplasm table in the ICD-9-CM code book establishes three categories of malignancy: primary, secondary and in-situ. Neoplasms should be coded to such and unknown sites must also be coded.
Current Cancer
Patients with cancer who are receiving active treat-ment for the condition should be reported with the malignant neoplasm code corresponding to the af-fected site. This applies even when a patient has had cancer surgery, but is still receiving active treatment for the disease.
Example: Malignant neoplasm of kidney, 189.0
Secondary Site with an Unknown Primary Site
Example: Metastatic carcinoma from lung 162.9 (Primary site – lung) + 199.1 (secondary site – unknown)
Secondary Site with Active Primary Site
A patient is admitted with metastatic bone cancer. The patient had a mastectomy 2 months ago and is having radiation treatments for the breast cancer. The neoplasm was located in the upper outer quadrant. Example: Code 198.5 Neoplasm, bone,
secondary
Code 174.4 Neoplasm, breast, upper outer quadrant
History of Cancer
Patients with a history of cancer and no evidence of current cancer should be reported as “Personal his-tory of malignant neoplasm” using a code from the V10 series. These codes require additional digits to identify the type of cancer and should be reported only when there is no evidence of current cancer and a patient’s presenting problem, signs, or symptoms may be related to the cancer history or impact the plan of care. These codes should not be reported routinely.
Example: Personal history of malignant neoplasm, kidney, V10.52
Aftercare Following Surgery for Neoplasm
Visits to determine the effectiveness of cancer surgery that fall within the global post-operative period should be reported as “Aftercare following surgery for neo-plasm”, code V58.42 and a second aftercare code to fully identify the reason for the encounter.
Example: Aftercare following surgery for malignant neoplasm, kidney, V58.42; Aftercare following surgery of the digestive system, V58.75
Follow-up for Patients with History of Cancer
Follow up exams to determine if there is any evidence of recurring or metastasizing cancers that result in no evidence of malignancy should be reported as ”Fol-low-up exam” using a code from the V67 category to identify the most recent therapy carried out.
Example: Follow-up exam following chemotherapy, V67.2
Cancer Drugs prescribed for reason other than Malignancy
Patients with no history of cancer who take prophylac-tic cancer drugs should not be reported with an active cancer diagnosis or a personal history of malignant neoplasm. Instead, code the reason for the prescrip-tion.
Example: Family history of malignant neoplasm, kidney V16.51
References: AHA Coding Clinic, July-August 1985; AHA Coding Clinic, 4th Quarter 2002; Part-B News,
Faye Brown’s ICD-9-CM Coding Handbook, 2007
Good coding and documentation clearly depicts the level of disease severity, co-morbidities, underlying disease and other factors that contribute to the level of complexity for the patient encounter. Per the ICD-9-CM Official Guidelines and Reporting:
Code all documented conditions that coexist at the time of the encounter/visit, and require or effect patient care treatment or management.
CMS reimbursement is increasingly leaning toward the principle of “illness burden”. Diagnosis codes are the criteria used for determining severity of illness, risk and resource utilization. Diagnostic coding influences the “level of risk” in determining CPT coding assignment. Moderate risk is equivalent to:
a) One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment, or
b) Two or more chronic stable illnesses High risk relates to:
a) One or more chronic illnesses with severe exacerbation, progression or side effects of treatment, or
b) Acute or chronic illnesses or injuries that pose a threat to life or body function Status Codes do indicate and contribute to the complexity level of the encounter: Consider these V codes:
Renal Dialysis Status V45.1
Tracheostomy Status V44.0
Respirator Dependence V46.XX
Lower Limb Amputee V49.7X
Artificial Openings for Feeding or Elimination V44.X
Major Organ Transplant V42.X and V42.XX
Asymptomatic HIV Status V08
The presence of one or more of these conditions would be taken into account by the physician in the decision making process and could effect patient care, treatment and management.
Other diagnosis codes that are not often reported, although the patient is being treated for the conditions, are:
Protein Calorie Malnutrition 263.X
Major Depression 296.XX
Drug Dependence & Alcohol Dependence 303.XX and 304.XX
History of Heart Attack 412
Good documentation is reflective of the “thought process” of the physician in treating patients. All conditions effecting the patient should be documented and coded.
A Comprehensive Diagnostic Patient Profile—
The Wave of the Future!
Codes Valid 10/01/07 to 9/30/08
3
Codes Valid 10/01/07 to 9/30/08
BLOOD DISEASE
285.21 Anemia in Chr Kidney Disease 280.9 Anemia, Iron Deficiency, unspec 285.9 Anemia, NOS
281.0 Anemia, Pernicious 280.0 Anemia, Sec Blood Loss
CARDIOVASCULAR / CARDIOLOGY
410.91 Acute MI, Initial Episode, NOS 410.92 Acute MI, Sub Episode, NOS 413.0 Angina Decubitus 413.9 Angina Pectoris, NOS 411.1 Angina, Unstable 427.31 Atrial Fibrillation
427.9 Cardiac Dysrhythmia, NOS
425.4 Cardiomyopathies, Primary, NOS 428.0 Congestive Heart Failure
414.2 Occlusion, Coronary Artery, Complete 414.00 Coronary Atherosclerosis, unspec 414.9 Heart Disease Ischemic, Chronic
428.9 Heart Failure, unspec 429.0 Myocarditis, unspec 412 Old MI
427.81 Sick Sinus Syndrome 427.0 Tachycardia, Atrial Parox. 427.1 Tachycardia, Ventric Parox.
CEREBROVASCULAR
437.0 Cerebral Atherosclerosis
436 Cerebrovascular Disease, Ill Defined, Acute
434.91 CVA/Stroke (Not for Office Use)
437.1 Ischemic Cerebrovascular Disease 435.9 TIA
Late Effects
438.20 Hemiplegia, Side unspec 438.21 Hemiplegia, Dom. Side 438.22 Hemiplegia, Non-dom. Side 438.41 Monoplegia, L-Limb, Dom. Side 438.42 Monoplegia, L-Limb, Non-dom. Side
438.40 Monoplegia, L-Limb, unspec Side 438.31 Monoplegia, U-Limb, Dom. Side 438.32 Monoplegia, U-Limb, Non-dom. Side
438.30 Monoplegia, U-Limb, unspec Side
438.10 Speech / Language Deficits, unspec
VASCULAR DISEASES
453.40 DVT, NOS
458.0 Hypotension, Orthostatic 440.4 Occlusion, Extr Artery, Total, Chronic
443.9 Peripheral Vascular Disease, NOS 451.11 Phlebitis, Femoral Vein 451.19 Phlebitis, Lower Extr, Deep
454.0 Varicose Lower Extr. w/Ulcer 459.81 Venous Insufficiency, Chronic, NOS
DERMATOLOGY
706.1 Acne, Other 702.0 Actinic Keratosis 701.9 Atrophoderma
691.8 Dermatitis, Atopic & Eczema 692.9 Dermatitis, NOS 054.9 Herpes Simplex w/o Comp. 053.9 Herpes Zoster w/o Comp. 702.11 Seb Keratosis, Inflamed 702.19 Seb Keratosis, NOS 110.1 Tinea of Nail ENDOCRINOLOGY 259.2 Carcinoid Syndrome 276.51 Dehydration 250.00 DM Type II Controlled 250.01 DM Type I Controlled 250.02 DM Type II Uncontrolled 250.03 DM Type I Uncontrolled
(Add 5th digits 0, 1, 2, or 3 to following DM
Codes. Also, Use Additional Code to Identify Manifestations as Exemplified Under Each Code Category)
250.4x DM w/ Renal Manifestation(s) 585.x CKD or Chronic Renal Failure 583.81 Nephritis / Nephropathy 581.81 Nephrotic Syndrome 403.91 Nephropathy w/ HTN & CRF 791.0 Proteinuria 250.5x DM w/ Ophthalmic Manifestation(s)
366.41 Cataracts (Type I Only)
362.01 Diabetic Retinopathy, NOS
365.44 Glaucoma
362.02 Prolif Diabetic Retinopathy
250.6x DM w/ Neurological Manifestation(s) 337.1 Autonomic (Peripheral) Neuropathy 536.3 Gastroparesis 607.84 Impotence 713.5 Neurogenic / Neuropathic Arthropathy. 357.2 Polyneuropathy in DM / Neuritis
707.1x Ulcers of Lower Limbs, Except Decubitus
250.7x DM w/ Peripheral Circulatory Disease
785.4 Gangrene
607.84 Impotence
443.81 Peripheral Angiopathy
707.1x Ulcers of Lower Limbs, Except Decubitus
250.8x DM w/ Other Chronic Manifestation(s)
731.8 Osteomyelitis (Also, Append the
Appropriate Code from Category 730, Osteomyelitis, Periostitis, and Other Infections Involving Bone).
(Ulcers: Assign to 250.8 when Ulcers
are not due to Neuropathy or PVD)
272.0 Hypercholesterolemia 272.2 Hyperlipidemia, Mixed 252.00 Hyperparathyroidism, Unspec 276.7 Hyperpotassemia 242.90 Hyperthyroidism w/o Crisis 272.1 Hypertriglyceridemia 257.2 Hypogonadism, Testicular 276.1 Hyponatremia 276.8 Hypopotassemia 244.0 Hypothyroidism, Postsurgical 244.9 Hypothyroidism, unspec 278.01 Obesity, Morbid 278.00 Obesity, unspec 263.9 Protein-Calorie Malnutrition GASTROENTEROLOGY
789.06 Abdominal Pain, Epigastric 789.07 Abdominal Pain, General 789.04 Abdominal Pain, Left Lower 789.02 Abdominal Pain, Left Upper 789.03 Abdominal Pain, Right Lower 789.01 Abdominal Pain, Right Upper 574.20 Cholelithiasis w/o Obstruction
571.2 Cirrhosis, Alcoholic 571.5 Cirrhosis, Non-Alcoholic, Liver
564.00 Constipation, unspec
555.9 Crohn’s Disease, NOS
562.11 Diverticulitis, Colon w/o Hem. 562.10 Diverticulosis, Colon w/o Hem. 536.8 Dyspepsia
560.39 Fecal Impaction
558.9 Gastroenteritis, Noninfectious 530.81 Gastroesophageal Reflux 569.3 Hemorrhage, Rectum / Anus 455.6 Hemorrhoids, NOS 571.1 Hepatitis, Alcoholic Acute
571.40 Hepatitis Chronic, unspec
070.9 Hepatitis, Viral, NOS 564.1 Irritable Bowel Syndrome 578.1 Melena
577.0 Pancreatitis, Acute 556.9 Ulcerative Colitis, unspec
GENITOURINARY DISEASE
592.0 Calculus of Kidney 592.1 Calculus of Ureter
Note: For CKD Below, Code First
Hypertensive Chronic Kidney Disease if Applicable, (403.00-403.91, 404.00-404.93)
585.1 Chronic Kidney Disease, Stage I 585.2 Chronic Kidney Disease, Stage II 585.3 Chronic Kidney Disease, Stage III 585.4 Chronic Kidney Disease, Stage IV 585.5 Chronic Kidney Disease, Stage V 585.6 End Stage Renal Disease 585.9 Chronic Kidney Disease, unspec
595.0 Cystitis, Acute 599.7 Hematuria 593.9 Renal Disease, NOS
584.9 Renal Failure Acute, unspec
597.80 Urethritis, unspec 599.0 Urinary Tract Infection, unspec
GU DISORDERS / FEMALE
795.04 Abn. Pap Smear w/ HGSIL 795.03 Abn. Pap Smear w/ LGSIL 795.08 Abn. Pap Smear, Unsatisfactory 611.72 Breast Lump / Mass 112.1 Candidiasis, Vulva & Vagina 616.0 Cervicitis
627.2 Menopausal Symptoms 620.2 Ovarian Cyst, NOS 616.10 Vaginitis, NOS
GU DISORDERS / MALE
600.01 BPH w/ Obstruction Use additional code to identify
the symptom(s)
600.00 BPH w/o Obstruction 604.90 Epididymitis / Orchitis, unspec 607.84 Impotence, Organic Origin 602.9 Prostatosis
HYPERTENSIVE DISEASE
(Heart Failure – Identify Type of Failure; CKD – Identify Stage of Disease) 401.1 Hypertension Essential, Benign 401.0 Hypertensive Essential, Malignant 401.9 Hypertension, unspec 403.90 Hypertensive CKD, w/ CKD Stage I-IV, or unspec
403.91 Hypertensive CKD w/ CKD Stage V, or ESRD, or unspec
404.91 Hypertensive Heart & CKD w/ Heart Failure & CKD Stage I-IV, unspec 404.93 Hypertensive Heart & CKD w/ Heart Failure & CKD Stage V, or ESRD, or unspec
404.90 Hypertensive Heart & CKD, w/o Heart Failure w/ CKD Stage I-IV, unspec
404.92 Hypertensive Heart & CKD, w/o Heart Failure, w/ CKD Stage V, or ESRD, or unspec
402.91 Hypertensive Heart Disease w/ Heart Failure, unspec
(Use Additional Code with 402.91 to
Identify the Heart Failure)
402.90 Hypertensive Heart Disease w/o Heart Failure, unspec
INFECTIOUS DISEASE 682.6 Cellulitis, Leg 682.9 Cellulitis, NOS 042 HIV V08 HIV, Asymptomatic 795.5 PPD Positive 079.99 Viral Infection, NOS
MUSCULOSKELETAL
714.0 Arthritis, Rheumatoid
726.5 Bursitis, Hip 726.60 Bursitis Knee, NOS 726.10 Bursitis Shoulder, NOS 723.4 Cervical Radiculitis 717.7 Chondromalacia Patella 924.20 Contusion, Foot 923.20 Contusion, Hand 920 Contusion, Head 924.11 Contusion, Knee 924.10 Contusion, Lower Leg 923.00 Contusion, Shoulder 722.4 DDD Cervical
722.52 DDD Lumbar / Lumbosacral 722.10 Displacement, Lumbar Disc 812.20 FX Arm Upper, NOS, Closed
821.00 FX Femur, unspec, Closed
816.00 FX Finger(s), unspec, Closed
820.8 FX, Hip, NOS, Closed
826.0 FX Toe(s), Closed
733.13 FX Vertebrae, Pathologic
814.00 FX Wrist, NOS, Closed 274.0 Gouty arthropathy 719.40 Joint Pain, unspec 724.2 Low Back Pain 724.4 Lumbosacral Neuritis 729.1 Myalgia / Myositis, NOS 715.97 Osteoarthrosis, Ankle & Foot 715.94 Osteoarthrosis, Hand 715.96 Osteoarthrosis, Lower Leg 715.90 Osteoarthrosis, NOS, unspec 715.91 Osteoarthrosis, Shoulder 733.00 Osteoporosis, unspec 729.5 Pain in Limb 728.71 Plantar Fasciitis
725 Polymyalgia Rheumatica
845.00 Sprain / Strain Ankle 845.10 Sprain / Strain Foot 842.10 Sprain / Strain Hand 843.9 Sprain / Strain / Hip 844.9 Sprain / Strain Knee & Leg 847.2 Sprain / Strain Lumbar 847.0 Sprain / Strain Neck 840.9 Sprain / Strain Shoulder 842.00 Sprain / Strain Wrist 726.32 Tendonitis, Elbow 726.90 Tendonitis, NOS 727.00 Tenonsynovitis, NOS 733.6 Tietze’s Disease NEUROLOGY 331.0 Alzheimer’s Disease Use Additional Code, where
Applicable, to Identify:
w/ Behavioral Disturbance (294.11), w/o Behavioral Disturbance (294.10)
354.0 Carpal Tunnel Syndrome
345.90 Epilepsy, unspec
346.10 Headache, Migraine
332.0 Parkinson’s Disease 356.9 Peripheral Neuropathy, unspec
ONCOLOGY
198.5 Malig Neo Bone, Secondary 174.1 Malig Neo Breast, Central 174.9 Malig Neo Breast, unspec 162.9 Malig Neo Bronchus / Lung 153.6 Malig Neo Colon Ascending
199.0 Malig Neo Disseminated 185 Malig Neo Prostate 199.1 Malig Neo w/o Spec Site
OPHTHALMOLOGY
366.9 Cataract, unspec 372.00 Conjunctivitis, Acute, unspec 372.14 Conjunctivitis, Allergic 930.9 FB Eye External, NOS
OTOLARYNGOLOGY
380.4 Cerumen Impacted 381.81 Eustachian Tube Dysfunction 380.10 Otitis Externa, Infective 381.01 Otitis Media, Serous, Acute 381.10 Otitis Media, Serous, Chronic 382.00 Otitis Media, Suppurative, Acute 462 Pharyngitis, Acute
461.0 Sinusitis Acute, Maxillary 473.9 Sinusitis Chronic, NOS
PSYCHIATRY
303.90 Alcoholism, Chronic
300.00 Anxiety State, unspec 311 Depressive Disorder, NEC
304.90 Drug Dependence, unspec
300.4 Dysthmic Disorder
296.20 Major Depressive disorder, Single episode, unspec 296.30 Major Depressive disorder, Recur episode, unspec 296.90 Mood Disorder, episodic, unspec
294.8 Organic Brain Syndrome
PULMONARY
415.0 Cor Pulmonale, Acute 415.19 Pulm Embol / Infarct, Other 416.9 Pulm Heart Disease Chronic, unspec
RESPIRATORY
493.90 Asthma, unspec
493.92 Asthma, unspec, w/ Acute Exacerbation
466.0 Bronchitis, Acute
491.9 Bronchitis, Chronic, unspec 496 COPD
492.8 Emphysema, NOS
486 Pneumonia, unspec 477.0 Rhinitis, Allergic, Pollen 472.0 Rhinitis, Chronic 461.0 Sinusitis, Maxillary, Acute 465.9 URI, Acute, NOS
SIGNS & SYMPTOMS
786.50 Chest Pain, unspec 786.2 Cough 787.91 Diarrhea, NOS 780.4 Dizziness and Giddiness 787.20 Dysphagia, unspec 786.00 Dyspnea, unspec 782.3 Edema
796.2 Elevated BP w/o Hypertension 785.6 Enlargement Lymph Nodes 780.6 Fever
785.4 Gangrene
784.0 Headache 786.01 Hyperventilation 780.51 Insomnia w/ Sleep Apnea 780.52 Insomnia, unspec 780.79 Malaise and Fatigue, Other 787.01 Nausea and Vomiting 785.1 Palpitations
780.39 Seizures, NOS
782.0 Skin Sensation Disturbance 780.2 Syncope and Collapse 788.30 Urinary Incontinence, unspec 783.21 Weight Loss Abnormal 786.07 Wheezing
V CODES
V49.70 Amputation, Lower Limb, unspec
V67.9 Follow-up Exam, unspec V67.00 Post-Op Exam V72.84 Pre-Op Exam
V45.1 Renal Dialysis Status
V76.2 Screen Mal Neo, Cervix V76.49 Screen Mal Neo, NOS V76.47 Screen Mal Neo, Vagina V74.5 Screen Venereal Disease
V44.3 Status – Colostomy
V58.32 Suture Removal
CARDIOVASCULAR/ CARDIOLOGY
PATIENT NAME CHART # DATE OF SERVICE
CEREBROVASCULAR DERMATOLOGY BLOOD DISEASE VASCULAR DISEASES GASTROENTEROLOGY ENDOCRINOLOGY GENITOURINARY DISEASE GU DISORDERS / FEMALE GU DISORDERS / MALE NEUROLOGY HYPERTENSIVE DISEASE ONCOLOGY INFECTIOUS DISEASE MUSCULOSKELETAL OPHTHALMOLOGY PSYCHIATRY OTOLARYNGOLOGY PULMONARY RESPIRATORY
SIGNS & SYMPTOMS
V CODES
COMMENTS OTHER DIAGNOSIS
Protein-Calorie Malnutrition
In order to improve the reporting of malnutrition
among the elderly, it is important for physicians to
document the condition in the medical record and
for coders to be aware of malnutrition as a
poten-tial diagnosis. Code Categories 262 and 263.
The most severe malnutrition problems are
as-sociated with Protein Calorie Malnutrition (PCM),
also known as Protein Energy Malnutrition
(PEM), which occurs in both chronic and acute
forms.
Subjective Global Assessment (SGA) for PEM
includes 6 clinical parameters, followed by a
personal judgement as to whether the patient has
(A) no malnutrition, (B) possible or mild
malnutri-tion, or (C) significant malnutrition.
1. unremitting, involuntary weight loss that is
greater than 10% in the previous
months, and especially in the last few weeks
2. Food intake is severely curtailed
3. Muscle wasting and fat loss, with attention
to the presence of edema, or ascites
present on physical examination
4. Persistent, essentially daily gastrointestinal
symptoms such as anorexia, nausea,
vomiting, or diarrhea in the previous 2
weeks
5. Marked reduction in physical capacity
6. Presence of metabolic stress due to trauma,
inflammation or infection
*Any combination of these conditions (especially
the first 3) indicates that the patient has
signifi-cant PEM.
Other standards are used and accepted as
indicators of Protein Calorie Malnutrition:
Body Weight as a value relative to the
estab-lished norms in the general population;
Body Mass Index (BMI) which can define Protein
Calorie Malnutrition as well as Obesity;
and a General Weight Loss Standard.
The overall opinion is that no “gold standard” for
the assessment of nutritional status exists.
Protein-calorie malnutrition may
accompany illnesses such as:
Cancer
Pancreatitis
Alcohol Abuse and/or Dependence
Liver Disease
Chronic Kidney Disease
Drug Abuse and/or Dependence
Obesity (Post Bariatric Surgery)
ESRD
Alcoholic Hepatitis
Cirrhosis
Celiac Disease
Cystic Fibrosis
Anemia
Depression
Diabetes Mellitus Diagnoses Codes
and Associated Manifestations
Fifth-digit subclassifications for use with category 250: 0 Type II (NIDDM), Unspec type, not stated as uncontrolled
1 Type I (IDDM), not stated as uncontrolled
2 Type II (NIDDM), unspecified type, uncontrolled (adult-onset diabetic patients, even if patient requires insulin) 3 Type I (IDDM), uncontrolled
Write the number (fifth digit) in the space provided
Fifth-digit subclassifications for use with category 250:
0 1 2 3
DM without mention of Complication
Diabetes with Ketoacidosis Indicate fifth digit subclassification (0,1,2,3)
Diabetes with Hyperosmolarity
Diabetes with Other Coma 337.1 Peripheral autonomic neuropathy in disorders classified elsewhere
Diabetes with Renal Manifestations 354.0 Carpal tunnel syndrome Must specify kidney manifestation 354.1 Other lesion of median nerve 583.81 Nephritis and nephropathy, not spec as acute or 354.2 Lesion of ulnar nerve
354.3 Lesion or radial nerve 581.81 Nephrotic syndrome in disease classified elsewhere 354.4 Causalgia of upper limb
354.5 Mononeuritis multiplex
250.5__ Diabetes with Ophthalmic Manifestation 354.8 Other mononeuritis of upper limb
Indicate fifth digit subclassification (0,1,2,3) 354.9 Mononeuritis of upper limb, unspecified Use additional codes to identify manifestations: 355.0 Lesion of sciatic nerve
362.01 Background diabetic retinopathy 355.1 Meralgia paresthetica 362.02 Proliferative diabetic retinopathy 355.2 Other lesion of femoral nerve 362.83 Retinal edema 355.3 Lesion of lateral popliteal nerve 365.44 Glaucoma associated with systemic syndromes 355.4 Lesion of medial popliteal nerve 366.41 Diabetic cataract 355.5 Tarsal tunnel syndrome 369.01 Better eye: total impairment; lesser eye: total impairment 355.6 Lesion of plantar nerve 369.02 Better eye: near total impairment; lesser eye: not further specified 355.71 Causalgia of lower limb 369.03 Better eye: near total impairment; lesser eye: total impairment 355.79 Other mononeuritis of lower limb 369.04 Better eye: near-total impairment; lesser eye: near total-impairment 355.8 Mononeuritis of lower limb, unspecified 369.05 Better eye: profound impairment: lesser eye: not further specified 355.9 Mononeuritis of unspecified site 369.06 Better eye: profound impairment; lesser eye: total impairment 357.2 Polyneuropathy in diabetes
369.07 Better eye: profound impairment; lesser eye: near-total impairment 358.1 Myasthenic syndromes in diseases classified elsewhere 369.08 Better eye: profound impairment; lesser eye: profound impairment 713.5 Arthropathy associated with neurological disorders 369.10 Impairment level not further specified
369.11 Better eye: severe impairment; lesser eye: blind, not further specified
369.12 Better eye: severe impairment; lesser eye: total impairment Indicate fifth digit subclassification (0,1,2,3)
369.13 Better eye: severe impairment; lesser eye: near-total impairment Use additional code to identify manifestations: 369.14 Better eye: severe impairment; lesser eye: profound impairment 785.4 Gangrene
369.15 Better eye: moderate impairment; lesser eye: blind, not further specified 443.81 Peripheral angiopathy in diseases classified elsewhere 369.16 Better eye: moderate impairment; lesser eye: total impairment
369.17 Better eye: moderate impairment; lesser eye: near total impairment
369.18 Better eye: moderate impairment; lesser eye: profound impairment Indicate fifth digit subclassification (0,1,2,3)
369.20 Impairment level not further specified
369.21 Better eye: severe impairment; lesser eye: not further specified 707.10 Ulcer of lower limb, unspecified 369.22 Better eye: severe impairment; lesser eye: severe impairment 707.11 Ulcer of thigh
369.23 Better eye: moderate impairment; lesser eye: not further specified 707.12 Ulcer of calf 369.24 Better eye: moderate impairment; lesser eye: severe impairment 707.13 Ulcer of ankle 369.25 Better eye: moderate impairment; lesser eye: moderate impairment 707.14 Ulcer of heel and midfoot
369.3 Unqualified visual loss, both eyes 707.15 Ulcer of other part of foot 369.4 Legal blindness, as defined in U.S.A. 707.19 Ulcer of other part of lower limb 369.60 Impairment level not further specified 707.8 Chronic ulcer of other specified sites 369.61 One eye: total impairment; other eye: not specified 707.9 Chronic ulcer of unspecified site
369.62 One eye: total impairment; other eye: near normal vision 731.8 Other bone involvement in diseases classified elsewhere 369.63 One eye: total impairment; other eye: normal vision
369.64 One eye: near-total impairment; other eye: not specified 250.9__ Diabetes with Unspecified Complications
369.65 One eye: near-total impairment; other eye: near normal vision Indicate fifth digit subclassification (0,1,2,3)
369.66 One eye: near-total impairment; other eye: normal vision
369.67 One eye: profound impairment; other eye: not specified 648.00 Diabetes Mellitus in Pregnancy,
369.68 One eye: profound impairment; other eye: near normal vision Unspec. Episode of care or N/A
369.69 One eye: profound impairment; other eye: normal vision
369.70 Impairment level not further specified 648.03 Diabetes Mellitus in Pregnancy,
369.71 One eye: severe impairment; other eye: not specified Antepartum condition or complication
369.72 One eye: severe impairment; other eye: near-normal vision 276.5 Hypovolemia 369.73 One eye: severe impairment; other eye: normal vision 359.2 Myotonic Disorders 369.74 One eye: moderate impairment; other eye, not specified 244.3 P-Amniosalicylic Acid (pas) 369.75 One eye: moderate impairment; other eye, near normal vision 657.03 Polyhdramnios 369.76 One eye: moderate impairment; other eye; normal vision 642.43 Pre-Eclampsia
369.8 Unqualified visual loss, one eye In addition report code from category 250 to indicate type of diabetes involved 369.9 Unspecified visual loss
Write the number (fifth digit) on the space provided
250.7__ Diabetes with Peripheral circulatory disorders
Use additional code to identify manifestations:
250.6__ Diabetes with Neurological Manifestations
Use additional code to identify manifestations:
250.3__ 250.4__ 250.1__ 250.2__
250.8__ Diabetes with Other Specified Manifestations
chronic, in diseases classified elsewhere
Diabetes Mellitus Diagnoses Codes and Associated Manifestations
Type II (NIDDM),Unspec type, not stated as uncontrolled Type I (IDDM), not stated as uncontrolled
Type II (NIDDM),unspecified type, uncontrolled (adult-onset diabetic patients,
(even if patient requires insulin)
Type I (IDDM), uncontrolled
250.0__
**PLEASE NOTE THIS IS NOT AN INCLUSIVE MANIFESTATION LIST**
276.52
Do at least four (4) of the following apply?
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In
children, consider failure to make expected weight gain. Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as
observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Does at least one (1) of the following apply?
Depressed mood most of the day, nearly everyday, as indicated by either subjective report (e.g., feels sad or empty) or
observation made by other (e.g., appears tearful).Note: In children and adolescents,
can be irritable mood.
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
Diagnosis of Major Depression may be assigned.
Does not meet diagnosis criteria for
Major Depression.
YES
YES
YES
NO
Does not meet diagnosis criteria for
Major Depression.
NO
NO
Sharp HealthCare Corporate Compliance 12/06
Doall of the following apply?
The symptoms do not meet criteria for Mixed Episode (i.e., Major Depression and Mania). The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of concern.
The symptoms are not due to the direct physiological effects of a substance. The symptoms are not better accounted for by bereavement.
The patient has had symptoms present for the same two week period.
Does not meet diagnosis criteria for
Major Depression.
Source: DSM-IV, 4th Edition DETERMINING MAJOR DEPRESSION
ICD-9 Diagnosis
296.2x Major Depression, Single Episode or
296.3x Major Depression, Recurrent
5
Codes Valid 10/01/07 to 9/30/08
6
