Use chapter-specific ICD-9-CM guidelines to resolve coding questions


Reading and understanding the chapter specific guidelines for ICD-9-CM can help unravel some confusion surrounding diagnosis coding. After all, the guidelines are designed to assist both healthcare providers and coders identify which diagnoses and procedures to report.

All coders use the ICD-9-CM codes to report diagnosis, regardless of whether they code for inpatient, outpatient, or physician services. The guidelines in the ICD-9-CM Official Guidelines for Coding and Reporting are the best resource for determining which code is appropriate.

The only other place to look is the AHA’s Coding Clinic, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, MA.

Coders need to know more than just the coding conventions found at the beginning of the ICD-9-CM Manual. They also need to read and understand the chapter-specific guidelines, says Jill Young, CPC, CEDC, CIMC, president of Young Medical Consulting, LLC, in East Lansing, MI. And they need to review the new guidelines each year.

Some of the guidelines, such as those for sepsis and HIV, are very complex, says Young. “If you don’t use them all of the time, you need to go back and read the guidelines.”

By learning the ICD-9-CM guidelines and staying current with the changes, coders can get a head start on preparing for ICD-10-CM. Approximately 90% of the guidelines are identical between the two systems, says McCall.

The changes are largely in the form of some additions. ICD-10-CM added new conventions, such as the placeholder, and identifies guidelines for laterality that aren’t in ICD-9-CM, McCall says. But, for the most part, the Centers for Disease Control mapped guidelines that are chapter specific in the current ICD-9-CM guidelines over to the appropriate chapter in ICD-10-CM.

Remember though that the ICD-10-CM guidelines are still in draft form and could change.

Some of the differences have sparked controversy, McCall says. For example, a patient is admitted for anemia associated with a neoplasm. The ICD-9-CM guidelines instruct coders to code the anemia as the principle diagnosis because it is the reason the admission occurred. ICD-10 includes a guideline that specifically states that if a patient is admitted for anemia and is solely treated for anemia, coders should report the malignancy as the principle diagnosis. That’s going to cause a shift in the MS-DRG, McCall says.

Diabetes mellitus
If you want to start working with physicians now to get ready for ICD-10-CM, start with diabetes, says Young.

In ICD-9-CM, diabetes mellitus falls under the 250 code series. These codes require a fifth digit to identify the type of diabetes mellitus and whether the diabetes is controlled or uncontrolled. Coders need to review the documentation carefully so they can select the correct fifth digit from this list:

  • 0, type II or unspecified type, not stated as uncontrolled
  • 1, type I [juvenile type], not stated as uncontrolled
  • 2, type II or unspecified type, uncontrolled
  • 3, type I [juvenile type], uncontrolled

If the physician doesn’t document the type of diabetes, coders default to type II. So if a physician doesn’t document complications or type of diabetes, coders default to code 250.00 (diabetes mellitus without mention of complications). In ICD-9-CM that’s a legitimate code, Young says.

However, in ICD-10-CM, coders will need to know the type of diabetes to get to the correct chapter. So anytime a physician documents diabetes mellitus, coders should ask for:

  • Type
  • Controlled or uncontrolled
  • Insulin dependent
  • Diabetes or secondary diabetes

If coders start asking for this information now, by the time ICD-10-CM rolls around, physicians will be used to providing it. “Let’s start helping the physicians out,” Young says.

ICD-9-CM also includes a code for long-term insulin use (code V58.67). Long-term use is for anyone who regularly uses insulin, including women with gestational diabetes. “Basically it’s anything other than an injectiontoday,” Young says.

Don’t assign code V58.67 if a physician provides insulin temporarily to bring a type II patient’s blood sugar under control during an encounter.

Secondary diabetes (code series 249) is always caused by another condition or event (e.g., cystic fibrosis, malignant neoplasm of pancreas, adverse effect of a drug, or poisoning). The fourth digit choices are the same as for diabetes mellitus (250 code series) and physicians need to document controlled or uncontrolled so coders can select the appropriate fifth digit.

When assigning codes for secondary diabetes and its associated conditions (e.g. renal manifestations), sequence the code(s) from category 249 before the codes for the associated conditions. The secondary diabetes codes and the diabetic manifestation codes that correspond to them are paired codes that follow the etiology/manifestation convention of the classification. Assign as many codes from 249.xx to identify all associated conditions for the patient. The corresponding codes are listed under each of the secondary diabetes codes.

The chapter-specific guidelines for HIV (and AIDS (both use code 042) contain “an incredible amount of information,” says Young. The guidelines contain information about how the physician should make the diagnosis to what makes a diagnosis for HIV/AIDS, as well as different tests he or she can perform.

The guidelines instruct coders to only code confirmed cases of HIV. Coders do not need documentation of a positive serology or culture for HIV. However, the provider must document that the patient is HIV positive or has an HIV-related illness.

When a patient without any documentation of symptoms is listed as “HIV positive,” “known HIV,” “HIV test positive,” or similar terminology, report code V08 (asymptomatic HIV infection status). Use code 042, not code V08, when documentation indicates that the patient:

  • Has AIDS
  • Is receiving treatment for an HIV-related illness
  • Has a condition related to his or her HIV positive status

Assign ICD-9-CM code 042 for patients with any known prior diagnosis of an HIV-related illness. Once a patient has developed an HIV-related illness, coders should always assign code 042 on every subsequent admission/encounter. The ordering of the diagnosis codes will depend on the specific situation.

Never assign codes 795.71 (nonspecific serologic evidence of HIV) or V08 for patients previously diagnosed with any HIV illness (code 042).

“You have to watch the diagnosis,” says Young. “Has it been officially documented by the physician? After that, the question becomes what is being treated. Go to the guidelines to see how to sequence the HIV codes.”

When it comes to coding for neoplasms (codes 140–239), coders know they have to first determine whether there is a pathology report, Young says. From that report, the coder needs to find out whether the neoplasm is benign, in?situ, malignant, or of uncertain histological behavior.

When a neoplasm is malignant, coders also need to look for secondary sites. If a physician mentions an extension, invasion, or metastasis to another site, code it as a secondary malignant neoplasm to that site. The secondary site may be the principal or first?listed. Use the V10 code (personal history of malignant neoplasm) as a secondary code.

If a physician excised a malignant tumor and the patient is no longer receiving treatment for it, select the appropriate code from the personal history section (V10 codes). When determining whether to use the active treatment or history codes, ask whether the physician is directing treatment to the site. That will determine which code to use, Young says.

When coding for complications of a neoplasm, coders need to look not only at the documentation, but also at payer rules, Young says. Insurance companies sometimes want things sequenced a certain way.

Also remember that when a single episode of care involves the surgical removal of a neoplasm followed by adjunct chemotherapy or radiation treatment, first assign the neoplasm code as principal or first-listed diagnosis (codes 140–198 or, when appropriate, 200–203).

However, if the patient only receives chemotherapy, immunotherapy, or radiation therapy, for the first listed or principle diagnosis assign one of the following codes:

  • V58.0, encounter for radiation therapy
  • V58.11, encounter for antineoplastic chemotherapy
  • V58.12, encounter for antineoplastic immunotherapy

If a patient receives more than one of these therapies during the same admission, coders may assign more than one of these codes in any sequence. Code the malignancy for which the therapy is being administered as a secondary diagnosis.

When a patient suffers pain as a result of a neoplasm, assign code 338.3 (neoplasm related pain) regardless of whether the pain is acute or chronic, Young says. If the physician documents the pain as the reason for the encounter, report 338.3 first and the underlying neoplasm as an additional diagnosis.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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