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Updates on ICD-9-CM Coding for Primary Care Conference – March 29, 2006

This comprehensive update from the Primary Care Conference on March 29, 2006, focuses on ICD-9-CM coding guidelines and their implications in clinical settings. It outlines the transition to ICD-10, provides coding tips for various conditions, and details the correct approaches for documenting diagnoses, including malignant conditions and complications related to diabetes mellitus. Key aspects cover nursing facility codes and the importance of accurate coding for effective patient management, particularly for individuals with complex diseases.

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Updates on ICD-9-CM Coding for Primary Care Conference – March 29, 2006

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  1. Coding Update 2006 Primary Care Conference March 29, 2006

  2. ICD-9-CM • International Classification of Diseases - 9th Edition - Clinical Modification • ICD-10 already in use internationally • 2009 for USA ??

  3. ICD-9-CM Coding Guidelines National Center for Health Statistics website http://www.cdc.gov/nchs/icd9.htm Coding Clinic – issued quarterly by American Hospital Association

  4. Diagnosis Code Tips Do not code diagnoses documented as rule out (R/O), probable, suspected, or consistent with…

  5. Abnormal findings Findings, abnormal, w/o diagnosis • Positive PPD • Prolonged bleeding time • Electrocardiogram • Liver function tests

  6. Signs & Symptoms • Fever • Dysuria • Wheezing • Fatigue • Knee pain

  7. ICD arranged by Condition • Bronchitis • Pain • Sprain • Bursitis • Cellulitis

  8. Site or Type • Pain, • ankle • knee • Arthritis • inflammatory • fingers • multiple sites

  9. Malignancy coding • Locate code by histological type; (eg melanoma, astrocytoma) • Code as malignancy as long as it is still being treated • Code as a history of malignancy once active treatment has ended

  10. Neoplasms Neoplasm Table • Primary • Secondary • Ca in situ • Benign • Uncertain Behavior • Unspecified

  11. Unknown primary malignancy Assign code 199.1 for unknown primary, if still actively treated

  12. Diabetes – compound coding If using a fourth digit to describe complication – code also the complication as a secondary code

  13. Diabetes Mellitus – 4th digits 250.0x = w/o mention of complication 250.1x = w/ketoacidosis 250.2x = w/hyperosmolarity 250.3x = w/other coma 250.4x = w/renal manifestations

  14. Diabetes Mellitus – 4th digit 250.5x = w/ophthalmic manifestations 250.6x = w/neurologic manifestations 250.7x = w/peripheral circulatory disorders 250.8x = w/other specified manifestations 250.9x = w/unspecified complications

  15. Diabetes – 5th digit • 0 type II or unspecified, not uncontrolled • 1 type I, not uncontrolled • 2 type II or unspecified, uncontrolled • 3 type I, uncontrolled

  16. Nursing Facility Codes • Skilled Nursing (SNF) • Intermediate Care (ICF) • Long Term Care (LTCF) • Psychiatric Residential Treatment Center

  17. Nursing Facility Services • Three levels of service for admissions • Four levels for subsequent care • Comprehensive annual assessment

  18. Domiciliary, Rest Home or Custodial Care services • Section revised to better capture care provided in these settings • Increasing number of patients with complex diseases (eg, Alzheimer patients)

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