ICD CM Coding Guidelines by mikeholy

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									Chapter 4
ICD-9-CM Coding Guidelines

The ICD-9-CM Official Guidelines for Coding and Reporting, used as a companion document to the official ver-
sion of the ICD-9-CM, is a set of rules developed to accompany and complement the official conventions and
instructions provided within ICD-9-CM. It is based on the coding and sequencing instructions in Volumes I,
II, and III of ICD-9-CM and provides additional instruction. This chapter allows students to interpret the
ICD-9-CM Official Guidelines for Coding and Reporting as well as ICD-9-CM chapter-specific guidelines and
coding conventions to assign codes to diagnosis and procedure statements.

At the conclusion of this assignment, the student should be able to:
●   List and explain general ICD-9-CM diagnosis coding guidelines.
●   Assign codes by interpreting general ICD-9-CM diagnosis coding guidelines.
●   Interpret abbreviations and lab values to assign ICD-9-CM codes appropriately.

The general ICD-9-CM diagnosis coding guidelines accompany and complement the official conventions and
instructions provided within ICD-9-CM. HIPAA requires that official coding guidelines be used when assign-
ing ICD-9-CM diagnosis (and procedure) codes. The ICD-9-CM diagnosis codes (Volumes I and II) have been
adopted under HIPAA for all health care settings. (Volume III ICD-9-CM procedure codes are reported for
inpatient hospital procedures.)

Assign ICD-9-CM codes to the following diagnostic statements. Refer to the general ICD-9-CM diagnosis
coding guidelines in your textbook when assigning codes (e.g., assigning codes to qualified diagnoses and
coding signs/symptoms when a definitive diagnosis is documented).
                         1. Hearing loss, fever, swollen axillary lymph nodes, and infective otitis externa
                         2. Abdominal epilepsy
                         3. Type 2 diabetes mellitus without complication
                         4. Personal history of thyroid cancer
                         5. Shortness of breath
                         6. Foot pain (especially in the morning), plantar fasciitis
                         7. Peripheral neuropathy due to type 2 diabetes mellitus
                         8. Prostatitis
                         9. Acute and chronic salpingo-oophoritis
                        10. Chlamydial pneumonia

22        Chapter 4

                         11. Hydronephrosis due to prostatic hyperplasia
                         12. Dysphasia due to previous CVA
                         13. Osteoarthritis of hand due to previous crush injury
                         14. Impending MI
                         15. Meningitis due to trypanosomiasis
                         16. RLQ abdominal pain
                         17. Late effect of blood vessel injury, head
                         18. Streptococcal tonsillitis
                         19. Cystic fibrosis with pseudomonas infection
                         20. Acute glomerulonephritis due to SLE

At the conclusion of this assignment, the student should be able to:
●   Interpret ICD-9-CM coding conventions and general and chapter-specific coding guidelines to assign
    ICD-9-CM codes to diagnosis statements.
●   Interpret abbreviations and lab values to assign ICD-9-CM codes appropriately.

Section I of the ICD-9-CM Official Guidelines for Coding and Reporting includes:
●   The structure and conventions of the classification.
●   General guidelines that apply to the entire classification.
●   Chapter-specific guidelines that correspond to the tabular list of diseases (and tabular list of procedures)
    chapters as they are arranged in the classification.
  To assign ICD-9-CM codes accurately to diagnoses (and procedures), both the official guidelines and the
conventions located in the classification must be followed.

Assign ICD-9-CM codes to each diagnosis statement below.
Infectious and Parasitic Diseases
                           1. Genital chancre
                           2. Acute poliomyelitis, type II
                           3. Gastroenteritis due to ECHO virus
                           4. Food poisoning due to botulism
                           5. Hansen’s disease
                           6. Scarlet fever
                           7. Shingles
                           8. Hepatitis E
                           9. Mumps encephalitis
                         10. Viral pharyngoconjunctivitis
                                                                         ICD-9-CM Coding Guidelines       23


     Make sure you use the Table of Neoplasms in the ICD-9-CM index to locate benign and malignant neoplasm

                      11. Benign neoplasm of cornea
                      12. Benign neoplasm of colon
                      13. Benign neoplasm of true vocal cords
                      14. Benign neoplasm of adrenal gland
                      15. Hemangioma of peritoneum
                      16. Malignant neoplasm of lower lip, inner aspect
                      17. Acute blast cell leukemia
                      18. Letterer-Siwe disease
                      19. Malignant neoplasm of brain, parietal lobe
                      20. Malignant neoplasm of ovary
Endocrine, Nutritional, Metabolic, Immunity
                      21. Atrophy of thyroid
                      22. Lorian-Levi dwarfism
                      23. Ascorbic acid deficiency
                      24. DiGeorge’s syndrome
                      25. PKU
                      26. Premature menopause
                      27. Postsurgical testicular hypofunction
                      28. Postsurgical hypoinsulinemia
                      29. Thymus abscess
                      30. Conn’s syndrome
Diseases of the Blood and Blood-Forming Organs
                      31. Sideroblastic anemia
                      32. Eosinophilia
                      33. Nonautoimmune hemolytic anemia
                      34. Mixed thalassemia
                      35. Imerslund’s syndrome
                      36. HbSS disease with crisis, crisis is acute chest syndrome
                      37. Pancytopenia, congenital
                      38. PTA deficiency
                      39. Fibrinolytic hemorrhage, acquired
                      40. Big spleen syndrome
Mental Disorders
                      41. Acute alcoholic hallucinosis
                      42. Senile dementia paranoid type
24     Chapter 4

                     43. Borderline schizophrenia
                     44. Agoraphobia with panic disorder
                     45. Heroin dependence
                     46. Dyssocial personality disorder
                     47. Night terrors
                     48. Tourette’s disorder
                     49. Nervous gastritis
                     50. Tension headache
Diseases of the Nervous System and Sense Organs
                     51. Meningitis due to Pseudomonas
                     52. Pick’s disease of the brain
                     53. Hematomyelia
                     54. Eales’ disease
                     55. Cluster headache
                     56. Bullous retinoschisis
                     57. Refsum’s disease
                     58. Tarsal tunnel syndrome
                     59. Vernal conjunctivitis
                     60. Acute radial nerve palsy
Diseases of the Circulatory System
                     61. Tricuspid valve insufficiency
                     62. External thrombosed hemorrhoids
                     63. Raynaud’s syndrome with gangrene
                     64. Horton’s disease
                     65. Atrial fibrillation and flutter
                     66. Rupture of papillary muscle
                     67. ASCVD
                     68. Right heart failure
                     69. Past MI diagnosed by EKG, no current symptoms
                     70. Benign hypertension
Diseases of the Respiratory System
                     71. Hypertrophic adenoids and tonsils
                     72. Legionnaires’ disease
                     73. Supraglottic edema
                     74. Acute exacerbation of bronchiectasis
                     75. Mediastinum abscess
                     76. Acute and chronic respiratory failure
                     77. Loffler’s syndrome
                     78. Smokers’ cough
                     79. Cyst of pharynx
                     80. Allergic rhinitis due to cat hair
                                                                       ICD-9-CM Coding Guidelines   25

Diseases of the Digestive System
                     81. Chronic periodontitis
                     82. Arthralgia of TMJ
                     83. Corkscrew esophagus
                     84. Furrowed tongue
                     85. Infection of gastrostomy due to E. coli
                     86. Recurrent femoral hernia, with gangrene, unilateral
                     87. Phlebitis of portal vein
                     88. Tropical steatorrhea
                     89. Gallstone ileus
                     90. Exostosis of jaw
Diseases of the Genitourinary System
                     91. Orthostatic proteinuria
                     92. Multinodular prostate
                     93. Galactocele
                     94. Prolapse of urethra
                     95. Floating kidney
                     96. Intrinsic urethral sphincter deficiency
                     97. Renal osteodystrophy
                     98. Nephrotic syndrome with lesion of membranous glomerulonephritis
                     99. Carbuncle of kidney
                    100. Hunner’s ulcer
Complications of Pregnancy, Childbirth, and the Puerperium
                    101. Postpartum hemorrhage, third stage
                    102. Acute renal failure immediately following labor and delivery
                    103. Vesicular mole
                    104. Mural pregnancy
                    105. Legally induced complete abortion complicated by shock
                    106. Miscarriage, incomplete
                    107. Postpartum fever
                    108. Postpartum dehiscence of cesarean wound
                    109. Delivery of twin boys, both alive
                    110. Premature labor, delivered healthy female
Diseases of the Skin and Subcutaneous Tissue
                    111. Cradle cap
                    112. Heel decubitus ulcer
                    113. Xerosis cutis
                    114. Angioma serpiginosum
                    115. Hypertrophic scar of the chest
                    116. Koilonychia
26      Chapter 4

                    117. Heat rash
                    118. Duhring disease
                    119. Third-degree sunburn
                    120. Rosacea
Diseases of the Musculoskeletal System and Connective Tissue
                    121. Panniculitis
                    122. Acquired wrist drop
                    123. Lordosis
                    124. Sicca syndrome
                    125. Crystal arthropathy of the hip
                    126. Caplan’s syndrome
                    127. Ganglion of tendon sheath
                    128. Golfers’ elbow
                    129. Tendinitis
                    130. Acute osteomyelitis of tibia
Congenital Anomalies
                    131. Nuclear cataract, congenital
                    132. Incomplete AV block, congenital
                    133. Microtia
                    134. Choanal atresia
                    135. Bilateral incomplete cleft lip
                    136. Flat foot, congenital
                    137. Congenital absence of right foot
                    138. Six toes on left foot
                    139. Edward’s syndrome
                    140. Strawberry nevus
Certain Conditions Originating in the Perinatal Period
                    141. Fetal alcohol syndrome
                    142. Perinatal alveolar hemorrhage
                    143. Fracture of clavicle of newborn at delivery
                    144. Hematemesis and melena due to swallowed maternal blood
                    145. Neonatal tachycardia
                    146. Birth weight of 650 grams, 25 weeks
                    147. Neonatal jaundice due to Gilbert’s syndrome
                    148. Neonatal hyperthyroidism
                    149. Vomiting, baby is 2 days old
                    150. Drug withdrawal syndrome, newborn, mother addicted to cocaine
Symptoms, Signs, and Ill-Defined Conditions
                    151. Shadow of lung found on chest x-ray
                    152. Elevated LDH
                    153. Ascites
                                                                          ICD-9-CM Coding Guidelines          27

                       154. Elevated blood pressure reading
                       155. Abnormal kidney function test
                       156. SIDS
                       157. Senility
                       158. Periumbilical abdominal pain
                       159. Elevated PSA
                       160. Elevated sedimentation rate
Injury and Poisoning
                       161. Injury to auditory nerve
                       162. Flail chest
                       163. C2 fracture with central cord syndrome
                       164. Fracture of coracoid process of scapula, closed
                       165. Open dislocation of wrist, carpal bone
                       166. Poisoning by barbiturates
                       167. Bimalleolar fracture of ankle, closed
                       168. Open fracture of two phalanges of foot
                       169. Bucket handle tear of knee
                       170. Closed skull fracture, three hours of unconsciousness
V Codes: Supplementary Classification of Factors Influencing Health Status and Contact with Health
                       171. Personal history of leukemia
                       172. Family history of Huntington’s chorea
                       173. History of heart valve replacement
                       174. Encounter for reprogramming of cardiac defibrillator
                       175. Long-term use of NSAIDs
                       176. Encounter for speech therapy
                       177. Nutrition counseling, patient recently diagnosed with type 2 diabetes mellitus.
                       178. Sleep deprivation
                       179. Blood alcohol test
                       180. Screening examination for cystic fibrosis
E Codes: Supplementary Classification of External Causes of Injury and Poisoning
                       181. Fire aboard a ship, injured person is a passenger
                       182. Accidental perforation during heart catheterization
                       183. Abandonment of newborn
                       184. Assault by human biting
                       185. Injury due to fight
                       186. Bee sting
                       187. Injury caused by dust storm
                       188. Mismatched blood in transfusion
                       189. Accidental poisoning with diazepam
                       190. Fall from chair
28       Chapter 4

At the conclusion of this assignment, the student should be able to:
●   Interpret ICD-9-CM coding conventions and general and chapter-specific coding guidelines to assign
    ICD-9-CM codes to procedure statements.
●   Interpret abbreviations and lab values to assign ICD-9-CM codes appropriately.

ICD-9-CM procedure codes describe procedures performed for the inpatient treatment of illness and injury.
Volume III of ICD-9-CM contains the classification system for diagnostic, surgical, and therapeutic proce-
dures. It includes both an alphabetic index and a tabular list.

Assign the appropriate ICD-9-CM procedure code to each statement.
Procedures and Interventions, Not Elsewhere Classified
                         1. Intravascular imaging of aorta
                         2. Implantation of CRT-D
                         3. Percutaneous angioplasty of intracranial vessels with injection of
                            thrombolytic agent
                         4. Computer-assisted surgery with fluoroscopy
                         5. Intravascular nonablative ultrasound, peripheral vascular vessels
                         6. Nitric oxide therapy
                         7. Intravascular ultrasound of intrathoracic vessels
                         8. Replacement of CRT-P
                         9. Implantation of CRT-P pulse generator only
                        10. Infusion of recombinant protein
Operations on the Nervous System
                        11. Repair of spinal meningocele
                        12. Anesthetic injection into peripheral nerve for analgesia
                        13. Aspiration of Rathke’s pouch
                        14. Excision of acoustic neuroma by craniotomy
                        15. Reduction of fracture of vertebrae
                        16. Spinal tap
                        17. Transtemporal excision of brain tumor
                        18. Subdural patch
                        19. Spinal blood patch
                        20. Needle biopsy of cerebral meninges
Operations on the Endocrine System
                        21. Complete thyroidectomy
                        22. Closed biopsy of adrenal gland
                        23. Partial excision of pituitary gland, transsphenoidal approach
                        24. Repair of adrenal gland
                                                                    ICD-9-CM Coding Guidelines   29

                    25. Autotransplantation of parathyroid tissue
                    26. Partial thyroidectomy
                    27. Incision of pineal gland
                    28. Excision of thyroglossal tract
                    29. Biopsy of thymus
                    30. Total pinealectomy
Operations on the Eye
                    31. Suture repair of ectropion
                    32. DCR procedure
                    33. Corneal biopsy
                    34. Ophthalmoscopy
                    35. Removal of orbital implant
                    36. Repair of retinal detachment, laser photocoagulation
                    37. Keratoplasty
                    38. Cataract extraction
                    39. Excision of chalazion
                    40. Excision of lesion of lacrimal gland
Operations on the Ear
                    41. Mastoid myoplasty
                    42. Fenestration of labyrinth with graft
                    43. Lysis of adhesions of middle ear
                    44. Reconstruction of auricle
                    45. Tympanoplasty, type III
                    46. Radical mastoidectomy
                    47. Biopsy of external ear
                    48. Otoplasty
                    49. Otoscopy
                    50. Electrocochleography
Operations on the Nose, Mouth, and Pharynx
                    51. Rhinoscopy
                    52. Odentectomy
                    53. Drainage of Ludwig’s angina
                    54. Correction of cleft palate
                    55. Tonsillectomy with adenoidectomy (T&A)
                    56. Correction of nasopharyngeal atresia
                    57. Epistaxis control by cauterization
                    58. Turbinectomy by cryosurgery
                    59. Closed biopsy of nasal sinus
                    60. Tooth extraction
30     Chapter 4

Operations on the Respiratory System
                    61. Lysis of adhesions of larynx
                    62. Exploratory thoracotomy
                    63. Thoracicogastric fistulectomy
                    64. Lung volume reduction surgery
                    65. Fiberoptic bronchoscopy
                    66. Fiberoptic bronchoscopy with fluoroscopic guidance with biopsy
                    67. Pleural biopsy
                    68. Repair of pectus deformity with implant
                    69. Whole lung lavage
                    70. Temporary tracheostomy
Operations on the Cardiovascular System
                    71. Mustard operation, patient on bypass
                    72. Total repair of tetralogy of Fallot
                    73. Intracardiac echocardiography
                    74. Clipping of aneurysm
                    75. Pericardiocentesis
                    76. Repair of mitral valve with homograft
                    77. Suture repair of lacerated blood vessel
                    78. Venous cutdown
                    79. Percutaneous angioscopy
                    80. Right ventricular infundibulectomy, patient on bypass
Operations on the Hemic and Lymphatic System
                    81. Partial splenectomy
                    82. Bone marrow aspiration from donor
                    83. Excision of axillary lymph nodes
                    84. Bone marrow biopsy
                    85. Total splenectomy
                    86. Closure of fistula of thoracic duct
                    87. Radical excision of groin lymph nodes
                    88. Cord blood stem cell transplant
                    89. Open biopsy of spleen
                    90. Biopsy of lymphatic structures
Operations on the Digestive System
                    91. EGD with biopsy
                    92. Right hemicolectomy
                    93. Proctotomy
                    94. Closure of anal fistula
                    95. Biopsy of perianal tissue
                    96. ERC
                                                                        ICD-9-CM Coding Guidelines   31

                     97. Laparoscopic cholecystectomy
                     98. Radical pancreaticoduodenectomy
                     99. Repair of diaphragmatic hernia, abdominal approach
                    100. Lysis of peritoneal adhesions
Operations on the Urinary System
                    101. Nephroscopy
                    102. Nephropexy
                    103. Transurethral cystoscopy
                    104. Ureteropexy
                    105. Implantation of artificial urinary sphincter
                    106. Urethrotomy
                    107. Biopsy of urethra
                    108. Kidney transplant, living donor unrelated to patient
                    109. Needle biopsy of kidney
                    110. Wedge resection of bladder
Operations on the Male Genital Organs
                    111. TULIP
                    112. TUNA
                    113. Orchiopexy
                    114. TUMT of prostate
                    115. Percutaneous biopsy of prostate
                    116. Cryosurgery of prostate
                    117. Unilateral orchiectomy
                    118. Aspiration of hydrocele of tunica vaginalis
                    119. Vasectomy
                    120. Biopsy of penis
Operations on the Female Genital Organs
                    121. Laparoscopic wedge resection of ovary
                    122. Biopsy of fallopian tube
                    123. Schauta operation
                    124. Cryoconization of cervix
                    125. Insufflation of fallopian tube
                    126. Culdoscopy
                    127. Division of Skene’s gland
                    128. Diagnostic D and C
                    129. Biopsy of uterus via hysteroscopy
                    130. LSH
Obstetrical Procedures
                    131. Low cervical cesarean section
                    132. Fetal pulse oximetry
32     Chapter 4

                   133. Spintelli operation
                   134. DeLee maneuver
                   135. Episiotomy
                   136. Artificial rupture of membranes to induce labor
                   137. Vacuum extraction with episiotomy
                   138. Manual removal of retained placenta
                   139. Repair of current obstetric laceration of bladder
                   140. Diagnostic amniocentesis
Operations on the Musculoskeletal System
                   141. Biopsy of tibia
                   142. Closed reduction of dislocated wrist
                   143. Tibiotalar fusion
                   144. Quadricepsplasty
                   145. Wedge osteotomy of ulna
                   146. Diskectomy of cervical disk
                   147. TKR
                   148. O’Donoghue operation
                   149. Exploration of tendon sheath
                   150. Fasciotomy
Operations on the Integumentary System
                   151. Removal of nail necrosis
                   152. Insertion of vascular (venous) access device (VAD)
                   153. Lumpectomy
                   154. Removal of breast implant
                   155. Chemical peel of skin
                   156. Escharotomy
                   157. Removal of necrosis of skin by washing
                   158. Dermabrasion
                   159. Biopsy of skin
                   160. Hair transplant
Miscellaneous Diagnostic and Therapeutic Procedures
                   161. Video EEG
                   162. ROM testing
                   163. Hypnosis
                   164. Ophthalmologic examination for glaucoma
                   165. Gastric lavage
                   166. Transfusion of plasma
                   167. Removal of peritoneal drain
                   168. Replacement of tracheostomy tube
                   169. Audiometry
                   170. Vaginal packing
                                                                            ICD-9-CM Coding Guidelines   33

Multiple Choice
Circle the most appropriate response.
 1. Diabetic retinopathy, patient has type 1 diabetes.
    a. 250.5, 362.01                                 c. 362.01, 250.5
    b. 250.51, 362.01                                d. 362.01
 2. Noise-induced hearing loss.
    a. 388.12                                       c. 389.20
    b. 388.2                                        d. 389.9
 3. Acute and chronic cystitis.
    a. 595.0                                        c. 595.2
    b. 595.0, 595.2                                 d. 595.89
 4. Endocarditis due to candidiasis.
    a. 112.81                                       c. 424.90
    b. 112.81, 424.90                               d. 424.90, 112.81
 5. Localized secondary arthritis of hand, late effect of crush injury.
    a. 715.24, 906.4                                  c. 906.4
    b. 716.14, 906.4                                  d. 906.4, 716.14
 6. Family history of colon cancer and personal history of breast cancer.
    a. V10.00, V10.3                                c. V16.0, V10.3
    b. V10.09, V10.3                                d. V16.0, V16.3
 7. Pneumonia due to SARS.
    a. 480.3                                        c. 486
    b. 480.3, 079.82                                d. 486, 079.82
 8. Primary neoplasm of mullerian duct, patient is a 45-year-old female.
    a. 184.8                                        c. 221.8
    b. 187.8                                        d. 222.8
 9. Open wound of finger with glass particles in wound.
    a. 883                                          c. 883.1
    b. 883.0                                        d. 883.2
10. Postoperative hypotension.
    a. 458                                          c. 458.8
    b. 458.29                                       d. 458.9
11. Mastoidectomy with skin graft.
    a. 20.41                                        c. 20.49
    b. 20.42, 18.71                                 d. 20.49, 18.79
12. Laparoscopic cholecystectomy with intraoperative cholangiogram.
    a. 51.23, 87.53                                c. 51.24, 87.51
    b. 51.23, 87.54                                d. 51.24, 87.53
13. ORIF of radius fracture.
    a. 79.02                                        c. 79.22
    b. 79.12                                        d. 79.32
14. Insertion of vascular port.
    a. 38.95                                        c. 86.07
    b. 86.06                                        d. 86.09
15. EGD with biopsy.
    a. 44.14                                        c. 45.16
    b. 44.19                                        d. 45.19
34      Chapter 4

16. CABG of two coronary arteries and internal mammary artery. Patient is also placed on cardiopulmonary
    a. 36.1
    b. 36.10, 36.12, 36.15, 39.61
    c. 36.12, 36.15, 39.61
    d. 36.12, 39.61
17. Intracoronary artery thrombolytic infusion of streptokinase.
    a. 36.04                                          c. 36.07
    b. 36.06                                          d. 36.09
18. Physical therapy and occupational therapy.
    a. 93.11, 93.83                                  c. 93.19, 93.83
    b. 93.11, 93.85                                  d. 93.39, 93.83
19. Removal of peripheral nerve lesion.
    a. 04.04                                         c. 04.07
    b. 04.06                                         d. 04.11
20. Nephrectomy of rejected kidney.
    a. 55.5                                          c. 55.53
    b. 55.52                                         d. 55.69

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