Chapter02 PDF

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P A R T
ICD9CM AND ICD10CM

2
Introduction to ICD-9-CM
ICD9CM Chapter-Specific
Guidelines, Part I:
Chapters 110
ICD-9-CM Chapter-Specific
Guidelines, Part II:
Chapters 1119
Introduction to
ICD-10-CM
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INTRODUCTION
TO ICD9CM
Learning
Key
TermsOutcomes
After completing this chapter, students should be able to:
2.1 Explain the structure of the ICD-9-CM

manual.
2.2 Describe how to use Volumes 1 and 2 to
determine diagnosis codes.
2.3 Define the conventions used in Volumes 1

and 2 that help coders identify correct
diagnosis codes.
Key Terms
Alphabetic Index of Diseases
(Volume 2)
Encounter
First-listed diagnosis
Hypertension Table
NEC (not elsewhere classifiable)
Neoplasm Table
NOS (not otherwise specified)
Principal diagnosis
Secondary diagnosis
Sign
Supplemental classification
Symptom
Table of Drugs and Chemicals
Tabular List of Diseases
(Volume 1)
Visit
2.4 Discuss general outpatient coding

principles to select appropriate diagnosis
codes.
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Introduction
Describing medical services completely requires the use of at least two out of three
separate coding systems. Two coding systemsCurrent Procedural Terminology
(CPT) and Healthcare Common Procedural Coding System (HCPCS)describe
the actual services provided and are discussed in later chapters of this book. A
third system, the International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM or ICD-9), describes the reasons those services were provided. These three coding systems can be thought of as the what and the why
regarding the services provided.
The ICD-9-CM coding system is based on the official version of the World Health
Organizations (WHO) ninth revision of the International Classification of Diseases
(ICD-9). The World Health Organization no longer maintains ICD-9, publishing
instead the ICD-10. Two federal agenciesthe National Center for Health Statistics
and the Centers for Medicare and Medicaid Servicesmaintain ICD-9-CM through
the ICD-9-CM Coordination and Maintenance Committee, which publishes annual
updates of the ICD-9-CM manual in October of each year. These two entities are
responsible for converting the ICD-9-CM coding system to two new systems,
ICD-10-CM (Diagnoses) and ICD-10-PCS (Procedures), scheduled to begin on
October 1, 2013.
Correct diagnosis coding facilitates payment for services, tracks disease and associated healthcare usage, advances research, and aids patient care. Diagnosis codes should
be reported to the highest level of specificity known and accurately represent information in the medical record. It is important to review the medical record sufficiently to
ascertain all the conditions treated. The ICD-9-CM diagnosis codes support the medical necessity of the treatments provided to the patient.
Reporting diagnosis codes will change significantly in 2013 when the ICD-10-CM
code set replaces the ICD-9-CM codes. ICD-10-CM will be discussed in detail in
Chapter 5. Some instructors may choose to teach ICD-9-CM and ICD-10-CM together,
whereas others may separate the two. To accommodate multiple approaches to learning the current coding system as well as the future codes, exercises in Chapters 3 and
4 will include answers for both.
CODERS TIP
Many payers have claim edits in their adjudication (claims processing) systems that
establish diagnosis to procedure code relationships to justify payments for the
claimed procedure. Coders should be familiar with the specific requirements for each
payer. When preparing a claim, review all diagnosis codes associated with the patient
and visit to make sure that important information for reporting the particular service
is not overlooked.
2.1 The Structure of the ICD-9-CM Manual

The ICD-9-CM code manual consists of three volumes. Volume 1 (Tabular List of
Diseases) and Volume 2 (Alphabetic Index of Diseases) are used together to determine appropriate diagnosis codes. These codes are used to report diagnoses in all
settings. Volume 3, which contains both a tabular and alphabetical list of procedure
codes, is used by hospitals to identify procedures performed on patients in their
facilities. Physicians and other professionals do not use Volume 3 to report
procedures.
Each volume is divided into chapters, tables, or appendices. The chapters in Volume 1
cover codes describing specific diseases and conditions. Volume 2 includes several
CHAPTER 2 | INTRODUCTION TO ICD9CM
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tables with information necessary to identify codes describing particular conditions.

Chapters in Volume 3 describe procedures on specific body systems. Each of these is
discussed in more detail below.
CODERS TIP
Coders must understand the basic structure of the ICD-9-CM manual and the information included in each volume. It is also important to understand which volumes are
used to report diagnosis and procedure codes in each healthcare setting.
Also available in
EXERCISE 2.1
Use the ICD-9-CM manual to answer the following questions.
1. How many volumes are included in the ICD-9-CM manual?
2. Identify the volumes by name and number.
3. Which healthcare entities use the codes in Volume 3?
2.2 Using Volumes 1 and 2 to Determine

Diagnosis Codes
Tabular List of Diseases
(Volume 1)
Volume 1 of the ICD-9-CM
manual, which covers codes
describing specific diseases and
conditions.
Alphabetic Index of
Diseases (Volume 2)
manual, which includes several
tables with information necessary to identify codes describing particular conditions.
Volume 1 is the Tabular List of Diseases. Volume 2 is the Alphabetic Index of

Diseases. Coders use both volumes in tandem to determine correct diagnosis codes.
When selecting a code to describe a diagnosis, coders actually use the Alphabetic Index in
Volume 2 first to identify possible diagnosis codes, and then use the list of individual
codes and their descriptors in Volume 1 to select the most appropriate code from
among them. Because coders should always use the volumes in this order, Volume 2
is presented first, then Volume 1.
Volume 2: Alphabetic Index of Diseases

The Alphabetic Index of Diseases lists diseases, conditions, and injuries along with
their accompanying codes. It is used as a guide in finding the correct codes. In
most manuals, Volume 2 actually precedes Volume 1, and the two volumes are always used together to validate or refine the code selection. Volume 2 has three
discrete sections:
When assigning codes for

neoplasms, begin with the
Neoplasm Table that appears in
manual.
Section 1: Alphabetic Index to diseases, conditions and injuries. This section

includes the Hypertension Table and Neoplasm Table, which coders use to select
the correct codes to describe related conditions. Figure 2.1 shows an example of
entries in the Alphabetic Index.
Section 2: Table of Drugs and Chemicals, which includes an extensive list of
drugs, industrial solvents, corrosive gases, noxious plants, pesticides, and other
toxic agents. Coders use this table to identify poisonings and external causes of
adverse affects.
Section 3: Alphabetic Index to External Causes of Injury and Poisoning (E-codes),
a list of codes and terms that describe environmental circumstances, such as accidents or acts of violence, and other conditions that may be the cause of injury or
other adverse effects.
38
CPT only 2010 American Medical Association. All rights reserved.
PART I | ICD9CM AND ICD10CM
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FIGURE 2.1 Example of Alphabetic Index Entries

C
Cacergasia 300.9
Cachexia 799.4
cancerous - see also Neoplasm, by site,
malignant 799.4
cardiac - see Disease, heart
dehydration 276.51
with
hypernatremia 276.0
hyponatremia 276.1
due to malnutrition 799.4
exophthalmic 242.0 5th
heart - see Disease, heart
hypophyseal 253.2
hypopituitary 253.2
lead 984.9
specified type of lead - see Table of
Drugs and Chemicals
malaria 084.9
malignant see also Neoplasm, by site,
malignant 799.4
marsh 084.9
nervous 300.5
old age 797
pachydermic - see Hypothyroidism
paludal 084.9
pituitary (postpartum) 253.2
renal (see also Disease, renal) 593.9

saturnine 984.9
specified type of lead - see Table of
Drugs and Chemicals
senile 797
Simmonds (pituitary cachexia) 253.2
splenica 289.59
strumipriva (see also Hypothyroidism) 244.9
tuberculous NEC (see also Tuberculosis)
011.9 5th
Caf au lait spots 709.09
Caffeys disease or syndrome (infantile
cortical hyperostosis) 756.59
Caisson disease 993.3
Caked breast (puerperal, postpartum)
676.2 5th
Cake kidney 753.3
Calabar swelling 125.2
Calcaneal spur 726.73
Calcaneoapophysitis 732.5
Calcaneonavicular bar 755.67
Calcareous - see condition
Calcicosis (occupational) 502
Calciferol (vitamin D) deficiency 268.9
with
osteomalacia 268.2
rickets (see also Rickets) 268.0
Diagnosis codes that identify the main reason for the encounter should be listed
first. When coding for professional medical services such as ophthalmology (rather
than physician visits), usually referred to as outpatient coding, the major diagnosis is
usually referred to as the first-listed diagnosis. For hospital coding, the major diagnosis is often referred to as the principal diagnosis. Because this text primarily addresses outpatient coding, the main diagnosis will be referred to as the first-listed
diagnosis. Additional or secondary diagnosis codes may be listed to identify other
conditions that are present.
CODERS TIP
It is imperative to use both Volumes 1 and 2 to determine the correct ICD-9-CM code.
Always start with Volume 2. After finding codes in Volume 2 that may describe
the condition, refer to those code sections in Volume 1 for critical guidance regarding
the use of additional digits, alternative codes, or additional codes.
CODING EXAMPLE
A patient presents with a migraine headache. Turning to Volume 2, coders can look
under migraine to find a list of four-digit codes ranging from 346.0 to 346.9 that
describe different conditions associated with migraines. Each of these codes includes
a symbol indicating that a fifth digit is necessary.
Volume 1 includes additional information regarding codes 346.0346.9, including
lists of conditions included under each code and specific excluded conditions. It is not
possible to determine the correct code without reviewing these inclusions and exclusions, as well as the fifth digits necessary to completely describe the patients condition.
hypertension table
A table containing a complete
list of all conditions that are
either due to or associated
with hypertension.
neoplasm table
A table used to select correct
codes for neoplasms.
table of drugs and
chemicals
A table that includes an extensive list of drugs, industrial solvents, corrosive gases, noxious
plants, pesticides, and other
toxic agents to identify poisonings and external causes of
adverse affects.
first-listed diagnosis
The major diagnosis used to
identify the main reason for outpatient or professional services.
principal diagnosis
The major diagnosis used to
identify the main reason for the
service when coding for the
hospital.
secondary diagnosis
Additional diagnoses used to
identify conditions that are
present in addition to the major
diagnosis.
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Volume 1: Tabular List of Diseases

The Tabular List of Diseases (Volume 1) consists of three parts:
etiology
The origins and causes for the
development of a disease.
supplemental classification
Additional information beyond
the diagnosis codes used to
fully describe the reason a
patient encountered the
healthcare system.
Disease classification by etiology (cause) or anatomical (body) site

Supplementary classification (V- and E-codes)
Appendices
Diseases are primarily classified by their causes or the anatomical sites affected by
those diseases. This section of Volume 1 is divided into 17 individual chapters containing categories and subcategories of codes that describe diseases (see Table 2.1).
Each category is designated by three-digit codes. In most cases, this is not sufficient to
accurately report the diagnosis or condition. Subcategories include codes with either a
fourth character or fourth and fifth characters to identify the diagnosis in sufficient detail
for reporting purposes. Figure 2.2 provides an example of entries in the Tabular List.
The second part of Volume 1 is comprised of Chapters 18 and 19. Codes in these
chapters describe supplemental classifications, which provide additional information beyond the diagnosis codes, including:
18. Supplementary Classification of Factors Influencing Health Status and Contact
with Health Services (V01V91)
19. Supplementary Classification of External Causes of Injury and Poisoning
(E800E999)
The use of V- and E-codes will be discussed in greater detail below.
TABLE 2.1 Tabular List Organization

Chapter Descriptive Title
40
Categories
1. Infectious and Parasitic Diseases
001139
2. Neoplasms
140239
3. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders
240279
4. Diseases of the Blood and Blood-Forming Organs
280289
5. Mental Disorders
290319
6. Diseases of the Nervous System and Sense Organs
320389
7. Diseases of the Circulatory System
390459
8. Diseases of the Respiratory System
460519
9. Diseases of the Digestive System
520579
10. Diseases of the Genitourinary System
580629
11. Complications of Pregnancy, Childbirth, and the Puerperium
630679
12. Diseases of the Skin and Subcutaneous Tissue
680709
13. Diseases of the Musculoskeletal System and Connective Tissue
710739
14. Congenital Anomalies
740759
15. Certain Conditions Originating in the Perinatal Period
760779
16. Symptoms, Signs, and Ill-Defined Conditions
780799
17. Injury and Poisoning
800999
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FIGURE 2.2 Example of Tabular List Entries

4th 585 Chronic kidney disease (CKD)
Includes Chronic uremia
Code first hypertensive chronic kidney disease, if applicable,
(403.00-403.91, 404.00-404.93)
Use additional code to identify:
kidney transplant status, if applicable (V42.0)
manifestation as:
uremic:
neuropathy (357.4)
pericarditis (420.0)
585.1 Chronic kidney disease, Stage I
585.2 Chronic kidney disease, Stage II (mild)
585.3 Chronic kidney disease, Stage III (moderate)
585.4 Chronic kidney disease, Stage IV (severe)
585.5 Chronic kidney disease, Stage V%
Excludes chronic kidney disease, stage V requiring
chronic dialysis (585.6)
585.6 End stage renal disease,
Chronic kidney disease, stage V requiring chronic dialysis
585.9 Chronic kidney disease, unspecified
Chronic renal disease
Chronic renal failure NOS
Chronic renal insufficiency
The third part of Volume 1 includes four separate appendices:

Appendix A: Morphology of Neoplasms
Appendix C: Classification of Drugs by American Hospital Formulary Services List
Number and Their ICD-9-CM Equivalents
Appendix D: Classification of Industrial Accidents According to Agency
Appendix E: List of Three-Digit Categories
Note that there is no Appendix B.
CODERS TIP
Appendix B (The Glossary of Mental Disorders) was officially deleted on October 1,
2004, and is no longer included in the ICD-9-CM manual.
Volume 3: Tabular List and Alphabetic

List for Procedure Codes
As mentioned earlier in this chapter, Volume 3 of the ICD-9-CM manual is used only
in hospital settings. CPT codes are used to describe procedures reported by professionals. These will be discussed in great detail later in this book.
The approximately 4,000 codes in Volume 3 are divided into 17 chapters designated as 0 through 16. Each chapter contains one or more two-digit sections describing particular types of procedures. Specific procedure codes include either a third digit
or third and fourth digits for specificity. In each Volume 3 code, there is a decimal after
the second digit, and coders must code to the greatest level of specificity if more
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detailed information is available. The 17 chapters of Volume 3 include broad categories of procedures designated by one or more two-digit sections:
00 Procedures and Interventions, Not Elsewhere Classified

0105 Operations on the Nervous System
0607 Operations on the Endocrine System
0816 Operations on the Eye
1820 Operations on the Ear
2129 Operations on the Nose, Mouth, and Pharynx
3034 Operations on the Respiratory System
3539 Operations on the Cardiovascular System
4041 Operations on the Hemic and Lymphatic System
4254 Operations on the Digestive System
5559 Operations on the Urinary System
6064 Operations on the Male Genital Organs
6571 Operations on the Female Genital Organs
7275 Obstetrical Procedures
7684 Operations on the Musculoskeletal System
8586 Operations on the Integumentary System
8799 Miscellaneous Diagnostic and Therapeutic Procedures
Also available in
Exercise 2.2
1. List the contents of Volume 2 of the ICD-9-CM manual.
2. Describe the structure of Volume 1 of the ICD-9-CM manual.
3. In general terms, describe the process that coders use to select the correct diagnosis code to describe the
condition for which the patient encountered the healthcare system.
2.3 ICD-9-CM Conventions

The ICD-9-CM manual is constructed with conventions intended to guide coders
when identifying diagnosis or procedure codes. Most editions of the manual include
a guide to these conventions at the beginning. The most common conventions span a
wide range:
Some diagnosis or procedure

codes are only appropriate for
patients of a particular age or
gender. When looking up the
code for a condition, pay attention to the instructions listed for
that code.
42
Abbreviations
Punctuation
Instructional notations
Use additional code instruction
Code first underlying disease instruction
Update notations
Additional digit specificity indicator
Diagnosis code-specific color highlights
Age conflict edits
Sex conflict edits
Hospital-acquired condition (HAC) indicators
These and other commonly encountered conventions are discussed on the following pages, including when coders are likely to encounter the use of these conventions
in the ICD-9-CM manual.
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Abbreviations
NEC (not elsewhere classifiable) identifies codes that are used when the available information indicates a specific diagnosis but the listed codes do not identify
the specific condition present in that patient.
NOS (not otherwise specified) indicates codes that are used when there is not
enough information to allow a specific diagnosis.
Punctuation
[ ] Brackets enclose synonyms, alternative wording, or explanatory phrases that
may be useful in identifying the correct diagnosis codes associated with a condition. Note: Red brackets [ ] appear in some codes in the Tabular List of Diseases. As
explained below, these have a different use than black brackets, and the two should
not be confused.
[ ] Italic brackets indicate that a separate code included within the italicized brackets must be listed with the diagnosis code to indicate an associated manifestation.
( ) Parentheses indicate that the enclosed words may be either present or absent in
the description of a condition without affecting the code used to designate that
diagnosis.
: Colons are used after an incomplete term in the Tabular List of Diseases to indicate that one or more of the modifiers following the colon is necessary to assign
that code.
NEC (not elsewhere

classifiable)
Identifies codes that are used
when the available information
indicates a specific diagnosis,
but the listed codes do not
identify the specific condition
present in that patient.
NOS (not otherwise
specified)
Indicates codes that are used
when there is not enough
information to allow a specific
diagnosis.
Instructional Notations
Includes Conditions following this notation are included in that category.
Excludes Conditions following this notation are NOT described by that code,
and other codes must be used to designate those conditions.
Use Additional Code Instruction

This instruction is included in the Tabular List when the code is insufficient on its
own to describe the diagnosis and additional code(s) must be listed. When this instruction appears, the choices of the required additional codes appear in parentheses
following the instruction.
Code First Underlying Disease Instruction

This instruction indicates that the code describes a manifestation that cannot be used
as the first-listed diagnosis. The code cannot be sequenced before the underlying disease. This instruction only appears in the Tabular List and requires that the etiology
or underlying disease must be listed first and the manifestation to which the instruction is attached listed secondarily.
CODERS TIP
It is important that coders understand the difference between the use additional
code and the code first underlying disease instructions. The use additional code
instruction indicates that the selected code is not sufficient on its own to describe
the first-listed diagnosis and other codes must be listed. Choices of additional codes
are listed in parentheses following the instruction. However, the code first underlying
disease instruction indicates that the code does not indicate a diagnosis. These codes
cannot be the first-listed diagnosis. Instead these codes are listed as secondary diagnoses after the first-listed diagnosis.
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Update Notations
A bullet in the Tabular List indicates a new category, subcategory, or code.
A triangle symbol in the Tabular List indicates that the category, subcategory, or
code has been revised.
Text Newly added text is indicated with underlining.
Text Newly deleted text is indicated with strikethrough.
Additional Digit Specificity Indicator

When a 4th or 5th symbol appears with three-digit or four-digit codes, an additional
digit is necessary to designate a more specific code. In most cases, the specific codes
with the additional necessary digits follow the code with the indicator.
In general, three-digit numbers identify categories of codes. In most cases, the
three-digit number is not a specific diagnosis code. Most category numbers have an
associated symbol indicating that a fourth digit is required to code correctly (see below
for a complete discussion of required digits indicators). A few three-digit codes are
sufficient to identify a specific disease and no 4th digit required symbol is present.
Four-digit numbers may identify a specific disease code or identify a subcategory of
codes, each of which is identified with a five-digit code number. When a fifth digit is
required, a 5th digit required symbol is added to the four-digit subcategory number.
In some cases, multiple codes have common fourth or fifth digits to indicate the specificity required for correct code selection. In these instances, the common code designations
are listed once in red at the beginning of the code section. Not all of the common code
designations necessarily apply to every code in that section. When only some of the common code designations listed at the beginning of the code section are applicable, those that
apply are listed in red parentheses (#) as a range or list of designations following the code.
Diagnosis CodeSpecific Color Highlights

In some editions of the ICD-9-CM manual, certain diagnosis codes may include a
color designation to indicate that the code cannot be used as the first-listed diagnosis.
A code with a blue background describes a manifestation of an underlying disease,
not the disease itself. A code with a red background describes circumstances that
influence an individuals health but are not a current illness or injury. Codes with
these backgrounds are not acceptable as the first-listed diagnosis.
Age Conflict Edits

Some diagnosis codes are only indicated for certain age ranges. In these cases, an age
indicator is included with the code to specify the appropriate ages for that diagnosis.
The age indicators include:
N (Newborn): 0 years of age, newborns and neonates only

P (Pediatric): 017 years of age
M (Maternity): 1255 years of age
A (Adult): 15 years of age and older
Sex Conflict Edits

Some diagnosis or procedure codes are only indicated for one gender, either male or
female. When this is the case, a gender symbol (male: , female: ) is included with
the code descriptor to indicate the appropriate gender.
Hospital-Acquired Condition (HAC) Indicator

Medicare and Medicaid are prohibited from paying for care provided to treat or correct
some conditions that were not present on admission to the hospital. Diagnoses with the
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HAC indicator (an H printed on a light-blue background in most ICD-9-CM manuals)

are not considered secondary diagnoses for purposes of hospital payments unless that
condition is coded as having been present when the patient was admitted to the hospital.
Other and Unspecified Codes

Other or other specified diagnosis codes are often indicated with an 8 as the
fourth digit or 9 as the fifth digit. These are used when the information in the record
provides enough information to indicate what the specific diagnosis is, but a separate
code describing that diagnosis does not exist. The use of NEC in the index indicates
that the condition should be designated with an other code.
Unspecified diagnosis codes are usually indicated with a 9 as the fourth digit or 0
as the fifth digit. These codes are used when the information available is insufficient to
determine the exact diagnosis.
See and See Also Instructions

The see instruction indicates that another term should be utilized to identify the
correct diagnosis code. Coders should refer to the term identified in the see instruction before choosing a diagnosis code to describe the condition.
The see also instruction indicates that another term may be referenced for additional information, but it is not necessary to do so. This means that the term that includes the see also instruction may be used as the correct diagnosis.
If clinical documentation indicates a specific diagnosis, do

not report codes for associated
signs or symptoms. However,
signs or symptoms can be assigned codes if there is no specific diagnosis, or if they are not
associated with the diagnosis.
Signs and Symptoms

ICD-9-CM diagnosis codes that describe signs and symptoms, rather than specific
diseases, may be used as the first-listed diagnosis when a specific diagnosis has not
been established for the patient. Many of the codes in Chapter 16 of ICD-9-CM
Volume 1 (780.0799.9) describe symptoms.
Signs and symptoms commonly associated with a specific reported diagnosis
should not be listed as additional diagnosis codes. However, signs and symptoms not
usually associated with a specific diagnosis may be listed if present.
sign
Objective evidence of disease.
symptom
Subjective manifestation of
disease.
Combination Codes
A combination code is a single code that designates two diagnoses, a single diagnosis
combined with one or more manifestations, or a single diagnosis with an associated
complication. Individual codes should not be used when a combination code exists
that accurately describes the patients condition. Combination codes can be identified
by the entries in the Alphabetic Index, or by referring to the inclusion and exclusion
notes in the Tabular List.
Each of the 17 etiology and anatomical disease-specific chapters and the two supplemental classification chapters have specific guidance or instructions associated with
them. These specific instructions will be covered in subsequent chapters of this book.
EXERCISE 2.3
From the perspective

of the . . .
CODER
To code accurately, it is important to understand the symbols
and instructional notes located
in the Tabular List found in
Volume 1.
Also available in
1. Define the meaning or use of the following common ICD-9-CM conventions:

a. Includes
b. Excludes
c. [ ]
d. ( )
(Continued)
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2. Distinguish between the see instruction and the see also instruction.
3. Distinguish between the code definition of other and the meaning of unspecified.
4. When is it appropriate to assign a code that describes signs and symptoms?
5. What does it mean when the instructional notes state, Code first underlying disease? Where in the ICD-9-CM
manual is this instruction found?
6. Describe the meaning of a combination code.
7. What do the symbols 4th and 5th indicate?
2.4 Outpatient Coding Principles
encounter
A patients interaction with the
healthcare system for a service
or procedure.
visit
Term often used interchangeably with encounter to describe an interaction with the
healthcare system for a service
or procedure.
Outpatient coding includes reporting professional services provided in offices, outpatient hospital settings, and inpatient hospital settings. Outpatient coding is also used
to report hospital services provided in the outpatient setting. Outpatient coding is not
used to report hospital services provided in the inpatient setting.
The major reason for a health system encounter or visit is reported as the first-listed
condition. The terms encounter and visit generally mean the same thing and will
be used interchangeably in this text. The first-listed condition is selected to the greatest degree of specificity that can be ascertained from the medical record.
A specific diagnosis may not be available after the first visit, but may be determined at a later date. When no specific diagnosis is documented in the medical record, codes describing signs and/or symptoms may be the first-listed condition. Many
ICD-9-CM codes describing signs/symptoms are listed in Chapter 16 (Symptoms,
Signs, and Ill-Defined Conditions). These will be discussed in greater detail in subsequent chapters.
For example, a patient may present with nonspecific signs or symptoms that do not
allow a definitive diagnosis, even after a physical exam. In those cases, the manifestations
of the disease (signs/symptoms) may be reported as the first-listed condition for that visit.
If a more definitive diagnosis can be made after the results of lab tests are obtained, the
more definitive diagnosis is reported as the first-listed condition on subsequent visits.
CODERS TIP
From the perspective

of the . . .
At times it is not possible to determine a specific diagnosis from the medical records.
For example, a patient may present with ecchymoses on his arms and legs. No specific
cause could be determined and none is documented in the medical record. The firstlisted condition is identified by the presenting signs/symptoms and is reported as
782.7 (spontaneous ecchymoses, petechiae). Lab work is ordered and the results come
back several days later revealing a low platelet count.
When the patient returns for a follow-up visit, the first-listed condition is reported
as 287.5 (thrombocytopenia, unspecified).
CODER
To correctly report surgical
procedures, it is necessary to
know the reason (diagnosis) the
surgeon performed the
procedure.
46
If a patient undergoes outpatient surgery, the reason for the surgery is reported as
the first-listed condition. This code is reported even if the surgery is subsequently canceled because of another condition or contraindication. The other condition may be
reported as an additional diagnosis.
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If a patient is admitted for observation of a medical condition, the medical condition

for which the observation is occurring should be coded as the first-listed condition.
When a patient undergoing outpatient surgery develops a complication that requires
observation, the reason for the surgery should be reported as the first-listed condition,
followed by codes for the complication necessitating the observation.
Diagnosis codes may have three, four, or five digits. Diagnosis codes must be reported to the greatest level of specificity that may be determined from the medical
records. When fourth or fifth digits are necessary to accurately report a diagnosis, indicators are included to alert coders to this. Three-digit diagnosis codes cannot be reported as definitive diagnosis codes unless the three-digit code is not further
subdivided. If fourth- and fifth-digit codes are available, they must be reported.
Some encounters occur for circumstances other than for the diagnosis and treatment of diseases or injuries. Those encounters are usually reported with codes
from the Supplementary Classification of Factors Influencing Health Status and
Contact with Health Services (V01V91). These codes will be discussed in detail
in Chapter 4.
Codes listed in Volumes 1 and 2
of the ICD-9-CM manual are
used to report the diagnoses
associated with professional
services provided in offices,
outpatient hospital settings,
inpatient hospital settings,
and other health care settings.
Specific Guidelines for Coding Outpatient Encounters

If a patient receives only diagnostic services during an encounter or visit, the firstlisted condition should be the medical diagnosis or condition for which the diagnostic
services are performed. Other conditions may be reported with additional codes.
V-codes may be used to report lab tests and/or radiological studies in the absence of
specific diagnoses, signs, or symptoms. If the results of lab tests or radiological studies
are known at the time of the encounter and the report of those results is available,
codes identifying confirmed diagnoses should be reported. Codes describing signs and
symptoms are not reported in addition to the definitive diagnosis codes.
If a patient receives only therapeutic services during an encounter, the code describing the diagnosis or condition for which the treatment is provided should be the
first-listed condition. Codes identifying other conditions may be listed as additional
diagnoses. The only exception to this instruction is when the primary reason for the
visit is chemotherapy, radiation therapy, or rehabilitation, in which case the appropriate V-code is the first-listed diagnosis followed by the code identifying the underlying
reasons for those treatments.
EXERCISE 2.4
Also available in
1. What is the major factor that determines which code should be identified as the first-listed condition?
2. What criteria are used to determine the first-listed condition if the medical record does not include a
diagnosis for the visit?
3. If the patient currently has a condition that is not the reason for the visit or that is not causing the patient any
difficulties at the time of the visit, are those conditions reported? If so, what codes are generally used to report
those conditions?
4. If a patient is admitted for observation of a medical condition, what would be the first-listed diagnosis?
5. What would be the first-listed diagnosis code if a patient receives only diagnostic services during an
encounter or visit?
6. Diagnosis codes must be reported to the
from the medical records
that can be determined
7. The major reason for a health system encounter or visit is reported as the
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CHAPTER 2 REVIEW
Summary
Learning
Outcome
Key Concepts/Examples
2.1 Explain the

structure of the
ICD-9-CM manual.
Pages
The ICD-9-CM manual is divided into three volumes.
2.2 Describe how to

use Volumes 1 and 2 to
determine diagnosis
codes.
Pages
Volumes 1 and 2 are used together to determine the correct diagnosis code(s) to describe any medical
condition. Coders begin with Volume 2 to locate possible diagnosis codes in the Alphabetic Index. Volume
1 is then used to determine which of these codes is most appropriate to report the diagnosis. These codes
are used to report the diagnoses of patients in any healthcare setting.
2.3 Define the

conventions utilized
in Volumes 1 and 2 that
help coders identify
correct diagnosis
codes.
Pages
Several conventions and notations are used in Volumes 1 and 2 to help coders determine the correct
diagnosis codes, including abbreviations, punctuation, notations, and specific instructions regarding how
a particular code may be used.
2.4 Discuss general

outpatient coding
principles to select
appropriate diagnosis
codes.
Pages
General guidelines are outlined to select diagnosis codes for reporting conditions in the outpatient
setting, including professional services. The first-listed condition should identify the main reason the
patient was seen. In most cases, this will identify a specific diagnosis.
Volume 1 is the Tabular List of Diseases. Volume 2 is the Alphabetic Index of Diseases. Volume 3 lists
procedures reported by hospitals. The codes in Volume 3 are not used to report procedures on physician
or outpatient claims.
Specific instructions list conditions that are included or excluded under a particular code. Indicators
specify age limits, sex limits, and whether a third, fourth, or fifth digit is necessary to accurately report that
condition.
In some cases, a specific diagnosis is not known at the time the patient is seen, particularly on a first visit.
In that case, codes identifying signs and/or symptoms may be reported as the first-listed condition. When
the actual diagnosis is known, that is reported instead of codes describing signs or symptoms.
When a patient undergoes outpatient surgery, the reason for the surgery is the first-listed condition, not
the surgery itself. Sometimes patients encounter the healthcare system for reasons other than to diagnose or treat an underlying condition. These encounters are reported using codes in categories V01V91.
Using Terminology
Match the key terms with their definitions:
1. LO2.1 Tabular List of Diseases
(Volume 1)
2. LO2.1 Alphabetic Index of
Diseases (Volume 2)
3. LO2.1 Hypertension Table
4. LO2.1 Neoplasm Table
5. LO2.1 Table of Drugs and
Chemicals
6. LO2.1 First-listed diagnosis
48
A. Codes that provide additional information beyond diagnosis codes

(e.g., V- and E-codes)
B. Not elsewhere classifiable
C. ICD-9 volume used to validate selection of diagnosis codes
D. List used to identify poisoning and external causes of adverse effects
E. Not otherwise specified
F. Outpatient/professional coding, major or primary diagnosis
G. Codes used to identify other conditions present
goL74989_ch02_035-053.indd Page 49
7.
8.
9.
10.
11.
12.
13.
14.
LO2.1
LO2.1
LO2.1
LO2.2
LO2.2
LO2.3
LO2.3
LO2.3
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Principle diagnosis
Additional diagnosis
Supplemental classification
NEC
NOS
Sign
Symptom
Encounter
H. ICD-9 volume that lists diseases, conditions, etc., and acts as a

guide to identifying a diagnosis code
I. Hospital coding, major or primary diagnosis
J. Term used to describe an outpatient service
K. Objective evidence of disease
L. Subjective manifestation of disease
M. Table used to identify diagnosis for a tumor
N. Table used to identify diagnosis for hypertensive renal disease
Checking Your Understanding

Select the answer that best completes the statement or answers the question.
1. LO2.1 Which volume of ICD-9 would be used rst to identify the code for a patient with congestive heart failure?
a.
b.
c.
d.
Volume 1
Volume 2
Volume 3
CPT
2. LO2.2 Which instruction indicates that another term should be utilized to identify the correct diagnosis?
a. See
b. See also
c. NEC
d. Includes
3. LO2.1 Where is the Neoplasm Table located within the ICD-9 manual?
a.
b.
c.
d.
Appendices
Volume 3
Volume 1
Volume 2
4. LO2.3 Which of the following should a coder use to assign a code when the outpatient medical record does not
state a denitive diagnosis?
a.
b.
c.
d.
Signs and symptoms

Probable diagnosis
Rule out diagnosis
Suspected liver failure
5. LO2.3 In which of the following settings would you use outpatient coding principles?
a. Physician office
b. Inpatient services
c. Hospital services
d. Skilled nursing facility
Enhance your learning by completing these exercises
and more at mcgrawhillconnect.com!
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6. LO2.3 A patient presented to the outpatient clinic with cough, chest congestion, and a fever. A chest x-ray was
performed and a diagnosis of bronchitis was made. The rst-listed diagnosis in this scenario would be which of
the following?
a.
b.
c.
d.
Cough
Chest congestion
Bronchitis
Fever
7. LO2.2 When looking up a code for abdominal pain in the Alphabetic Index of the ICD-9 manual, the 5th symbol
appears next to the code for 789.0. What does this symbol indicate?
a.
b.
c.
d.
The code has been deleted.

The code is new.
The code requires additional digit(s).
The patient required moderate conscious sedation.
8. LO2.2 Which convention means that the physicians documentation was not specic enough to give the diagnosis
a more detailed code?
a.
b.
c.
d.
NEC
NOS
Includes
Excludes
9. LO2.2 Which convention provides additional descriptions, terms, or phrases that are included in the description
of the code?
a.
b.
c.
d.
Brackets
Parentheses
Braces
Colons
10. LO2.1 ICD-9-CM codes identify:

a.
b.
c.
d.
The why of a healthcare encounter.

The who of a healthcare encounter.
The where of a healthcare encounter.
The when of a healthcare encounter.
11. Which of the following qualies as medical necessity?

a.
b.
c.
d.
The procedure does not meet insurance payer criteria for coverage based upon the correct diagnostic code linkage.
A preexisting condition was treated under HIPAA Administrative Simplification I.
The provider was qualified to provide the service or treatment.
The medical service can be substantiated based upon correct code linkage between procedure and diagnosis.
12. LO2.3 Which of the following information is used to code from a physicians report?
a.
b.
c.
d.
50
A definitive diagnosis
Subjective reasons for the visit (symptoms)
Objective reasons for the visit (signs)
All of these
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13. LO2.1 Which of the following is another way to describe V-codes?

a.
b.
c.
d.
Poisoning codes
Adverse effect codes
Supplemental classification codes
Morphology codes
14. LO2.2 Coding to the highest level of specicity for a disease means coding to which digit?
a. Third digit
b. Fourth digit
c. Third, fourth, or fifth digit
d. Always the fifth digit
15. LO2.2 Where would the code describing a benign skin lesion on the back be found?
a.
b.
c.
d.
Neoplasm Table
Volume 1 (Tabular List)
Volume 3
HCPCS manual
16. LO2.2 Which of the following statements is true?

a.
b.
c.
d.
A coder may use the Alphabetic Index to assign a code.

A coder should use the Tabular List first when searching for code assignment.
A coder may only use the Alphabetic Index to Disease and Injuries when assigning a code.
A coder must reference the Alphabetic Index and then assign a code from the Tabular List.
17. LO2.2 Which fth-digit subclassication is for use with code 550.1, bilateral inguinal hernia with obstruction,
without mention of gangrene or recurrence?
a.
b.
c.
d.
0
1
2
3
18. LO2.3 Which of the following would be the main term to look for in the Alphabetic Index (Volume 2) of the
ICD-9-CM manual when the diagnosis is congestive heart failure?
a.
b.
c.
d.
Congestive
Heart
Failure
Disease
19. LO2.1 Where in the ICD-9-CM manual can you nd an extensive list of drugs, gases, pesticides, and other toxic
agents used to identify poisonings and external causes of adverse effects?
a.
b.
c.
d.
Alphabetic Index to External Causes of Injury and Poisoning

Volume 3
Appendices

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20. LO2.1 Where in the ICD-9-CM manual would codes be found to describe environmental circumstances and
conditions contributing to injury or other adverse effects?
a.
b.
c.
d.
Index to External Causes of Injury and Poisoning (E-codes)

Volume 3
Appendices
Applying Your Skills

Fill in the blank with the word(s) to complete each sentence.
1. LO2.1 ICD-9-CM Volume 1 is also known as the
2. LO2.1 ICD-9-CM Volume 2 is also known as the
3. LO2.1 ICD-9-CM Volume 3 is also identified as the
4. LO2.1 Third-party payers look for diagnostic codes that are appropriately linked with their corresponding procecriteria for reimbursement.
dures in order to meet
5. LO2.1 Agencies that make up the ICD-9-CM Coordination and Maintenance Committee are the
and
.
6. LO2.2 A coder would look up
as the main term in Volume 2 (Alphabetic Index)
when a patient is seen in the office for migraine headaches.
7. LO2.1 The three sections of Volume 2 are
, and
8. LO2.1 The three sections of Volume 1 are
, and
9. LO2.1 The code range used for diseases of the digestive system is
10. LO2.1 To report a congenital anomaly, the coder would use code range
11. LO2.2 In Volume 3, the decimal occurs after the
.
digit.
12. LO2.2 A bullet next to a code in the Tabular Index indicates
13. LO2.2 An italic bracket next to a code indicates that a
must also be coded.
14. LO2.2 The abbreviation for a hospital-acquired condition is
15. LO2.2 The age range included in the age indicator for maternity (M) is
16. LO2.2 The age range included in the age indicator for a newborn (N) is
17. LO2.3 If a patient undergoes outpatient surgery, the
18. LO2.3 The
be referenced for additional information.
.
is reported as the first-listed diagnosis.
instruction indicates that another term may
19. LO2.3 A patients appointment for a service or procedure is referred to as an
or visit.
20. LO2.3 When a patients medical record states that the patient has a diagnosis of rapid heart rate, the main term the
.
coder would look for in Volume 2 (Alphabetic Index to Diseases) is
21. LO2.3 If you do not know the definitive diagnosis at the time of the encounter or visit, it is permissible to code
.
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22. LO2.3 When a surgery is cancelled because of another condition or complication, the first-listed diagnosis is the
.
23. LO2.3 If a patient undergoes surgery and develops a complication that requires observation, the first-listed diagnoand the second code would be for the
.
sis would be the
24. LO2.3 During an encounter, a patient receives diagnostic services only. The first-listed diagnosis should be for the
.
25. LO2.3 When reporting lab tests and radiological studies in the absence of a specific diagnosis or signs and symp.
toms, the coder may report a
26. LO2.3 When a patient receives only therapeutic services during an encounter, the code describing the diagnosis or
.
condition for which the treatment is provided is the
27. LO2.1 The
diagnosis is defined as the reason the encounter occurred.
28. LO2.2 The symbol that indicates that one or more modifiers of a diagnosis code follow is a
29. LO2.2 Conditions following the

by that diagnosis code.
notation are among the specific conditions described
30. LO2.2 Conditions following the

not described by that diagnosis code.
notation are among the specific conditions that are
Thinking It Through
Use your critical-thinking skills to answer the questions below.
1. LO2.1 How does a coder know that a code from Volume 1 or 2 requires a fourth or fifth digit?
2. LO2.1, LO2.2 Why are codes carried out to specific digits in certain cases?
3. LO2.2 Explain the necessity for the designation of a hospital-acquired condition (HAC).
4. LO2.2 Using Volume 2 of your ICD-9 manual, find and list an example of each of the following conventions: NEC,
NOS, and Excludes.
5. LO2.2 Using your ICD-9 manual, identify symbols for the followingrevised code, new code, and deleted code.

53

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ICD9CM AND ICD10CM

After completing this chapter, students should be able to:

2.1 Explain the structure of the ICD-9-CM

2.3 Define the conventions used in Volumes 1

2.4 Discuss general outpatient coding

2.1 The Structure of the ICD-9-CM Manual

CHAPTER 2 | INTRODUCTION TO ICD9CM

tables with information necessary to identify codes describing particular conditions.

2.2 Using Volumes 1 and 2 to Determine

Volume 1 is the Tabular List of Diseases. Volume 2 is the Alphabetic Index of

Volume 2: Alphabetic Index of Diseases

When assigning codes for

Section 1: Alphabetic Index to diseases, conditions and injuries. This section

CPT only 2010 American Medical Association. All rights reserved.

PART I | ICD9CM AND ICD10CM

FIGURE 2.1 Example of Alphabetic Index Entries

renal (see also Disease, renal) 593.9

CHAPTER 2 | INTRODUCTION TO ICD9CM

Volume 1: Tabular List of Diseases

Disease classification by etiology (cause) or anatomical (body) site

TABLE 2.1 Tabular List Organization

PART I | ICD9CM AND ICD10CM

1. Infectious and Parasitic Diseases

3. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders

4. Diseases of the Blood and Blood-Forming Organs

6. Diseases of the Nervous System and Sense Organs

7. Diseases of the Circulatory System

8. Diseases of the Respiratory System

9. Diseases of the Digestive System

10. Diseases of the Genitourinary System

11. Complications of Pregnancy, Childbirth, and the Puerperium

12. Diseases of the Skin and Subcutaneous Tissue

13. Diseases of the Musculoskeletal System and Connective Tissue

14. Congenital Anomalies

15. Certain Conditions Originating in the Perinatal Period

16. Symptoms, Signs, and Ill-Defined Conditions

17. Injury and Poisoning

CPT only 2010 American Medical Association. All rights reserved.

FIGURE 2.2 Example of Tabular List Entries

The third part of Volume 1 includes four separate appendices:

Volume 3: Tabular List and Alphabetic

CHAPTER 2 | INTRODUCTION TO ICD9CM

00 Procedures and Interventions, Not Elsewhere Classified

2.3 ICD-9-CM Conventions

Some diagnosis or procedure

PART I | ICD9CM AND ICD10CM

CPT only 2010 American Medical Association. All rights reserved.

NEC (not elsewhere

Use Additional Code Instruction

Code First Underlying Disease Instruction

CHAPTER 2 | INTRODUCTION TO ICD9CM

Additional Digit Specificity Indicator

Diagnosis CodeSpecific Color Highlights

Age Conflict Edits

N (Newborn): 0 years of age, newborns and neonates only

Sex Conflict Edits

Hospital-Acquired Condition (HAC) Indicator

PART I | ICD9CM AND ICD10CM

CPT only 2010 American Medical Association. All rights reserved.

HAC indicator (an H printed on a light-blue background in most ICD-9-CM manuals)

Other and Unspecified Codes