October 15, 2007

Meeting Needs: Conventions for ICD-9-CM
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 21 P. 6

Perhaps you’re envisioning a convention with a couple morning presentations, a great restaurant for lunch, and one or two afternoon in-services to follow. Then hit up a couple good vendor booths for freebies, a spa before dinner, and party ‘til dawn.

Sorry, wrong convention. While you can probably fulfill the above fantasy at either the American Academy of Professional Coders or the AHIMA conventions, what we will review here involves a different definition of the word.

Although software is available for the chores of daily coding life, the fact remains that if you can’t operate the code book itself, you could find yourself up the proverbial creek without a paddle. Whether a major event such as a system crash requires you to code—gasp!—manually, or you simply decide to get (or add) coding credentials, sooner or later you’re going to have to get back to basics. If you move from a career of daily coding to one comprised mostly of auditing, you’ll need to defend your code changes with something more credible than “the software said this is right.” And if you’re the defendant rather than the auditor, the same still holds true.

With those needs in mind, let’s take a look at some of the major “coding conventions” that can be reviewed from your desk. ICD-9 defines conventions as that group of punctuation, abbreviations, typefaces, symbols, and instructional notes enabling the coder to correctly use ICD-9-CM. Bold type is used for codes and titles in the tabular and main terms in the index. Italic type is used for exclusion notes and to identify those identifiers not to be used for describing the primary diagnosis.

One common mistake in using the index properly is misunderstanding the use of parentheses. If a word or words used to further describe a term are in parentheses, the presence or absence of those enclosed adjectives or adverbs does not affect code assignment. They are often referred to as nonessential modifiers. Look at main terms and modifiers:

Bronchiolitis (acute)(infectious)(subacute) 466.19

and then look at

Bronchitis (diffuse)(hypostatic)(infectious)(inflammatory)

(simple) 490

If the physician describes “diffuse, hypostatic, simple inflammatory bronchiolitis,” the code is correctly assigned to 466.19 despite the modifiers. The mere fact that they can be found in parentheses after bronchitis does not change code assignment to 490.

Brackets are used to direct proper sequencing of codes. In the case of

Neuropathy, neuropathic

Diabetic 250.6* [357.2]

slanted brackets direct the coder to first sequence the code 250.6* and then the code appearing in brackets. If brackets are beneath a code, they can contain fifth digits valid with that code. They can also hold synonyms or explanatory notes for the coder’s aid. Braces are used to enclose a series of terms, with each of those terms modified by the statement to the right of the term. An example can be found in the tabular under 560.2, Volvulus, or under code 461, Acute Sinusitis.

Don’t let “includes notes” fool you. If a group of adjectives, sites or conditions, or adverbs or related terms are under a code in the tabular section following “includes,” you must remember that the examples given are just that—examples. They are not all-inclusive, and if your description has different modifiers, they still may be correctly designated by that code. Go back to the index to be certain.

Exclusion terms are additional examples of instructional conventions. They are designated “excludes” and provide critical direction for cases in which the coder should look elsewhere for the correct code. If the diagnosis or procedure is accurately described by an example following the excludes note, the correct code(s) will be listed in parentheses after the related description.

If there are no instructional notes directly beneath the code you are considering, you are not necessarily home free. Check the beginning of the category—and even the chapter—to make sure there are no issues critical to the entire body of codes in question. A good example would be the several paragraphs of direction at the start of the entire chapter of V codes.

“See” directs the coder to check some other area, term, or section. This code must always be followed to assign the correct code. More specific is the instructional note “see category” that lists the exact code group to which you must move. This is another mandatory directional note. “See also” may be followed if the coder is unable to code the information at hand: for example, if the immediate terms and subterms are insufficient to finalize the code assignment.

“Code first” is a note found in the tabular section as a reminder concerning a code that may have been found in square brackets in the index. Remember, a dependent code may not be sequenced first and requires an initial code for its cause or underlying disease. A similar convention is the direction to “use additional code.” This directive reminds coders they that can use more than one code to fully describe a diagnosis or procedure. See code 090.4 in the tabular section for an example.

If a colon is part of a description, it is found after an incomplete phrase or a term that has to be further modified with at least one modifier indented underneath before a code can be assigned. Examples can be found in fifth-digit subclassification lists and includes and excludes notes.

Abbreviations used in the code description can be confusing to novice coders, as well as nonprofessionals. NOS means not otherwise specified and is synonymous with unspecified. On the other hand, NEC is not interchangeable with the previous abbreviation. It means not elsewhere classified and is a warning to the user that there may be a more appropriate code assignment. Be certain to follow all directions, conventions, and instructional notes before assigning a code with this description.

If you aren’t sufficiently confused yet, consider the term and as found in ICD-9 coding. It doesn’t mean what you would expect: If you see and in a title, whether code or diagnosis-related group, always translate to “and/or,” which is the correct meaning in this context. If you see the term with, it means that in order to use the related code correctly, it is required that both parts of the title must be present in the diagnostic statement.

Now that coding conventions are second nature, let’s try to find as close to a grand slam as we can. To index Alzheimer’s dementia, start with the noun, dementia.

Dementia

Alzheimer’s — see Alzheimer’s, dementia

This direction is mandatory, so move to index

Alzheimer’s

dementia (senile)

with behavioral disturbance 331.0 [294.11]

without behavioral disturbance 331.0 [294.10]

We now know that we need two codes, and 331.0 must be sequenced first. The tabular indicates no other instructions with this code. Next, move to the tabular section and find category 294, where we see that it includes:

organic psychotic brain syndromes (chronic), not elsewhere classified Under the specific 294.1, we find all kinds of conventions. There is a title Dementia in conditions classified elsewhere and a comment “Dementia of the Alzheimer’s type.” Next, we see instructions to

Code first any underlying physical condition, as:

dementia in: (followed by a long list of indented underlying causes that would need to be sequenced before this one). Immediately following is another warning that this

Excludes: dementia (and subsequently indents other causes that will move you out of this specific code assignment). Even now we aren’t finished—we need to select a fifth digit. Here, we learn that our diagnosis codes to

294.10 Dementia in conditions classified elsewhere without behavioral disturbance

Dementia in conditions classified elsewhere NOS

331.0 + 294.10—in that order—are the correct codes we need, and we could not have gotten to them correctly without using several of our coding conventions. We used “see,” parentheses, square brackets, italics, bold type, includes notes, fifth digits, “with,” excludes notes, NEC, NOS, “code first,” and a whole collection of colons—and all to correctly assign the code pair for a simple two-word diagnosis.

Coding is similar in many ways to any language, with formats in logic and medical terminology. As with any other language, it is necessary to learn its basic structure to make anything intelligible in translation. When the software fails or you have a need to validate your final coding decision against someone else’s conflicting choice, remember the basics and take time out for a coding convention or two.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.