HCC Guidebook

Accuracy in Documentation and Coding:
A Guide to Risk Adjustment and the CMS-HCC Model 20122013 Edition
Authors:
randy schwartz stacey hernandez, CCs-P Moon Leung, PhD stuart Levine, MD, MhA
Contributors:
Zachary Gerbarg, MD, CPC Principal Eagle Medical Management LLC huan Guu, MD Assistant Professor of Medicine David Geffen School of Medicine at University of California, Los Angeles tim schwab, MD Chief Medical Officer SCAN Health Plan tam Pham Judy Yip, PhD russell brower, MD Medical Director SCAN Health Plan susan Erickson
CLiniCAL PEEr PAnEL:

Chester Choi, MD Program Director & Academic Chief of Medicine St. Marys Medical Center robin K. Dore, MD Clinical Professor of Medicine David Geffen School of Medicine at University of California, Los Angeles C. Gregory Albers, MD, FACG Medical Director Diagnostic GI Services University of California, Irvine Comprehensive Digestive Diseases Center William J. French, MD, FACC Professor of Medicine David Geffen School of Medicine at University of California, Los Angeles Director, Anticoagulation Service Harbor-UCLA Medical Center stuart Levine, MD, MhA Corporate Medical Director Health Care Partners Assistant Clinical Professor, Internal Medicine David Geffen School of Medicine at University of California, Los Angeles
A Guide to Risk Adjustment and the CMS-HCC Model | 1
John tayek, MD Associate Professor (in Residence) of Medicine David Geffen School of Medicine at University of California, Los Angeles Harbor-UCLA Medical Center Lewis rosenberg, MD Board Certified Ophthalmologist Long Beach, CA
2012 SCAN Health Plan. All Rights Reserved. This publication is intended for educational purposes only and is provided as is without warranty of any kind, either expressed or implied. Despite the best efforts to provide accurate material, any publication may include technical inaccuracies or typographical errors. SCAN Health Plan assumes no responsibility for and disclaims all liability for any errors or omissions in this publication or in other documents, which are referred to within or linked to this publication. In the event that the reader has any questions regarding the CMS risk-adjusted reimbursement methodology or the coding of any particular diagnosis, the reader is advised to consult experienced counsel or other appropriately trained professional advisors. 2 | A Guide to Risk Adjustment and the CMS-HCC Model
Table of ConTenTs
Chapter 1. Introduction ....................................................5 Chapter 2. General Principles of Documentation and ICD-9-CM Coding ............................................................9 Chapter 3. Avoiding Errors in Documentation ...................21 Chapter 4. Risk Adjustment Data Validation (RADV) ..........25 Chapter 5. EMR White Paper: A Primer for the Practical-Minded Clinician ...................................29 Chapter 6. Diagnostic and Coding Criteria of Common Geriatric Conditions ......................................39 Diagnoses in alphabetical order ......................................41 Diagnoses by ICD-9 Code ...............................................81 appendix 1. CMS-HCC Risk Adjustment Model Community and Institutional Factors .............................115 appendix 2. Disease Hierarchies for the CMS-HCC Model ...............................................125 appendix 3. CMS-HCC Model Relative Factors for Aged and Disabled New Enrollees.............................129 appendix 4. Approved Physician Specialties for Risk Adjustment .....................................................133 appendix 5. Clinical Abbreviations for the Medical Record .................................................135 appendix 6. Medicare Preventive Services......................141
4 | A Guide to Risk Adjustment and the CMS-HCC Model
Chapter 1. IntRoduCtIon CMS-hCC riSk adjuStMent Capitation payMent SySteM

the Balanced Budget Act of 1997 directed the Centers for Medicare & Medicaid Services (CMS) to replace the demographic-based capitation payment system to Medicare Advantage (MA) plans with one that took enrollees health status into account. After evaluating several risk-adjustment models, CMS adopted the Hierarchical Condition Categories (HCC) model, developed with CMS funding by researchers at RtI International and Boston university, with clinical input from physicians at Harvard Medical School. Prior to implementation, CMS staff and HCC model developers simplified the original model with fewer HCCs and used Medicare subpopulations to develop weights, resulting in the CMS-HCC model. this riskadjusted payment methodology stratifies Medicare beneficiaries on the basis of the number and severity of concomitant chronic diseases. Implemented in a 5-year phase-in process, all health plans were fully risk adjusted as of 2008. diagnostic classification systems aggregate ICd-9-CM codes into broader categories for various purposes. Although HCC looks like other diagnostic classification systems such as the major diagnostic categories (MdC) or the clinical classification system (CCS), it is a risk-adjustment model. It not only classifies ICd-9-CM codes to clinically similar groupings, but also assigns weights to each grouping to account for severity. CMS-HCC is an attempt to capture the beneficiaries health burden so that MA plans caring for these beneficiaries will be reimbursed accurately. Commonly within a group of HCCs, several conditions are more severe than the others. under the CMS-HCC model, the more severe manifestation of a given disease process will be weighted more heavily than the less severe one. to address how the more severe condition has a greater impact on cost of care, the model imposes a hierarchy among related HCCs, such that an enrollee is only assigned the most severe manifestation among the related diseases. For unrelated HCCs, the model treats them as additive. Each HCC carries a weighted score, relative to the cost of care. A more severe HCC would have a higher weighted score, and a less severe HCC would have a lower weighted score. Weighted scores are then summed for the individual patient. Although the original model includes 189 HCCs using all the ICd-9-CM codes, only 70 HCCs are currently included in the CMS-HCC payment model. In addition to the diagnosis categories, the CMS-HCC model also has demographic and eligibility/enrollment adjusters, including mutually exclusive age/sex demographic adjusters and indicators of Medicaid and disability status. Currently, approximately 3200 of 13,000+ ICd-9 codes are used in the CMS-HCC model for coding the diagnoses listed in patients medical records. these 3200 ICd-9 codes correspond to 70 HCCs, which are used, along with its weighted score, to reimburse Medicare Parts A and B services to MA plans. Medical information used in assigning HCCs for payment is derived from any of the following three (3) sources: hospital inpatient, hospital outpatient, and face-to-face physician (which includes chiropractors, podiatrists, nPs, PAs and psychologists) visits.
iCd-9 Coding SySteM

Assigning numerical codes to diagnoses is no easy task. Because of the complexity of diseases, etiology, manifestation, and complications, different ways of classifying diseases exists. the official format in the united States is the International Classification of diseases, 9th Revision, Clinical Modification (ICd-9-CM). the ICd-9-CM system is developed and revised by four cooperating parties: the Centers for Medicare and Medicaid Services (CMS), the national Centers for Health Statistics (nCHS), the American Health Information Management Association (AHIMA) and the American Hospital Association. the ICd-9-CM is used to code and classify disease information (signs, injuries, diseases, symptoms) in both inpatient and outpatient settings. different from the other official coding systems, Current Procedure terminology, CPt and Healthcare Common Procedure Coding System, HCPCS (which are used to code procedures), ICd-9-CM primarily focuses on the clinical reasons for which a medical service is necessary (table 1). the ICd-9-CM also includes a procedural coding system which is used only by inpatient facilities.
Table 1
Basic Structure of an ICD-9-CM Code
250.42
These 3 digits provide basic diagnosis categories (e.g. 250 diabetes mellitus) The 4th digit identies complications related to the primary disease (e.g. 250.4 diabetes with renal manifestations) The 5th digit identies additional specic evaluation of the primary disease (sub-classications) (e.g. 250.42 uncontrolled type II or unspecied type diabetes)
the ICd-9-CM manual is made up of three volumes: Volume 1 is a tabular listing of disease code numbers and descriptions; Volume 2 an alphabetical index to the disease entries; and Volume 3 is a listing of procedure codes used solely by hospitals.
to properly and accurately assign codes to diagnoses, providers are required to follow the ICd-9-CM official Guidelines for Coding and Reporting.
aCCurate CodeS
Maintaining an accurate coding practice not only facilitates better care for patients, but also helps physicians maintain more accurate reimbursement. Accurate coding facilitates the capture of conditions underlying the manifested symptoms and helps determine the 6 | A Guide to Risk Adjustment and the CMS-HCC Model
overall disease burden that might affect the care of the patient. As an example, under section 250-259 diseases of other Endocrine Glands, 250 is the code for diabetes mellitus and the 4th and 5th digits describe the complications, type, and control level of the disease in the individual patient diagnosed. From a medical coding perspective, physicians need to specify the condition more by adding a 4th or 5th digit to the preceding three-digit code (250). Just coding 250 is incomplete. At the 4th digit level, providers are able to specify the manifestation of the condition, but 250.0-250.9 still requires a 5th digit to be submitted. It is at the 5th digit level (the highest level) that providers can accurately capture the condition of the patient. In this example, at the 5th digit level, it specifies if the diabetic condition is type 1 or type 2, and/or if the condition is controlled or not. It is at this level that the code documents to the highest level of specificity and is most accurate.
ChallengeS to the phySiCian CoMMunity

the CMS-HCC system (and HIPAA) mandates accurate coding, but more importantly, an accurate retrospective and prospective analysis of each patients acute and chronic conditions may lead to better care. While most MA plans argue that this is a coding challenge, it is actually a challenge for the physician community which must more accurately understand and manage the complex array of chronic diseases of each patient. Physicians will be challenged to work with their respective delivery systems, including fellow physicians and specialists, to collect the most accurate and complete assessment of each patients acute and chronic conditions, and to develop a comprehensive and individualized treatment plan. through this approach, quality of care will be markedly improved, and the need for comprehensive patient care will be reinforced. In addition, accurate and complete collection and documentation of this diagnosis data drives an enhanced revenue engine, which in turn will support the additional cost of providing high-quality care. Since the CMS-HCC system is designed to reimburse health plans more accurately, plans have been working aggressively with physician partners to collect accurate and timely encounter data. Significant efforts are being devoted to accurately coding diagnoses and procedures and effectively documenting the clinical rationale for these codes in the medical chart. Health plans and physicians should note the following: 1. Although MA plans submit diagnosis codes to CMS, only those with the most severe manifestations of each disease within a specific disease category will be considered in the final risk score according to the CMS-HCC system. Accurate diagnosis related documentation yields accurate reimbursement. Current-year reimbursement is based on encounter data from last year. If no encounter data is submitted, payment in the following year will be based only on demographic data, resulting in decreased reimbursement. CMS does not carry over chronic diagnoses, so these diagnoses must be evaluated and reported at least yearly. Because physician diagnostic data account for approximately 80% of the entire encounter submission, physician documentation drives the amount CMS pays on behalf of each member.
2. 3.
4.
the message of needing more specific and more accurate coding is very clear. At a broader level, the physician community is challenged to: A Guide to Risk Adjustment and the CMS-HCC Model | 7
1. 2.
understand and manage the complex array of chronic diseases of each patient; Work with respective delivery systems, including fellow physicians and specialists, to collect the most accurate and complete picture of each patients acute and chronic conditions; develop a comprehensive and individualized treatment plan; Maintain a balance between generating a thorough record for better continuity of care and treatment and an enhanced revenue engine that in turn supports the additional cost of providing high-quality care.
3. 4.
An accurate, improved diagnosis coding and documentation practice has many benefits to physicians in the clinical management of their patients, as well as in the financial management of their practice. Accurate diagnosis documentation and coding improves: 1. 2. 3. 4. Patient medical record problem lists tracking of patients current diagnosis Patient risk stratification for care management Risk management
general approaCh to proper Coding

1. Good and accurate coding starts with accurate documentation. Make sure the disease/condition is documented in the medical record: If it is not documented in the medical record, it didnt exist! Fully assess all chronic conditions annually in face-to-face patient visits. Remember to code not only the conditions related to the symptoms for the immediate visit, but also any chronic conditions that are assessed and/or treated that affect the care of the patient. Conditions may be coded for faceto-face physician visits in inpatient hospital, outpatient hospital, office and visits to the patients home. Clearly and thoroughly document in the medical chart all conditions evaluated during each visit. Code to the highest level of specificity; fully utilize the ICd-9 diagnosis coding system. document and code the most comprehensive or all inclusive diagnoses for the patients condition. document and code for all secondary or associated diagnoses when clinically indicated.
2.
3. 4. 5. 6.
Whether to improve quality of patient care, reduce the exposure to risk-related liabilities, or achieve more accurate reimbursement, it is the physicians responsibility to provide accurate coding and documentation of the patients health-related conditions. this guidebook provides coding criteria and tips on medical record documentation designed to assist physicians and their practice.
Chapter 2. GeneRAl PRinCiPleS of DoCuMentAtion AnD iCD-9-CM CoDinG

I. Only a physICIan Or apprOved ClInICIan Can Make a dIagnOsIs fOr rIsk adjustMent purpOses. if the doctor1 documents clearly that a patient has specific diagnoses, then the correct iCD-9 diagnosis codes can be selected. if an iCD-9 code has been submitted for a patient visit, then the medical record must include language which supports the diagnosis in a signed and dated progress note. it is not enough for the doctor to know the patients diagnosis; the doctor must write it down (or dictate) clearly in a progress note for an iCD-9-CM diagnosis code to be valid. if you know a patient has CHf, but do not mention it anywhere in your note, you cannot submit the diagnosis code for CHf (428.0). A medical record progress note signed by a nurse practitioner (nP), a certified clinical nurse specialist, or physician assistant (PA) is also a valid source for diagnosis coding. (A complete list of valid specialties appears in the appendix.) A note from a nurse, wound specialist, marriage family therapist, medical assistant or other healthcare worker cannot be used to for coding purposes. A licensed clinical psychologist or social worker (lCSW), physician assistant (PA) or nurse practitioner (nP) may code mental health diagnoses resulting from a face-to-face patient visit. A lab test, order for a test, authorization for a service or other administrative record cannot be used for coding purposes. the physician must interpret a test and document the resulting diagnosis in the progress note. the written report of an anatomical pathology service may be used for coding purposes. this is an exception to the requirement for a face-to-face visit. only information recorded in a progress note as the result of a face-to-face patient visit that has been signed by a doctor or approved clinician can be used for coding purposes. in addition to stating that a patient has a particular diagnosis, there should be evidence in the medical record to support that diagnosis. for example, a patient who is newly diagnosed with major depression, single episode should have some documentation of the criteria necessary for making that diagnosis. Suspicions or rule outs cannot be coded as diagnoses. if a definitive diagnosis has not been made, the symptoms or signs should be coded. note
Although the term doctor is used throughout the text, the term includes other approved clinicians. Please see the appendix for a list of approved clinicians. A Guide to Risk Adjustment and the CMS-HCC Model | 9
that there are diagnosis codes for most symptoms. these are found in the 78X series of iCD-9-CM. All chronic conditions must be fully assessed annually to properly report the members health status to CMS. Physicians must thoroughly document in the chart all conditions evaluated during each visit and code to the highest level of specificity based on their documentation. each encounter in the medical record must stand alone, and only conditions evaluated during the encounter should be documented and coded. Some examples of terms that indicate evaluation and treatment: Stable on meds Condition worseningmedication adjusted (include name of medication and change made) tests ordereddocumentation reviewed and results incorporated into treatment plan Condition improving (include any changes to treatment plan made).
listing medications and prescriptions in a medical record does not meet documentation requirements to indicate that an evaluation for a condition was performed. Checking off a code on an encounter form or listing a diagnosis on a medical record problem list does not meet documentation requirements. the diagnosis must be present in the progress note in order to meet documentation requirements. Diagnostic statements should be clear and unambiguous. listing a series of symptoms, signs and laboratory results cannot substitute for a diagnosis.
II. a valId MedICal reCOrd has tO Meet speCIfIC CrIterIa Legibility: the medical record must be legible. A reviewer must be able to read what is written. if others cannot read your writing, you should dictate or move to an eMR system. it is the responsibility of the physician to review dictated notes, make any corrections according to accepted medical record principles, and sign them.
Patient Name and ID: for a medical record to be valid, every page must clearly identify the patient by last name, first name, and some other form of identification, such as a medical record number, account number, or date of birth.
Visit Date: the medical record documentation must include the date of the patient visit with month, day, and year clearly stated. if the note spans multiple pages, the date must appear on each page.
Standard Abbreviations: only standard abbreviations should be used to ensure clear understanding. (See a brief listing of some of the most common abbreviations for significant diagnoses in the back of this book.) the use of symbols is discouraged because they cannot be used for coding purposes. for example, lipids cannot be coded as hyperlipidemia.
Organized Note: the visit note should be organized in a logical fashion and clearly demonstrate that this was a face-to-face visit (usually identified by documenting the presence of physical findings). the most common example is the use of the SoAP format (S = subjective; o = objective; A = Assessment; P = Plan). Diagnoses should be clearly noted as part of the assessment.
Patient Diagnoses: All the patients diagnoses should be documented at least once each year in a progress note, with a brief update of the status of each diagnosis.
Follow-up Plan: the medical record should include the follow-up plan comprising tests ordered, referrals made, patient instructions, and when the next appointment should be scheduled.
Signature and Credential: the progress note must include a clear clinician signature, with a credential after the name. it is important to know which clinician is responsible for the note.
III. OffICIal OutpatIent COdIng guIdelInes2 dIagnOstIC COdIng and repOrtIng guIdelInes fOr OutpatIent servICes, effeCtIve 10-1-2011
these coding guidelines for outpatient diagnoses have been approved for use by hospitals/providers in coding and reporting hospital-based outpatient services and provider-based office visits. information about the use of certain abbreviations, punctuation, symbols, and other conventions used in the iCD-9-CM tabular list (code numbers and titles), can be found in Section iA of these guidelines, under Conventions used in the tabular list. information about the correct sequence to use in finding a code is also described in Section i. the terms encounter and visit are often used interchangeably in describing outpatient service contacts and, therefore, appear together in these guidelines without distinguishing one from the other.
Although these guidelines are called the outpatient coding guidelines, they apply to all services performed by a physician, regardless of place of service, based on Coding Clinic, Q3, 2000 pages 67. A Guide to Risk Adjustment and the CMS-HCC Model | 11
though the conventions and general guidelines apply to all settings, coding guidelines for outpatient and provider reporting of diagnoses will vary in a number of instances from those for inpatient diagnoses, recognizing that: the uniform Hospital Discharge Data Set (uHDDS) definition of principal diagnosis applies only to inpatients in acute, short-term, long-term care and psychiatric hospitals. Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.
a. seleCtIOn Of fIrst-lIsted COndItIOn

in the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. in determining the first-listed diagnosis, the coding conventions of iCD-9-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. it may take two or more visits before the diagnosis is confirmed. the most critical rule involves beginning the search for the correct code assignment through the Alphabetic index. never begin searching initially in the tabular list as this will lead to coding errors.
1. OutpatIent surgery
When a patient presents for outpatient surgery, code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.
2. ObservatIOn stay
When a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses.
b. COdes frOM 001.0 thrOugh v91.99

the appropriate code or codes from 001.0 through V91.99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.
C. aCCurate repOrtIng Of ICd-9-CM dIagnOsIs COdes

for accurate reporting of iCD-9-CM diagnosis codes, the documentation should describe the patients condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. there are iCD-9-CM codes to describe all of these.
d. seleCtIOn Of COdes 001.0 thrOugh 999.9

the selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the encounter. these codes are from the section of iCD-9-CM for the classification of diseases and injuries 12 | A Guide to Risk Adjustment and the CMS-HCC Model
(e.g. infectious and parasitic diseases; neoplasms; symptoms, signs, and ill-defined conditions, etc.).
e. COdes that desCrIbe syMptOMs and sIgns

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Chapter 16 of iCD-9-CM, Symptoms, Signs, and ill-defined conditions (codes 780.0 - 799.9) contain many, but not all codes for symptoms.
f. enCOunters fOr CIrCuMstanCes Other than a dIsease Or Injury

iCD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. the Supplementary Classification of factors influencing Health Status and Contact with Health Services (V01.0- V91.99) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.
g. level Of detaIl In COdIng 1. ICd-9-CM COdes wIth 3, 4, Or 5 dIgIts

iCD-9-CM is composed of codes with either 3, 4, or 5 digits. Codes with three digits are included in iCD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater specificity.
2. use Of full nuMber Of dIgIts requIred fOr a COde

A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit subclassifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code.
h. ICd-9-CM COde fOr the dIagnOsIs, COndItIOn, prObleM, Or Other reasOn fOr enCOunter/vIsIt
list first the iCD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. list additional codes that describe any coexisting conditions. in some cases the firstlisted diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
I. unCertaIn dIagnOsIs
Do not code diagnoses documented as probable, suspected, questionable, rule out, or working diagnosis or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Please note: this differs from the coding practices used by shortterm, acute care, long-term care and psychiatric hospitals.
j. ChrOnIC dIseases
Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
k. COde all dOCuMented COndItIOns that COexIst

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.
l. patIents reCeIvIng dIagnOstIC servICes Only

for patients receiving diagnostic services only during an encounter/ visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. for encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign V72.5 and/ or a code from subcategory V72.6. if routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the V code and the code describing the reason for the non-routine test. for outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses. Please note: this differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.
M. patIents reCeIvIng therapeutIC servICes Only

for patients receiving therapeutic services only during an encounter/ visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. the only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy, radiation therapy, or rehabilitation, the appropriate V code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.
n. patIents reCeIvIng preOperatIve evaluatIOns Only

for patients receiving preoperative evaluations only, sequence first a code from category V72.8, other specified examinations, to describe the pre-op consultations. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any findings related to the pre-op evaluation.
O. aMbulatOry surgery
for ambulatory surgery, code the diagnosis for which the surgery was performed. if the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.
p. rOutIne OutpatIent prenatal vIsIts

for routine outpatient prenatal visits when no complications are present, codes V22.0, Supervision of normal first pregnancy, or V22.1, Supervision of other normal pregnancy, should be used as the principal diagnosis. these codes should not be used in conjunction with chapter 11 codes.
Iv. keys tO suCCessful dOCuMentatIOn and COdIng fOr MedICare patIents

See each Medicare patient at least once each year and document and code every significant diagnosis in your progress note for that visit. treatment plans should be added or modified as appropriate based on these findings. According to coding guidelines, you cannot submit a code based only on what is written in a patient problem list. following are some tips for specific significant diagnoses. Cardiology be specific. if the patient has stable angina or a history of myocardial infarction (Mi), document this condition as opposed to a less specific diagnosis such as coronary artery disease (CAD) or atherosclerotic heart disease (ASHD). documenting myocardial infarction. for coding purposes, an Mi is considered acute within the first 8 weeks of the eventafter that, you should document an old Mi. Also, for an acute Mi, the coding is defined by episodes of care, so from initial hospitalization through the 8 weeks is the initial episode. if the patient is re-hospitalized for care related to the Mi, a subsequent episode of care begins which has a different diagnosis code. arrhythmias. Do not forget to document and code ongoing chronic conditions such as atrial fibrillation or arrhythmias, whether symptomatic or asymptomatic due to pharmacological treatment. Arrhythmias that no longer exist due to ablation should not be coded. heart failure. Documentation of heart failure should be specific. Codes exist in category 428 for systolic, diastolic and congestive heart failure. More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure. Codes also exist for acute on chronic heart failure.
Endocrine Diabetic Complications are frequently omitted conditions in physician medical records.
if you simply document DM or diabetes in your progress note in the medical record, the correct code is the code for uncomplicated diabetes, type ii or unspecified type (250.00).
only the doctor can make a diagnosis of a manifestation of diabetesthe person coding the medical record cannot assume anything. for example, if a patient has diabetes and a lab test with a creatinine of 3.0, the coder can only code diabetes unless the doctor documents the renal complications of diabetes.
even the clinician cannot code something he or she did not write. that same notation of a creatinine of 3.0 along with a diagnosis of DM is still only 250.00. the clinician must document the complication in a clear diagnostic statement. additional codes. for many diabetic manifestations, a second diagnosis code is required along with the primary diagnosis. for example, for a patient with adult diabetic nephropathy, you should submit the code 250.4X for Diabetes with nephropathy as well as Diabetic nephropathy 583.9 or Chronic Kidney Disease (CKD) Stages iV 585.X if appropriate. evaluate every patient with diabetes, especially those with renal disease, for the presence of malnutrition (see below/monitor the patients albumin and/or weight loss/BMi) and anemia and code appropriately. evaluate every patient with diabetes for all manifestations and comorbidities of the disease. All complications should be coded in addition to the diabetes code(s) when applicable. diabetic control. the 5th digit in diabetes coding is used to refer to the level of diabetic control. for example, 250.00 is uncomplicated type ii diabetes, not stated as uncontrolled and 250.02 is uncomplicated type ii diabetes, stated as uncontrolled. note that poor control in the record is coded as controlled, per coding guidelines. in addition, remember to use the V code when a patient documented to be on insulin.
Category 249 represents secondary diabetes. this category uses the same 5th digit classifications as category 250. When documenting secondary diabetes, your documentation should include the cause of the diabetes, e.g., diabetes secondary to long term steroid use.
Neurology documenting and coding stroke. Patients with acute cerebrovascular accident (CVA) usually present in an eR or hospital setting. Patients who recover from CVA without sequelae should be documented as history of CVA and assigned code V12.54 as an additional code for history of cerebrovascular disease when no neurologic deficits are present. unless the patient is still hospitalized for the CVA, you should not be using codes in the 434.XX series. late effects of stroke. Assess and document all late effects of CVA. late effects such as aphasia, aphagia, hemiparesis, etc., should be documented and coded using codes from the 438.XX series.
epilepsy should be fully described (e.g., convulsive, non-convulsive, petit mal status, grand mal status) and should describe intractable epilepsy (e.g. pharmacology resistant, medically refractive) if present. Dementia should be described fully and include a description of causative factors if they exist.
Nutritional Physicians sometimes neglect to document nutritional deficiency in patients with illnesses such as cancer, CoPD, CHf, or renal failure. Assuming they do assess, physicians often neglect to document and code nutritional deficiency in patients with chronic illnesses. Malnutrition and cachexia. typically, malnutrition or cachexia results from involuntary weight loss as the result of a chronic illness. Be sure to evaluate, and document these conditions when they occur in your patients. Regularly check on the patients albumin, weight and BMi trend/loss, especially in the frail, older adult, patients with dementia, and in patients with CKD.
Oncology the iCD-9 guidelines for oncology are often counterintuitive to physicians and do not follow current thinking on oncology. Review them to code malignancies properly. Malignancies are considered active disease until the patient has completed definitive treatment, which includes any combination of surgical excision, chemotherapy or radiation, and shows no sign of the disease. this criterion means that patients who are not treated still have active disease. Patients with no sign of the disease (e.g., those under post treatment surveillance with no evidence of recurrence or metastases) must be documented and coded as having a history of the malignancy. note any metastases and code them as metastatic disease, not as a new primary malignancy. Metastatic disease is coded at the site of the metastasis, not the primary site. So, breast CA metastatic to bone would be 198.5, secondary neoplasm of bone and bone marrow and 174.9, breast cancer, site unspecified. Metastatic disease. Document and code the primary as well as the metastatic sites of the cancer. Patients on adjuvant therapy for breast and prostate cancer (e.g., tamoxifen, lupron) continue to be coded as having an active malignancy, even in the absence of any sign of the disease. this guideline is an exception to the general rules.
Psychiatry Making the specific diagnosis is the key to appropriate documentation.
Many physicians are hesitant to document psychiatric disorders because of concerns that this information will be shared with a clearinghouse that provides medical information on people who apply for
insurance. Diagnoses submitted to SCAn Health Plan are not shared with any agency except CMS. depression. if you simply document depression in the medical record, then the correct code is a 311, depression not otherwise specified. However, if your patient meets the clinical criteria for major depression, then your documentation should indicate that the patient has major depression, and indicate whether its a single episode or recurrent episode. Patients on chronic antidepressant therapy for major depression should also be documented appropriately. once bipolar, obsessive-compulsive disorder (oCD), and schizophrenia is diagnosed, it is a lifetime diagnosis as long as it is documented. alcohol dependence. Dependence on alcohol is common in Medicare patients, so be sure to document these conditions at least once each year in your progress notes and then code them. A CAGe questionnaire can be completed to screen for alcohol dependence. Sleep disorders are common in geriatrics patients. Patients should be screened for sleep disorders and their medications reviewed for long-term hypnotics. Also, alcohol-induced sleep disorder is common and should be evaluated when patients are screened positive for alcohol dependence. Delirium is also a common condition in the elderly. When possible, the underlying cause of the delirium should be identified and documented, which leads to more accurate code selection. treatment of the delirium should be documented as well.
Pulmonary Do not forget to document and code chronic pulmonary diseases at least once each year. COpd, chronic bronchitis, and emphysema. these chronic conditions should be documented and coded at least once each calendar year. Be sure to include chronic respiratory failure for those patients who meet the clinical criteria of Pao2 value of less than 60 mm Hg while breathing air or PaCo2 of more than 50 mm Hg. Do yearly spirometry screening for all at-risk patients. Review all patients for recurrent acute bronchitis and multiple-inhaler prescriptions for possible chronic bronchitis and CoPD. for bacterial pneumonia, be sure to document the causative organism and/or the radiologic findings.
Renal CKD coding (585.X) has been changed to conform with the stages of CKD. these changes include stages i-V based on a patients glomerular filtration rate (GfR), which is estimated from a urinalysis and/or serum creatinine and basic patient demographics. Remember that some Medicare patients with normal creatinine levels may still have significantly impaired renal function.
for people at risk, creatinine clearance or GfR should be estimated at least twice per year. note that stages i and ii of CKD must have 3 months of reduced GfR or evidence of kidney damage documented.
Skin and Orthopedics Chronic skin ulcers. Be sure to document and code chronic skin ulcers as either decubitus or caused by other factors. the location of the ulcer should also be documented to facilitate accurate code selection. if caused by vascular disease, this finding should be documented and coded as well. if it is a decubitus ulcer, the ulcer must be staged, and an iCD-9-CM code for the stage of ulcer (707.20-707.25) should be submitted as well.
Because amputations are permanent, they should be assessed, documented and coded on a yearly basis. Coding of traumatic fractures. the site and type (closed vs. open) must be documented in order to choose an accurate code. the acute fracture codes are only used during active treatment, which iCD-9-CM describes as surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. After active treatment, the aftercare codes (V54.X) for healing fractures should be used. Coding of pathological fractures - acute fractures vs. aftercare. Pathologic fractures are reported using subcategory 733.1, when the fracture is newly diagnosed. Subcategory 733.1 may be used while the patient is receiving active treatment for the fracture. examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. Aftercare codes are in the V54 series. there are a number of important codes that describe a patients status which are often overlooked in documentation and coding. Physicians know the patient has these conditions, but because they are often long-standing, annual documentation is omitted. Common status conditions include: Gastrostomy, ileostomy, tracheostomy or colostomy status (V44.X) Cystostomy or nephrostomy status (V44.X) Renal dialysis status (V45.1) lower limb amputation status, including toes (V49.7X) long term use of medications (V58.6X) Wheelchair dependence (V46.3); describe and code the reason the patient is wheelchair dependent first
Status Codes
Vascular peripheral vascular disease (pvd). PVD is relatively common in elderly patients, especially where it may be a manifestation of diabetes. When PVD is documented as due to diabetes, code the diabetic code first (250.70) and then the PVD (443.81). atherosclerosis. Aortic atherosclerosis and peripheral atherosclerosis are chronic conditions that should be assessed, documented and coded each year. these conditions may have been identified through findings on a radiology procedure, but must be assessed by the treating physician. to code these conditions, the diagnosis must be stated in the progress note. they cannot be coded from the radiology report. According to Coding Clinic, the term aortic atherosclerosis is inadequate for coding because it isnt clear if it is the vessel or the valve. Your wording should make it clear which is ivolved.
Chapter 3. AvoidinG ERRoRS in doCuMEntAtion

over the past 5 years, CMS has audited thousands of MA members charts. the results have been both alarming and encouraging. Alarming because the error rate remains high, Risk Adjustment data validation (RAdv) studies (audits) have increased in scope, and the potential effect on both MA organizations and providers. CMS has published a final rule on RAdv, and overpayments will be extrapolated across a health plans network. However, it should encourage physicians to know that a small handful of errors in documentation make up the vast majority of coding errors. Better yet, these errors are easily corrected, once physicians understand the underlying iCd-9 coding rules. First and foremost, physicians must understand that the iCd-9 and clinical medicine have little in common. Second, physicians must distance themselves from their clinical knowledge, both in general and specifically, about the patient at hand. the iCd-9 doesnt allow assumption, and relies solely on whats written in the progress note1. this is the point at which the iCd-9 begins to make no sense to the practicing physician, who often writes a note, and then chooses a code reflecting whats wrong with the patient, not what theyve documented in the medical record. the physician may document signs, symptoms, and historical data, and fail to record a diagnosis. then, knowing whats wrong with the patient, they may choose a diagnosis on a superbillwithout it having been recorded in the progress note.
So, what are the most common mistakes made, and more importantly, what can physicians do to support their diagnosis code selections?
problem: Choosing a code that looks right, without knowing the rules for using that code. example: Coronary atherosclerosis of unspecified type of vessel, native or graft (414.00).
Solution: understand the rules for use of commonly used codes in your practice. to use code 414.00, you must state that the patient has had a CABG, but fail to state whether a native or non-native vessel is affected. if your note simply says coronary atherosclerosis or ASHd, and does not reference a previous CABG, then the correct code is 414.01.
Coding rules dont allow choosing a code based on lab or radiology reports, unless the physician references them in the body of the progress note. Further, such references must be specificnoting that the result is abnormal or writing a lab value doesnt support iCd-9 selection. A Guide to Risk Adjustment and the CMS-HCC Model | 21
problem: trying to use iCd-9 titles to support a code selection, or simply writing the iCd-9 code in the medical record. example: diabetes with renal manifestations (250.40).
Solution: document both diseases in a brief narrative. For example, if the patient has Stage 3 CKd due to diabetes mellitus, then your note should reflect that.
problem: Writing only a diagnosis code in the chart. example: impression: 250.40.
Solution: Since coding is derived from a narrative description of the disease state, writing 250.40 in the chart cannot be coded. documentation should clearly reflect the condition of the patient. in this case, a notation such as: end stage renal disease secondary to dM clearly describes the condition.
problem: documenting and coding CvA in the office setting. A CvA is an acute event. once the patient is discharged from the hospital or rehabilitation setting, the diagnosis of acute CvA is inaccurate and leads to miscoding. example: Each time a status post CvA patient is evaluated, the physician documents CvA in the record and codes 434.91 (CvA, ischemic or unspecified).
Solution: document that the patient is status post CvA or has a history of CvA (v12.54). What is often overlooked are the sequelae of CvA, since they have often been present for many years. When assessing the patient, its important to document and code these as well. there are iCd-9 codes for all of the common and pertinent sequelae of CvA in the 438.XX series of iCd-9.
problem: documenting acute, severe, past illnesses as if they were current conditions. example: diseases like sepsis, unstable angina, and acute respiratory failure that the patient was hospitalized for previously.
Solution: document these conditions as a history of and do not code the previous conditions.
problem: Malignancy coded when the correct coding would be personal history of malignancy of ___________. in the case of malignancies, the iCd-9 again differs from current clinical thinking. the iCd-9 allows coding of the malignancy until definitive treatment is finished (unless there are signs of active disease). definitive treatment is that aimed at eradicating the cancer, such as surgery, chemotherapy and/or radiation therapy. Patients with biopsy proven malignancies who are not treated continue to be coded with the diagnosis of cancer. example: Patient who is status post pneumonectomy for lung cancer 5 years ago. the patient is on no therapy, but surveillance is continued for the patients lifetime.
Solution: document and code personal history of the cancer. these codes are found in the v10.XX series of the iCd-9.
problem: documentation of multiple primary sites of malignancies when the patient has metastatic disease. example: Patient has primary breast cancer which has metastasized to the brain.
Solution: if the patient is being assessed or treated for both, then coding for the breast cancer would be in the 174.X (depending on area of the breast) and 198.3, secondary neoplasm of brain or spinal cord.
problem: not restating and coding long standing disease. the iCd-9 and the CMS HCC risk adjustment model have no inherent memory. A disease only exists at the time it is assessed, documented and coded. All chronic diseases disappear from the risk adjustment model each year, and must be resubmitted. example: A patient who is 10 years status post colon resection for carcinoma, with colostomy.
Solution: When your attention is directed to the illness, or in this case the site (assessing skin integrity or signs and symptoms of a recurrence of the cancer) it is appropriate and important to document and code these conditions. there are codes for artificial openings (tracheostomy, colostomy, ileostomy, etc.) in the v44.X series.
problem: History of means the disease is in the past. You cannot code an active disease you have documented as a history of. example: History of CHF.
Solution: Remember to use the term history of only for diseases which have resolved. in the case of chronic conditions like CHF and atrial fibrillation, use terms like compensated or controlled to reflect their ongoing status.
problem: using a general term to support a specific disease. example: depression
Solution: the term depression is very general, and could mean anything from a mild, transient condition to major depression with suicidal ideation. the iCd-9 codes for depression are very specific, and require you to fully describe the patients depression. in the case of major depressive disorder, the iCd-9 requires that you indicate if this is a single episode, or recurrent episode of depression. describing the depression fully allows you to choose the code that correctly describes your patients condition.
Although there are thousands of rules in the iCd-9 coding system, following a few simple changes in documentation will help you accurately document and code your patients illnesses.
Chapter 4. RiSk AdjuStMent dAtA VAlidAtion (RAdV) CMS has instituted the RAdV process in order to ensure payment integrity and accuracy of the Medicare Advantage CMS-HCC payment model. As the CMS-HCC model is predictive of care delivery costs, and the members diagnoses drive monetary reimbursement to plans and onward to groups and physicians, it is necessary to validate that these diagnoses are appropriately documented in medical records, demonstrating care delivery and treatment. the CMS RAdV process results in revenue adjustments based on whether the medical records submitted support paid HCCs or not. the process occurs after the final data submission deadline for a given calendar year. Beginning with the 2007 Calendar Year Plan level RAdV, based on 2006 dates of service, CMS has determined that validation error rates will result in statistically extrapolated revenue adjustments impacting a plans entire membership. there are six stages in the RAdV process, which are outlined in the instructions sent to selected health plans. the process may change over time, as CMS gains more experience with the RAdV process. 1. Sampling and Medical record request: in this stage, CMS or its vendor selects contracted Medicare Advantage organizations (MAos) to be included in the process and subsequently selects the members for which medical records will be requested. CMS sampling methodology may be random or targeted. the latter method may be based upon prior RAdV error rates or HCC prevalence rates compared to other MAos or specific contract types. the CY 2007 CMS-RAdV plan level sample was based upon the MA Coding intensity Study, which analyzed differences in risk score changes between MA and Medicare Fee for Service. next, CMS or its vendor provides the MAo with member and paid HCC lists and asks the MAo to select the one best medical record to support each paid HCC. the MAo collects medical records from groups and providers, reviews these records to identify the one best record, and submits the record for each paid HCC. lastly, the MAo reconciles to receipt reports to ensure that submitted records are noted as received. Records submitted must fulfill all CMS-HCC model requirements, including qualified provider type and specialty, a face to face visit, within the appropriate dates of service, and coded according to iCd-9-CM official Guidelines. the CY 2007 RAdV allotted 12 weeks for MAos to submit the records. 2. Medical record review: CMS uses Medical Record Review Contractors (MRRCs) who employ certified coders to perform medical record review. CMS initial Validation
Contractor (iVC) vendor reviews the submitted records and identifies risk adjustment discrepancies where the submitted record does not match the paid HCC for a member. All discrepancies undergo second review by the CMS Second Validation Contractor (SVC). Coders review records based on record type (inpatient, outpatient, or physician) and the relevant iCd-9-CM official Guidelines for each record type. 3. Documentation Dispute: the documentation dispute process will apply only to the errors that arise out of operational processing of medical records selected for RAdV audit and submitted to CMS by established deadlines. For example, if an MAo submits a two-page medical record that inadvertently becomes separated into two medical records upon receipt by the CMS Medical Record Review Contractor, CMS would permit the MAo to resubmit the two-page medical record so that the record can be reviewed in its intended two-page format. Another example of an error relating to logistical/ operational processing would be technical failures that led to missed/or obliterated pages. Contract Level Findings and payment adjustments: CMS shares medical record review findings, risk adjustment discrepancies, payment adjustment amounts and adjustment timeframe with the MAo. post Documentation Dispute payment adjustments: CMS recalculates payment error rates based upon outcomes from documentation dispute findings and provides this information to MAos. appeals: CMS has not fully defined this stage of the RAdV process, but has stated that Appeals will be facilitated by the CMS office of Hearings. the appeals process will be more fully described by CMS at a later date.
4.
5.
6.
to be prepared to fully support the RAdV process, consider the following checklist: RADV preparation ensure that your data systems appropriately track claims and encounter data at the diagnoses and provider level and that reporting is readily available. ensure your enrollment information is up-to-date. Provide and keep updated RAdV point of contact information to the MAos that your group contracts with to the physicians that your group contracts with.
ensure that your contact information for physicians, hospitals and other facilities is up-to-date to be able to send out notifications
in advance of the start of a RAdV and to make sure record collection processes are efficient. if your coding chart audit process includes receipt of image files, create indexing and storage processes for these files for future RAdV efforts. Build your processes to be HiPAA compliant, limiting health information disclosure to the minimum necessary persons and entities.
Build appropriate education programs educate physicians on the technical components required on each visit note: member name, member identifier such as date of birth, clinician signature and credentials, and date of visit. educate physicians on documentation requirements that support diagnoses submitted. educate billers and coders on the CMS-HCC model and the RAdV process. Audit their work for accuracy in data submission of claims and encounters.
Evaluate your Electronic Health Record (EHR) system for documentation compliance and printing Review eHR system to ensure that its signature format is within standards published by CMS in the Risk Adjustment data technical Assistance Participant Guide. Check that your eHR is submitting valid and accurate diagnoses via the Practice Management module that generates claims. do not submit diagnoses on the historical problem lists that are not related to the current date of service. ensure that your eHR is able to readily print records for a given member for a full calendar year period.
Conduct ongoing mock or independent RADVs to evaluate accuracy by clinician, and educate based upon outcomes Resource and/or identify your internal RAdV team to support record pursuit. Build appropriate systems to make your efforts efficient. Create a transparent RAdV calendar that your team can adhere to. develop and use coversheets that quickly identify the member, date of service, and clinician or facility contained in a record submission.
Create processes to carry out RAdV that include quality assurance.
Network Management Consider incentive plans that reward physicians whose documentation appropriately supports diagnoses submitted. ensure your contract language supports medical record collection efforts.
Chapter 5. EMR WHitE PAPER: A PRiMER foR tHE PRACtiCAl-MindEd CliniCiAn

this chapter is a reprint of the White Paper presented at SCAns EMR EHR Conference on october 24, 2009. this information may be useful to you if you are planning to implement an EMR.
IntroduCtIon
the primer is an old-fashioned concept, a book that covers the basic elements of a subject. Here, then, is a brief primer on EMRs because, for all the literature and discussion of EMRs, surprisingly few start with the very basics, like what are they, what should they do, and which one should i buy (and when). the subject of EMRs merits an old-fashioned approach simply because there is so much being said about them, many assertions, and many promises. Among what is being said, it may be difficult to sort out the practical first steps, practical to achieve amidst the day-to-day challenges of caring for patients and sustaining an office to continue caring for those patients. first and next steps; these are the objectives of this paper and, if useful, more will follow. this White Paper is not intended to be a whole book, but it is intended for clinicians and their staff as busy professionals who dont have time to read a whole book, but do need to know the basic facts about EMRs, their current importance and practical utility.
how thIs prImer works

objeCtIves: establish basic Information offer practical recommendations
the Primer establishes basic information and offer recommendations on where each reader might build from that base. Some information here will be too elementary for some readers, so it should be used accordingly, skimming the easy to prepare for the harder. Each section will have one or more key points highlighted as bullets, so it can also be read in sections or referred to by section. dont print or copy it all. only use those sections that capture your attention or apply to some issue or problem you are focused on today. other parts you can return to tomorrow as needed, since it will be available at all times in its entirety on your SCAn website. As with any advice from a distance always make sure it makes sense for your needs and requirements.
the very, very basICs

for those who find themselves somewhat bewildered by all the EMR discussions these days, welcome to a very, very large club. lets start with just the term itself. despite all the well-informed and knowledgeable resources on the subject, there is even still a lot of inconsistent use of words, descriptions, and terms. Remember, for most, this is a whole new area and it will take time for even the vocabulary to settle in. Meanwhile, some of the most basic terms remain sources of vigorous debate among experts, so one neednt worry about finding the territory a bit uncertain to navigate. nobody has all the answers; nobody knows everything they need to know. if youre feeling uncertain, that is entirely appropriate. All of us are figuring this one at the same time. A Guide to Risk Adjustment and the CMS-HCC Model | 29
if the reader is not among the somewhat bewildered or the uncertain, though, reviewing key areas of this paper will also work to serve very well nonetheless for two reasons: 1) the EMR landscape is changing rapidly and 2) many people have not looked at EMRs from the point of view of basic business records and medical records fundamentals which, unfortunately, can be a source of substantial potential problems, implementation failures, and possibly even patient harm or legal risk; trust, but verify.
terms
Consider first the terms EMR (Electronic Medical Records) and EHR (Electronic Health Records). Even these get used in different and irregular ways. for the purposes of this primer, well refer to all as EMRs, as electronic replacements of your practices clinical record. Even in settings where formal EMR standards are being developed, the use of a key term can be inconsistent and confusing. there was one authoritative attempt to settle the What is an EMR vs. an EHR discussion, also not entirely accepted1. this all naturally results from the fact that were far from fully adapted to these new tools and capabilities. More specifically, here an EMR will be considered a compilation of hardware and software systems that, at the minimum, support computerized capabilities2 to: 1. Create, maintain, and manage patient care records that include: a. b. All patient care and pertinent records created by the practice itself (including prescriptions) Pertinent records created elsewhere (including test reports, consults, discharge summaries, etc.) that are commonly and routinely used in the clinicians medical decision making.
2.
Exchange important business operations information with a Practice Management (PM) system a. b. Coding assistance and capture Patient demographics consistency
3.
Provide basic intra-office messaging, task and event management function, for secure, PHi-appropriate communications for information exchange that may or may not be individual patient-specific. Provide commonly used and key required outputs that include: a.
4.
Patient summaries configurable to the practices needs (e.g., an easily accessible view that summarizes a patients active and past problems, past pertinent histories, medications, and allergies. Especially handy are indicators of gaps in the patients care and the practices quality guidelines.) Garets, dave, and davis, Mike, Electronic Medical Records vs. Electronic Health Records: Yes, there is a difference A HiMSS Analytics White Paper http://www.himssanalytics.org/docs/ wp_emr_ehr.pdf note: it is important to note that just because a computerized system has a particular capability doesnt require that it is used for all tasks. for example, an EMR must have a way to capture images of paper documents. However, all paper documents need not be in the EMR. A 5 year old discharge summary doesnt necessarily have to be in the EMR, but key points from it might be entered into a patient record, with a notation that the original is kept elsewhere, maybe even in its original paper form.
b.
Properly detailed and configured encounter notes on demand, electronic or print formats, including appropriate level of associated integrity authentication data. frequently used clinical communications outputs (e.g., patient summaries, consult requests or consult reports, and, for those contemplating federal incentives programs, Care Quality data exports). HiPAA Security Audit Reports, Release of Records outputs.
c.
d.
Any EMR project is very likely to have a longer list than this one, but it is recommended that all lists include these. indeed, while this may seem a comparatively short list, these are actually very complex functions and include the fundamentals that every system must do to provide a proper platform for thereafter adding more complex functions. if a system cannot properly create and maintain a valid, trustworthy, and user-friendly encounter note, then all the whistles and bells are like putting chrome on a car with no wheels. Unfortunately, the current EMR marketplace has some that are heavily chrome-plated but with suspect and missing wheels. Well return to this point shortly.
FIgure 1: FunCtIon-orIented emr deFInItIon wIth outlIne oF the mInImum neCessary FunCtIonal requIrements For an emr system. Support computerized capabilities3 to:
1. Create, maintain, and manage patient care records that include: a. b. All patient care and pertinent records created by the practice itself (including prescriptions) Pertinent records created elsewhere (including test reports, consults, discharge summaries, etc.) that are commonly and routinely used in the clinicians medical decision making.
2.
Exchange important business operations information with a Practice Management (PM) system a. b. Coding assistance and capture Patient demographics consistency
3.
Provide basic intra-office, intra-system messaging, task and event management function, for secure, PHiappropriate communications for information exchanges that may or may not be individual patient-specific. Provide commonly used and key required outputs that include: a.
4.
Patient summaries configurable to the practices needs (e.g., an easily accessible view that summarizes a patients active and past problems, note: it is important to note that just because a computerized system has a particular capability doesnt require that it is used for all tasks. for example, an EMR must have a way to capture images of paper documents. However, all paper documents need not be in the EMR. A 5 year old discharge summary doesnt necessarily have to be in the EMR, but key points from it might be entered into a patient record, with a notation that the original is kept elsewhere, maybe even in its original paper form. A Guide to Risk Adjustment and the CMS-HCC Model | 31
past pertinent histories, medications, and allergies. Especially handy are indicators of gaps in the patients care and the practices quality guidelines.) b. c. Properly detailed and configured encounter notes on demand, electronic or print formats. frequently used clinical communications outputs (e.g., patient summaries, consult requests or consult reports, and, for those contemplating federal incentives programs, Care Quality data exports). HiPAA Security Audit Reports, Release of Records outputs.
d.
welCome to the world oF dIgItal ClInICal reCords objeCtIves:

understanding that emrs are not yet plug and play how (and when) to move Forward
the world of EMRs is truly a diverse one, with so many different EMRs using different technologies, approaches, and widely varying costs. the EMR marketplace is still young, with a lot of competing products out there. furthermore, despite the availability of technical and functional standards, it will take a while yet before these standards are incorporated into actual EMR designs. for now, then, EMRs are not yet standardized and probably wont be for, in this authors opinion, another 310 years. EMR certification helps narrow the pack some; but, at least as of late 2009 and into mid2010, certification still doesnt cover key requirements that every doctor must have, like the ability to create, maintain, and manage records according to known requirements for records and electronic records in general, and for medical records in particular.4 Even those systems that have the capability of creating a proper record can be installed or inadvertently used in a way that is problematic and risky, which is a key reason why this primer will be of useto help steer clear of such pitfalls as you navigate this diverse world. Although their origins are quite recent, EMRs cannot be called new in information technology terms. EMRs have been around for over 30 years, most commonly in Western Europe and, in the US, in large academic and governmental institutions. these have tended to be very large systems where everyone uses the same function the same way, with minimal customization or flexibility. in the US, though, weve generally decided we arent yet ready for one big national health care system; we like the idea of variety and choice. Since we want variety and choice, we need variety and choice in EMRs. Achieving this is much more difficult than building one big system and telling everyone they have to use it. to have lots of different, smaller and more flexible systems, we had to wait 4 two examples: Current Certification, using 2009 CCHit requirements, will, after long delay, include a basic requirement for all records management-retention of the original version of an amended or corrected record. few would consider modifying a finalized version of a medical record, but that is permitted under CCHit requirements through 2008 and until a product is Certified against 2009 requirements. Accurate assignment of authorship in display, electronic or printed versions of a multiauthor record is not currently required but is roadmapped for the future. Both of these are long-standing requirements for all legal business records types, including medical records, for admissibility purposes.
until the cost of computing power and software development fell far enough to become affordable to the many different types and sizes of medical practices. think about the computer you were using ten years ago and the one youre using today. these changes have been nothing short of incredible. Similarly, an EMR that might cost $10,000 today would have cost $10,000,000 ten years ago, and their costs will continue to fall and their sophistication rise. Again, for now there is a huge amount of variation in EMRs. they range from old, reputable, and expensive, to newer, less expensive and shorter track record. Some are installed in computers in the purchasers office, others are accessed over the internet, and some involve a mixture of both. for the purpose of the busy medical office, though, the most important attribute is not the technology but the usability; a fancy system that nobody understands can be worse than no EMR at all. Reportedly, up to one third of EMR implementations fall short of goals or fail completely, but wellplanned and supported implementations fail much less5. this is testimony to the importance of making sure the acquired system works and meets the actual daily and practical needs of the staff. Being able to create visually attractive color graphs of a patients blood pressures over time may be impressive, but taking 10 clicks to find the most recent lab test, which used to always be on top of the lab section of the paper chart, will quickly kill enthusiasm for the system. inevitably, as EMRs are becoming more affordable, they will become more common; which, in turn, will speed their improvement to becoming safe and reliable. Unfortunately, part of that process will be doctors, nurses, and other clinicians finding out that their records, when challenged, wont hold up. Such events will appear in the press and in the legal system, with the unwary innocent caught in the process as well. Again, that is why this Primer focuses on the very basic functions required for a reliable EMR; to make sure that the reader can make an informed and educated decision among the many products available. the system chosen must meet basic functional requirements and it must be used correctly as a record system. Until EMRs comply with EMR standards, it will remain the purchasers and users choice and duty to make sure what theyre buying will meet their clinical needs and their business and medical records requirements. for now, if you have seen one EMR, you have seen just one EMR. Every single one has significant differences from the next one. furthermore, any given EMR can be installed in so many different ways that the same system in one place can be set up very different in another.
Is It tIme to move Into the world oF dIgItal ClInICal reCords?

Simply, yes, it is time to plan that move. there is one circumstance, though, where you should necessarily plan on selecting, implementing, and using one within the next 912 months and that is if you are starting a new practice from scratch. for existing organizations, the practice assessment and planning phases are 5 Goroll, Allan H., Md, Simon, Steven R., Md, MPH, tripathi, Micky, MPP, Ascenzo, Carl, BS, Bates, david, Md, MSc, Community-wide implementation of Health information technology: the Massachusetts eHealth Collaborative Experience in Journal of the American Medical informatics Association (JAMiA), Vol. 16, no. 1, Jan/feb 2009, pp. 132 139. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2605598/ pdf/132.S1067502708001850.main.pdf A Guide to Risk Adjustment and the CMS-HCC Model | 33
absolutely necessary to minimize the disruption and productivity losses for patient care. there are so many differences among EMRs, and since nobody is protecting you against a choice that doesnt work out, how (and when) to select EMR is critical. the most important when is when there is understanding of, in a given specific practice, what functions are needed to improve patient care, solve real problems, and improve your practices operations sufficient to justify the monetary and headache costs. Conversely, unless an office is planning to cease operations in 5 years or less, do begin today evaluating and planning; because, while still small, the body of knowledge on care quality improvement with EMRs is growing. in that cause alone implementing an EMR in time is both operationally sound and a professional duty, but again only in due course with a plan, knowing what problems the EMR is intended to solve and what improvements it is intended to support. Again, unless the situation is a brand new practice, the planning and requirements assessment process will take at least 612 months. during that time EMRs will only improve further, making it a win-win all around. that is the other main purpose for this series of essays, to outline the simple steps to take to identify what you need from any EMR you might buy, and then make sure thats what you get. Currently there is no entity enforcing minimum standards6 for all EMRs, so it is up to you to make sure that those standards that do apply to you, like business records and medical records requirements, are met by whatever system you have or choose.
why all the push For emrs now?

objectives: understand why the us government is pressing you now maintaining Focus on Improving patient Care and Improving practice operations
for a practice already busy seeing patients, a new cost and complication like an EMR nonetheless makes good sense if it helps improves patient care, improves office operations, or both. Right now relatively few medical practices are using EMRs and there are many reasons for that. Before addressing those reasons, though, lets look at the big picture reasons why the federal Government is now pushing them forward so hard, first with a carrot (paying incentives to help cover the costs) then later with a stick (eventually cutting payments to those without EMRs). Whats the hurry? the push From washIngton dC and saCramento: the bIg pICture
federal and State Governments are hurrying EMRs along in the hope that theyll help cut health care costs. those costs are enormous and expected to grow even more unless something changes soon and of those enormous costs, half are paid by federal and State governments. for States, health care is tied with education for the number one spot on their costs. the problem isnt just that were just paying a lot of money for health care, its also two more factors: 6 Comment: it is accurate to say that there are no minimum requirements for an EMR. there are minimum requirements to receive subsidy funding; but, if a given EMR doesnt meet them, it doesnt mean you cannot use it, it only means you dont get the subsidies or the other incentives.
We pay two to three times more compared to other countries; but, we get either only slightly better or worse results7.
Chart II-1 Health Care Spending per Capita in 2004
Adjusted for Differences in Cost of Living
$7,000
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
this trend, rising costs and shrinking results, with widening performance gaps compared to other countries, means that were becoming uncompetitive as a country. furthermore, it isnt just the absolute dollar cost, it is also what economists refer to as opportunity Cost, the fact that a dollar spent on health care also loses the opportunity to spend it on, say, education or improved mass transit systems or to leave those dollars in the pockets of individuals to save or spend as they want. 7 Cylus, Jonathan, and Anderson, Gerald f., Multinational Comparisons of Health Systems data 2006, Johns Hopkins University, May 2007, p. 14. http://www. commonwealthfund.org/~/media/files/Publications/ Chartbook/2007/May/Multinational%20Comparisons%20 of%20Health%20Systems%20data%20%202006/Cylus_ multinationalcomparisonshltsysdata2006_chartbook_972%20 pdf.pdf A Guide to Risk Adjustment and the CMS-HCC Model | 35
$0
United States
Canada
France
Netherlands
Germanya
Australiaa
OECD Median
United Kingdom
Japana
New Zealand
the people of the United States, including all the people who work in the health care industry, need for that industry to improve; because, while some parts are going great, others are doing very poorly. Some parts are very efficient, and some are not only inefficient, but dangerous, with thousands injured or dead yearly because of mistakes. Add up all the problems and the result is that we the people are not getting our moneys worth from our collective dollars and so we spend more than necessary to get enough. Money we spend on health care isnt getting spent on building more modern factories, improving schools, or repairing roads, so then our factories become obsolete, our schools dont keep up, and our roads and bridges fall apart. So we need to do better, but how do we define better? We define better with information, where we measure what we are doing, and we compare that with what weve decided is better, and try different ways of doing. Which ever way gets us results that are better, that is the better way. to do that, though, requires better information. there is some general evidence that information technology can improve care and improve clinical operations. However, its not like a straightforward change, such as it takes an hour to get to work, but when technology is applied (like a bicycle), then it only takes 10 minutes. Even in such a simple case, there can be complexities and complications. What if youve never ridden a bicycle? What if your walking route is over rough, rocky ground and the bike route is twice or three times as long? What if the bike doesnt work right and the nearest repair shop is 10 miles distant?
onCe you know what you need then just add teChnology?
Unfortunately, there is just no thing as just add technology, because technology alone wont give the desired improvements, just as an EMR, to be a success, should and must be much more than a computerized substitute for your paper chart. furthermore, what you end up calling your EMR is more likely to be several different systems that all operate together. this isnt significantly different from having several systems on your home computer; one for email, another for word processing, yet another for downloading pictures from your digital camera, with the ability to send information from any of these to another device, like a printer. Some readers will be old enough to remember a time not long ago when getting your printer to work with your computer could be difficult, and some software didnt work well with others. in a way, this is not unlike the state of EMRs today; there are lots of components and lots of programs, and one isnt necessarily compatible with another. for example, you may have an electronic practice management (PM) system that you use already, and you want to add an EMR. not every EMR will work well with your PM system and even a PM system that works with one particular EMR may not completely work with it. Your PM system may be able to receive information (unidirectional interface or integration) from your EMR, but not also send information back to it (bidirectional). these matters are best sorted out in the planning stages or they can become a major cause of future headaches as we will later see. if you have other systems you rely on already, like laboratory test order entry and results retrieval, these also may or may not work with a given EMR and may cost substantially more to install and to maintain.
plannIng the FIrst small steps

three attributes recur in evaluation of successful EMR implementations: Planning, Champions, and Support from leadership. there are a number of good tools available8 for planning EMR implementations and assistance identifying goals and objectives that will help inventory how an EMR will support improvements in your practice. Remember, its these improvements that must be understood and measured to judge whether you should move to implement sooner or later, but in all cases now is the time to begin the planning. this, then, brings us to the first tasks as you consider migrating to an EMR: identify who is going to be in the EMR Readiness Group that will plan the first steps. then, begin to collect information on two basic questions:
question 1: What computerized or computer-installed functions do you and your office staff use now? (You may use a lot more than you first think.) Examples: Practice Management software for patient appointments, electronic billing dictation/transcription Voice recognition laboratory services ordering and/or results retrieval Electronic communications (such as email, electronic reminder phone calls, etc.) Electronic charge capture for hospital rounds Electronic prescribing Registries
When you add an EMR to your practice, it works best when all electronic functions are connected and it works worst when none are connected, so you end up entering the same information (like a prescription) into more than one system. question 2: two parts: What practice or clinical-care issues is the EMR intended to address and how will you identify (measure) improvements to know youve been successful? these first steps will be built upon in the months ahead. for the purposes of this first paper, though, well conclude with reading assignments, in preparation for our next one, on practical steps for making sure your EMR meets all your medical records system needs.
readIng lIst (all avaIlable Free)

AHiMA e-HiM Work Group on Maintaining the legal EHR. Update: Maintaining a legally Sound Health Record Paper and Electronic. Journal of AHiMA 76, no.10 (november-december 2005): 64A-l. Available on the AHiMA website by search or the direct link below: http:// Each States Quality improvement organization built a library of EMR implementation tools under the doctors office Qualityinformation technology (doQ-it) Program ending early 2009. these have been developed and improved in the course of actual EMR implementations. A Guide to Risk Adjustment and the CMS-HCC Model | 37 5.
library.ahima.org/xpedio/groups/public/documents/ahima/ bok1_028509.hcsp?ddocname=bok1_028509 6. for general rules on required documentation content, see CMSs 1995 or 1997 documentation Guidelines for Evaluation and Management Services: http://www.cms.hhs. gov/MlnEdwebGuide/25_EMdoC.asp See the october, 2009 Presentations from the SCAn EMR EHR Education Seminar, available to you on the SCAn website: Achieving Meaningful Use of EHRs by dr. Paul tang EHR documentation Pitfalls by dr. Reed Gelzer
7.
a. b.
bIblIography
Cylus, Jonathan, and Anderson, Gerald f., Multinational Comparisons of Health Systems data 2006, Johns Hopkins University, May 2007, p. 14 http://www.commonwealthfund.org/~/ media/files/Publications/Chartbook/2007/May/Multinational%20 Comparisons%20of%20Health%20Systems%20data%20%202006/ Cylus_multinationalcomparisonshltsysdata2006_chartbook_972%20 pdf.pdf Garets, dave, and davis, Mike, Electronic Medical Records vs. Electronic Health Records: Yes, there is a difference A HiMSS Analytics White Paper. http://www.himssanalytics.org/docs/wp_emr_ehr.pdf Goroll, Allan H., Md, Simon, Steven R., Md, MPH, tripathi, Micky, MPP, Ascenzo, Carl, BS, Bates, david, Md, MSc, Communitywide implementation of Health information technology: the Massachusetts eHealth Collaborative Experience, in Journal of the American Medical informatics Association (JAMiA), Vol. 16, no. 1, Jan/feb 2009, pp. 132139. http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2605598/pdf/132.S1067502708001850.main.pdf trites, Patricia A. and Gelzer, Reed d., How to Evaluate Electronic Health Record (EHR) Systems, AHiMA, 2008.
Chapter 6. DiAGnoStiC AnD CoDinG CRiteRiA of CoMMon GeRiAtRiC ConDitionS

this chapter is a dictionary of the most common diagnoses utilized in the practice of medicine for SCAn seniors in Southern California. every diagnosis has the necessary iCD-9 coding criteria as well as validated diagnosis criteria. this chapter is not definitive nor is it meant to replace any of the valuable reference texts available for physicians. the purpose is to provide a quick but accurate guide for the practicing physician to assist in the accuracy of making a diagnosis and the use of specific iCD-9 codes.
Diagnoses in Alphabetical Order
DiAGnoSeS in AlPHABEtICAl ORDER

clinical criteria
Epigastric pain/discomfort, diagnosed clinically Generalized abdominal pain/discomfort, diagnosed clinically Abdominal pain/discomfort, diagnosed clinically
DX Description
DX Code de
Hcc
Hcc Description
Documentation requirements for coDe use
aBDmnal pain epiGastric
789.06
This code is used when the documentation indicates that the patient has epigastric abdominal pain.
aBDmnal pain GeneraliZeD
789.07
This code is used when the documentation indicates generalized abdominal pain.
aBDmnal pain otH spcf st
789.09
This code is used when the documentation describes abdominal pain in an area of the abdomen that does not have a specific code. This includes descriptive terms such as abdominalgia, or colic.
aBDmnal pain unspcf site
789.00
Used when documentation states abdominal pain and a quadrant is not specified.
Non-specific abdominal pain, diagnosed clinically Abnormal blood test value, diagnosed based on lab value
aBnorm BlooD cHemistrY nec
790.6
This code is assigned when the documentation indicates an abnormal (blood) laboratory test, but the significance or related diagnosis is not determined or documented.
DX Description
Abnormal ECG findings
DX coDe de
Hcc
Hcc Description
clinical criteria
aBnorm electrocarDioGram
794.31
This code is only used when the documentation indicates that the EKG is abnormal but the nature of the abnormality is unknown or unstated.
aBnorm finDinGs-lunG fielD
793.1
Used when the documentation indicates lung shadow, abnormal radiology finding in lung, lung infiltrate, or lung coin.
Abnormal lesions in the lungs, including infiltrate, mass/ nodules, abcess, etc, diagnosed by image studies
aBnorm loss of WeiGHt
783.21
Used when the documentation indicates abnormal weight loss, or weight loss of unknown cause.
Losing more than 10% of the usual weight over 3-6 months, diagnosed clinically Abnormal pattern of walking, diagnosed clinically
aBnormalitY of Gait
781.2
Used when the documentation indicates ataxic gait, gait abnormality, gait disturbance, paralytic gait, scissor gait, spastic gait, staggering gait or imbalance.
ac Vnus emB & tHrmB uns Dp Ves lW eXt
453.40
105
Vascular Disease
Used when the documentation indicates deep venous thrombus of the leg, acute deep venous thrombus of the leg, or deep venous thrombosis of the leg.
Thrombus of lower extremity, confirmed by ultrasound or venogram.
acciDent in Home
E849.0
This is a supplemental code, and should never be used alone. Use this code when the documentation indicates that the patient suffered an injury in their home. Precancerous skin growth usually caused by sunexposure, diagnosed clinically and by skin biopsy Acute infection/inflammation of bronchus often leading to productive cough and/or sputum production diagnosed clinically Acute infection or inflammation of pharynx, diagnosed clinically
Accident at home
actinic Keratosis
702.0
Used when the documentation indicates actinic keratosis, AK, senile keratosis, senile hyperkeratosis, senile keratoma, keratosis senilis, solar keratosis, senile wart, verruca senilis, or senile wart.
acute BroncHitis
466.0
Used when documentation states acute bronchitis.
acute pHarYnGitis
462
This code is used when the documentation indicates pharyngitis, acute pharyngitis, sore throat, adenopharyngitis, catarrhal angina, fauces, hypopharyngitis, or phlegmonous pharyngitis.
acute renal failure nos
584.9
131
Renal Failure
Used when documentation indicates renal failure or acute renal failure. Chronic Renal Failure is never assumed, it must be explicitly stated.
Sudden rise in Creatinine level (>1.4mg/dL) or decrease in urine output (<30 cc/hr), diagnosed clinically or by lab findings Acute pulmonary failure as defined by severe hypoxia (pO2 < 60) or hypercapnia (pCO2>40) often needing emergent intervention such as intubation Acute infection or inflammation of sinus, often diagnosed clinically and/or by x-ray, CT findings
acute respiratrY failure
518.81
79
Cardio-Respiratory Failure and Shock
This code is used when the documenation indicates respiratory failure, pulmonary failure, or acute respiratory failure.
acute sinusitis nos
461.9
Use this code when the documentation indicates acute sinusitis.
DX Description
Nonspecific acute viral infection of upper repiratory tract, involving nose and throat characterized by runny nose, sore throat, headache and ill-feeling, diagnosed clinically Unspecified acute cerebrovascular disease other than CVA
DX coDe de
Hcc
Hcc Description
clinical criteria
acute uri nos
465.9
Used when documentation indicates respiratory infection, URI, or viral respiratory infection.
acute, ill DefineD cereBroVascular Disease
436
96
Ischemic or Unspecified Stroke
Use only when unspecified cerebrovascular disease is documented. Coding Clinic comments indicate this code should rarely be used. It is not the correct code for CVA. The correct series of codes for CVAs is 434.1X.
allerGic rHinitis nos
477.9
Used when the documentation indicates allergic rhinitis, Bostocks disease, febris aestiva, hay fever, allergic rhinitis, vasomotor rhinitis, paroxysmal rhinorrhea, or spasmodic rhinorrhea.
Nonspecific allergic inflammation of nose, leading to sneezing, congestion, a runny/itchy nose, diagnosed clinically and/or by rhinoscope A loss or decrease in the level of awareness of self and environment combined with markedly reduced responsiveness to environmental stimuli Dementia characterized by impairment in memory, thinking and behavior, diagnosed clinically and by mini-mental state examination 0 minimum cog Anemia in chronic kidney disease
altereD mental status
780.97
This code is used when the documentation indicates altered mental status, alteration of mental status or changes in mental status.
alZHeimers Disease
331.0
Use when documentation indicates Alzheimers disease, atrophic brain degeneration, or Alzheimers type dementia.
anemia in cHronic KiDneY Disease
285.21
This code is used when the documentation indicates that the patient has anemia of chronic kidney disease, or ESRD or EPO resistant anemia. The underlying chronic condition (e.g., ESRD 585.6) should also be coded.
anemia nos
285.9 Nonspecific atypical cardiac chest pain, diagnosed clinically
Used when the documentation says anemia, erythrocytopenia or low hematocrit.
Nonspecific Low RBC level (Hgb < 16 for men; Hgb < 14 for women), diagnosed by laboratory values
anGina pectoris nec/nos
413.9
83
Angina Pectoris/ Old Myocardial Infarction
Use when documentation says angina, angina pectoris, Heberdens syndrome, Likoffs syndrome, Schaufenster krankheit, anginosus, stenocardia, sternalgia, or stable angina.
anXietY state nos
300.00
Use when documentation says anxiety, neurosis, neurotic state, abnormal apprehension, apprehensiveness, psychogenic anxiety, anxiety state, psychoneurotic anxiety, asphyctic anxiety or anxiety disorder.
Condition characterized by a pattern of frequent worry and anxiety about several different events/activities, diagnosed clinically Condition where fatty material is deposited in the walls of aorta leading to narrowing, hardening and/or blockage, diagnosed clinically or by angiogram/image studies Disorder or damage involving aortic valve, stenosis or insufficiency regurgitation, diagnosed by echo, angiogram or other image studies
aortic atHerosclerosis
440.0
105
Vascular Disease
This code is used when the documentation indicates sclerotic aorta, arteriosclerotic aorta, calcified aorta or atherosclerosis of the aorta.
aortic ValVe DisorDer
424.1
Used when the documentation indicates acquired aortic valve disorder, aortic deformity, endocarditis with aortic valve involvement, arteriosclerotic aortic valve, aortic valve insufficiency, aortic valve obstruction, aortic valve stenosis, or aortic murmur. s/p CABG
aortocoronarY BYpass
V45.81
This code is used when the documentation indicates that the patient is status post coronary bypass surgery. If there is residual disease, this should be fully described and coded.
DX Description
Nonspeicific joint pain diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
artHropatHY nos-unspec
716.90
Use this code when the documentation states arthritis, nonpyogenic arthritis, arthropathy, joint inflammation, or rheumatism and no area of the body is mentioned.
astHma nos
493.90
Used when documentation indicates asthma, and there is no indication of an exacerbation.
Reversible reactive airway disease resulting from an allergic reaction to foreign substances such as vapor, pollen, etc. diagnosed clinically and/or by PFT showing obstructive pattern (FEV1/FVC < 80%) and reversibility Refraction error of the eye characterized by an aspherical cornea leading to distorted image, diagnosed clinically Rapid irregular heartbeat diagnosed by exam, ECG or rhythm monitor Nonspecific back pain Any cardiac condition due to HTN, including cardiomegaly, cardiomyopathy, cardiovascular disease without CHF, diagnosed clinically HTN (SBP >140, DBP > 90 on 2 occasions) without any end organ (eye, kidney, or cardiovascular) damage, diagnosed clinically
astiGmatism nos
367.20
Used when the documentation indicates astigmatism, acquired astigmatism, congenital astigmatism, refractive astigmatism or congenital astigmatism.
atrial fiBrillation
427.31
92
Specified Heart Arrhythmias
Used when documentation states atrial fibrillation. Be sure to also document and code long term or current use of anticoagulant V58.61.
BacKacHe nos
724.5
Used when documentation states backache, or vertebrogenic syndrome.
BeniGn HYp Ht Dis W/o Hf
402.10
Used when the documentation indicates benign hypertensive heart disease, hypertensive heart disease or heart disease secondary to hypertension.
BeniGn HYpertension
401.1
Documentation must indicate benign or benign essential hypertension. If documentation only indicates hypertension, see 401.9, below.
BeniGn neoplasm lG BoWel
211.3
Used when the documentation indicates adenomatosis, Cronkhite-Canada syndrome, colon polyp, appendix polyp, caput coli polyp, cecum polyp, ileocecal polyp, hepatic flexure polyp or familial adenomatous polyp.
Non-cancerous lesion in colon, diagnosed by colonoscopy and/or radiologic studies Nonspecific abnormality involving bone and cartilage, diagnosed clinically
Bone & cartilaGe Dis nos
733.90
Used when the documentation indicates bone lesion, osteolytic lesion, bone mass, osteocopic pain, osteodynia, osteopenia, bone pain, cartilage pain, tibia pain, xyphoid pain, scapulalgia, xiphoidenia, xiphoidalgia or bone changes.
BpH W/o urinarY oBs/luts
600.00
Used when documentation states BPH.
Enlargement of prostate without obstructive sxs (urinary retention, dripping or hesitancy), diagnosed clinically Infection or inflammation of bronchus charaterized by cough and/or CXR normal (no infiltrate) diagnosed clinically Nonspecific non-sinus rhythm diagnosed by EKG or rhythm monitor
BroncHitis nos
490
This code is used when bronchitis is the only description in medical record. In diseases where there is both a chronic and acute form of the disease, its important to note which form of the disease is present.
carDiac DYsrHYtHmia nos
427.9
Used when the documentation indicates only arrythmia, cardiac dysrhythmia or cardiac arrythmia. When the type of arrythmia is known, it should be documented and coded appropriately.
carDiac DYsrHYtHmias nec
427.89
Used when the documentation indicates cardiac arrhythmia, cardiac dysrythmia, gallop rhythm, nodal rhythm disorder, alternating pulse, bigeminy, bigeminal rhythm, trigeminy, trigeminal rhythm, pulsus alternans, a-v nodal rhythm or ectopic rhythm.
Nonsinus rhythm diagnosed by ECG or rhythm monitor
DX Description
Enlarged heart, diagnosed clinically or by image studies
DX coDe de
Hcc
Hcc Description
clinical criteria
carDiomeGalY
429.3
This code is used when the documentation states only cardiomegaly, without any indication of the underlying disease. If documentation indicates it is due to HTN use codes 402.0-402.9. Opacification of lens leading to impaired vision, diagnosed clinically Nonspecific infection of the skin leading to warmth, erythema, swelling, diagnosed clinically and/or by image studies
cataract nos
366.9
Used when documentation indicates cataract, lens changes, intumescent lens, or lens opacity without further description.
cellulitis & aBscess leG eXcept foot
682.6
Used when the documentation indicates abscess of leg/ankle, cellulitis of leg/ankle, abscess/cellulitis of hip, femoral abscess/ cellulitis of knee, popliteal abscess/cellulitis, pre-patellar abscess/cellulitis, or abscess/cellulitis of the thigh.
cellulitis nos
682.9
This code is used when the documentation indicates cellulitis, diffuse cellulitis, chronic cellulitis, phlegmonous cellulitis or when multiple sites of cellulitis are documented.
Nonspecific infection of the skin leading to warmth, erythema, swelling, diagnosed clinically and/or by image studies Symptoms of neck pain/discomfort, diagnosed clinically Nonspecific noncardiac chest pain/discomfort, diagnosed clinically
cerVicalGia
723.1
This code is used when the documentation indicates cervicalgia, neck pain or cervical pain and no cause of the pain is documented.
cHest pain nec
786.59
Used when the documentation states chest pain, chest discomfort, atypical chest pain, musculoskeletal chest pain or noncardiac chest pain.
cHest pain nos
786.50 Cardinal symptoms include SOB, edema, or CP, diagnosed by clinical findings and +PVC on CXR...echo may reveal low EF (<50%) and/or normal EF with diastolic dysfunction Chronic obstructive lung disease often diagnosed with smoking hx, wheezing, PFT showing obstructive pattern (FEV1/FVC < 80%)
Used when documentation indicates chest pain or rib pain.
Nonspecific or non cardiac chest pain / discomfort, diagnosed clinically
cHf nos
428.0
80
Congestive Heart Failure
Used when documentation says Bernheims syndrome, CHF or heart failure.
cHronic airWaY oBstruct nec
496
108
Chronic Obstructive Pulmonary Disease Nonspecific chronic ischemic heart disease, diagnosed clinically and/or cardiac testing
Used when documentation indicates COPD. When known, the type of airway obstruction should be documented and coded (e.g., chronic bronchitis).
cHronic iscHemic Hrt Dis nos
414.9
This code is used when the documentation indicates ischemic coronary changes, coronary damage, ischemic heart, coronary disease, ischemic heart disease, cardiac ischemia, coronary ischemia, or acquired coronary ischemia and no additional information is given.
cHronic KiDneY Dis nos
585.9
131
Renal Failure
Use when the documentation indicates chronic kidney disease, chronic renal failure, chronic kidney disease or chronic uremia. Note that chronic kidney disease coding should include a diagnostic statement of the stage of kidney disease whenever possible.
Nonspecific chronic renal dysfunction characterized by impaired GFR.
cHronic KiDneY Dis staGe ii (milD)
585.2
131
Renal Failure
Used when documentation indicates that the patient has CKD stage 2 and there is a documented GFR of 60-89.
Chronic renal dysfunction characterized by GFR of 60-89
DX Description
Chronic renal dysfunction characterized by GFR of 30-59 Chronic renal dysfunction characterized by GFR of 15-29 3 mos or with signs of kidney damage (e.g., microalbuminuria, proteinuria, etc.) Clinical markers of chronic hypoxemia, such as polycythemia or cor pulmonale, suggest a long-standing disorder. May manifest as CO2 retention resulting in a respiratory acidosis. Chronic respiratory acidosis results in a metabolic alkalosis with elevated serum bicarbonate level. Fracture of femur, diagnosed by x-ray. Nonspecific constipation, diagnosed by history Symptom of cough, diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
cHronic KiDneY Dis staGe iii
585.3
131
Renal Failure
This code is used only when the documentation indicates Stage III Chronic Kidney Disease AND there is a documented GFR from 30-59.
cHronic KiDneY Dis staGe iV (seVere)
585.4
131
Renal Failure
Used when documentation indicates that the patient has stage 4 CKD and there is a documented GFR of 15-29
cHronic respiratorY failure
518.83
79
This code is used when the documentation indicates chronic respiratory failure, or chronic respiration failure.
clos fracture unspec part necK fem
820.8
158
Hip Fracture/ Dislocation
Use this code when the documentation indicates fracture of the neck of femur, fracture of the femur, upper end of the femur, or hip.
constipation nos
564.00
Use when documentation states constipation.
couGH
786.2
This code is used when the documentation indicates cough, laryngeal syncope or tussive syncope.
crBl art ocl nos W infrc
434.91
96
This code is used when the documentation indicates CVA, Cerebral accident, cerebrovascular accident, acute cerebrovascular disease, ischemic CVA, brain stem infarct(ion), lacunar infarction, cerebellar infarction, cortical infarction, or stroke. Atherosclerosis of coronary arteries defined by positive stress test or positive cardiac cath without specification of whether native or graft vessel is involved in a patient with graft vessels Atherosclerosis of coronary arteries defined by positive stress test or positive cardiac catheterization
Development of blood clot in the cerebral arteries with brain tissue damage leading to motor, sensory, and/or speech deficit, diagnosed clinically and/or by image studies
crnrY atH unsp Vsl ntV/Gft
414.00
Use when documentation indicates coronary atherosclerosis or arteriosclerosis AND you have stated that the patient has both native and non-native vessels--but you have not indicated which type of vessel is affected.
crnrY atHrscl natVe Vssl
414.01
Use only when atherosclerosis or arteriosclerosis is stated to be of native vessel or there is no documentation of a prior CABG.
DeHYDration
276.51
This code is used when documentation says Luetschers syndrome, Luetschers dehydration, dehydration or anhydration.
Loss of fluid from the body leading to weakness, thirst, fast heartbeat, poor skin turgor, hypernatremia, etc, diagnosed clinically A progressive, neurodegenerative disease characterized by loss of function and death of nerve cells in several areas of the brain leading to loss of cognitive function such as memory and language.
Dementia cce W/o BeHaV DisturB
294.10
This code is only used as a secondary code. In any disease that may have dementia as a symptom, the primary disease (e.g., Huntingtons Chorea, Alzheimers disease, Picks Disease, etc.), and dementia without mention of behavioral disturbance is mentioned, this code should be used in addition to the code for the primary disease.
DepressiVe DisorDer nec
311
Use this code when the documentation indicates depression or depressive disorder with no further description.
Depressive disorder not elsewhere classified, may have some symptoms of depressed mood and loss of interest, change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate but not MDD
DX Description
Nonspecific depression (depressed mood, loss of interest, change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate, or suicide thoughts) with delusion and/or hallucination Inflammation of the skin leading to erythema, swelling, itchiness, diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
DepressiVe psYcHosis-unspec
296.20
55
Major Depressive, Bipolar, and Paranoid Disorders
Used when the documentation indicates an episode of involutional depression, melancholia, depressive psychosis, melancholia, involutional melancolia, menopausal melancholia, stuporous melancholia, agitated depression, psychotic depression, or melancholy.
Dermatitis nos
692.9
Used when the documentation indicates dermatitis, venenata dermatitis, contact dermatitis, allergic dermatitis, occupational dermatitis, acneiform dermatitis, anaphylactic dermatitis, allergic agent (unspecified) or eczematoid dermatitis (unspecified).
DermatopHYtosis of nail
110.1
Used when the documentation indicates dermatophytosis of nail, fungus of nail, toenail fungus, or fingernail fungus.
Fungal infection of the nail, diagnosed clinically or by biopsy Protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm, diagnosed by EGD and/or image studies Symptoms of diarrhea (frequent stool: > 3 daily), diagnosed clinically. Also diagnosed based on stool appearance (watery)
DiapHraGmatic Hernia
553.3
Used when the documentation indicates hiatus hernia, diaphragmatic hernia, sliding diaphragmatic hernia, Bochdalek hernia, Morgagni(an) hernia, hiatal hernia, paraesophageal hernia, Saint triad, or Saints hernia.
DiarrHea
787.91
This code was used when the documentation indicates diarrhea, acute diarrhea, autumn diarrhea, bilious diarrhea, bloody diarrhea, catarrhal diarrhea, choleraic diarrhea, chronic diarrhea, diarrhea gravis, green diarrhea, infantile diarrhea, or lienteric diarrhea.
DifficultY WalKinG
719.7 Specified lesion or process involving the nail, including deformity, discoloration, abnormal growth, etc, diagnosed clinically
Used when documentation indicates that the patient has difficulty in walking, but no cause is described.
Difficulty walking, diagnosed clinically
Diseases of nail nec
703.8
This code is used when the documentation indicates achromia unguium, acquired anonychia, atrophia unguium, Beaus lines, brittle nails, clubnail, defluvium unguium, nail discoloration, eggshell nails, fragilitas unguium, fragile nails or furrowing nails. Symptoms of feeling dizzy, imbalanced, diagnosed clinically
DiZZiness anD GiDDiness
780.4
This code is used when the documentation indicates dizziness, giddiness, dysequilibrium, lightheadedness, swimming in the head, Mal de Debarquement or vertigo. Controlled DM 1 without complication
Dmi Wo cmp nt st uncntrlD
250.01
19
Diabetes without Complication
This code should be used when you have documented DM 1 or juvenile diabetes is documented.
Dmii circ nt st uncntrlD
250.70
15
Diabetes with Renal or Peripheral Circulatory Manifestation
This code is used when the documentation indicates that circulatory disorders are secondary to or caused by diabetes mellitus. For example, diabetic angiopathy, gangrene 2 diabetes, peripheral circulatory disease 2 diabetes, or diabetic microangiopathy.
DM 2, not stated as uncontrolled, and vascular findings including claudication, ulcers, gangrene, atherosclerosis (i.e. peripheral vascular disease, erectile dysfunction, CVA, CAD) or positive findings on ABI, ultrasound, CT angiogram, MRA or angiogram Controlled DM 2, with neurological manifestations 2 DM including numbness, tingling, burning sensations, gastroparesis, erectile dysfunction, autonomic instability or positive finding on nerve conduction study or failed monofilament test of foot
Dmii neuro nt st uncntrlD
250.60
16
Diabetes with Neurologic or Other Specified Manifestation
Use this code when the documentation indicates that the patient has a neurological complication of their diabetes. The documentation must indicate that the complication is secondary to the diabetes. The neurological complication must be specified.
DX Description
Controlled DM 2, which has caused eye findings such as Macula edema, vision change, retinopathy, cataract, retinal edema, vitreous hemorrhage, microaneurysms, and blindness, diagnosed clinically and/or by ophthalmoscopic exam Controlled DM 2 with other complications caused by the diabetes such as skin findings, infections, etc, not stated as uncontrolled
DX coDe de
Hcc
Hcc Description
clinical criteria
Dmii opHtH nt st uncntrlD
250.50
18
Diabetes with Ophthalmologic or Unspecified Manifestation
Used when the documentation indicates that ophthalmological conditions are secondary to, or caused by diabetes. The documentation must indicate the causal relationship. This code is not used when an eye condition simply co-exists (i.e., comorbid) with diabetes.
Dmii otH nt st uncntrlD
250.80
16
This code is used when the documentation indicates that there is a diabetic complication (i.e., a condition CAUSED by the diabetes) that is not included in a more specific diabetes complication code. For example: diabetic bone changes, diabetic dermatitis.
Dmii renl nt st uncntrlD
250.40
15
Use only when documentation indicates the patient has renal disease that is secondary to diabetes, or diabetic renal disease. The ICD-9 does not assume a causal relationship, so you must include it in your documentation. You must also code the renal disease.
Controlled DM 2 with renal manifestations caused by the diabetes (renal manifestation included albuminuria, proteinuria, decreased GFR, Cr, etc) Diabetic Neuropathy MA/CR>299
Dmii W/renal uns/uncntrlD
250.42
15
Use when the documentation indicates uncontrolled or out of control diabetes(either type II or no type stated) with renal manifestations or complications.
Diabetes with abnormal blood glucose values and proteinuria or other evidence of kidney damage
Dmii Wo cmp nt st uncntrlD
250.00
19
If diagnosis indicates DM, diabetes mellitus or diabetes, this is the correct code. When unspecified in the medical record, diabetes is assumed to be type II based on ICD-9 guidelines.
DM 2 without complication, not stated as uncontrolled, diagnosed clinically
Dmii Wo cmp uncntrlD
250.02
19
Diabetes without Complication Non-bleeding colon diverticulosis diagnosed by colonoscopy or other image studies
This code is used when the documentation indicates that the patient has DM II (or the type is not stated) and the physician specifically states that the diabetes is uncontrolled or out of control. NOTE: poor/poorly control is not acceptable.
Uncontrolled DM 2 without end-organ complication. Micro albumin/Cr ratio<299
DVrtclo colon W/o HmrHG
562.10
Used when documentation states diverticulosis.
DYspHaGia unspecifieD
787.20
Used when the documentation indicates dysphagia, or difficulty swallowing.
Difficulty swallowing, diagnosed clinically or by radiological studies. Diagnosed generally clinically, x-rays only if patient is aphasic. Accumulation of fluid, usually in the lower extremities and dependent area, diagnosed clinically Elevated PSA level, diagnosed based on lab value
eDema
782.3
Use this code when the documentation indicates anasarca, Secretans edema, infectious edema, pitting edema, or edema.
elVtD prstate spcf antGn
790.93
This code is to be used when you have documented that the patient has an elevated PSA. If you only note the lab value, you cannot code thisyou must state that it is elevated.
empHYsema nec
492.8
108
Chronic Obstructive Pulmonary Disease
Used when the documentation indicates emphysema, atrophic, centriacinar, centrilobular, chronic, diffuse, essential, hypertrophic, interlobular, lung, obstructive, panlobular, paracicatricial, paracinar, postural, pulmonary, senile, subpleural, or traction pulmonary disease.
Damage to alveoli frequently diagnosed by smoking history, wheezing, CXR finding and obstructive PFT (FEV1/FVC < 70%)
DX Description
End-stage renal disease (ESRD) is an administrative term based on the conditions for payment for health care by the Medicare ESRD Program. This term denotes kidney disease at a level that requires dialysis or transplantation. Backflow of stomach fluid to esophagus leading to acidic taste in the mouth, epigastric abdominal pain diagnosed clinically and/or by EGD Decrease visual acuity or central vision loss due to aging diagnosed clinically. Should be based on prior or concurrent exam by ophthalmologist. Performance of eye and vision examination Used to indicate the cause of an injury
DX coDe de
Hcc
Hcc Description
clinical criteria
enD staGe renal Disease
585.6
131
Renal Failure
This code is used when the documation indicates end stage renal disease, ESRD, or kidney disease requiring dialysis.
esopHaGeal refluX
530.81
Used when documentation indicates GERD or reflux.
eXuDatV senl maculr DeGenrat-ret
362.52
Used when the documentation indicates Kuhnt-Junius disease, disciform macula, exudative macular degeneration, wet macular degeneration, Kuhnt-Junias retina, Kuhnt-Junias degeneration or disciformis retinitis.
eYe & Vision eXamination
V72.0
Used to indicate a patient seen for eye examination
fall nos
E888.9
This code is used when the documentation indicates that the patient fell, without further information. The code series E888.X has very specific codes for falls, based on how or where they occurred. When this information is available, it should be documented.
feVer unspecifieD
780.60
Used when the documentation indicates fever, chills with fever, pyrexia, fever of unknown origin, ephemeral fever, or febricula.
Presence of fever without further detail; generally >= 99.5 F or 37.5 C
Gastr/DDnts nos W/o HmrHG
535.50
Used when the documentation indicates gastritis, gastroduodenitis, gastrohepatitis, gastrojejunitis or pyloritis and there is no mention in the documentation of hemorrhage or bleeding. Nonspecific bleeding involving GI tract, diagnosed clinically and or by endoscopies or radiological studies Pain in multiple joints without inflammation.
Nonbleeding inflammation of stomach or duodenum diagnosed clinically and/or by endoscopy/image studies
Gastrointest Hemorr nos
578.9
Used when the documentation indicates gastric bleeding, gastrointestinal bleeding, stomach bleeding, enterorrhagia, bowel hemorrhage, cecal bleeding, gastric hemorrhage or gastroenteric hemorrhage.
Gen osteoartHrosis inVlV mX sites
715.09
Use this code when the documentation indicates generalized osteoarthritis/osteoarthrosis, polyarticular osteoarthrosis, idiopathic general osteoarthosis/arthritis, polyarticular arthrosis, generalized joint disease, or generalized arthritis.
General osteoartHrosis
715.00
Used when the documentation indicates generalized osteoarthrosis or generalized arthritis. This code should not be used when the medical record indicates arthritis, which is coded 715.9not stated whether localized or generalized.
Generalized OA involving multiple joints, diagnosed clinically or by image studies
Glaucoma nos
365.9
Used when documentation only states glaucoma with no further information.
Increase in intraocular pressure causing optic nerve damage, leading to visual impairment diagnosed by tonometry and/or ophthalmoscopic exam Condition caused by the accumulation of uric acid crystals, may deposit in joints (arthritis), kidney (stone), gallbladder (stone), dignosed clinically with/without elevated uric acid
Gout nos
274.9
Used when documentation indicates gout, urate thesaurismosis, uric acid diasthesis, gouty diasthesis or podagra.
DX Description
Symptoms of headache or head discomfort, diagnosed clinically Nonspecific loss of hearing, diagnosed clinically or by audiology
DX coDe de
Hcc
Hcc Description
clinical criteria
HeaDacHe
784.0
Used when the documentation indicates headache, cephalgia, vascular headache, face or facial pain or head pain.
HearinG loss nos
389.9
Used when the documentation indicates hearing loss, deafness, auditory deafness, impaired hearing, auditory imperception, hereditary deafness, congenital deafness, or acquired deafness with no description of the etiology of the impairment.
Hematuria unspecifieD
599.70
Used when the documentation indicates hematuria, blood in the urine, Tommasellis disease, bloody urine, idiopathic hematuria, intermittent hematuria, paroxysmal hematuria or sulfonamide hematuria (if correct drug administered properly).
Blood in the urine, diagnosed clinically or by UA (+blood or +RBC)
Hemipl affct uns siDecereBrVasc DZ
438.20
100
Hemiplegia/ Hemiparesis
Used when the documentation indicates hemiplegia/hemiparesis following (or status post) CVA, hemiplegia as a late effect of CVA or CVA with hemiplegia or hemiparesis. NOTE: Per Coding Clinic, Q1 2005, weakness status post CVA is coded as 438.89, Other late effects of cerebrovascular disease and code 728.87, Muscle weakness, for residual muscle weakness secondary to late effect of cerebrovascular accident.
Hemiplegia/Hemiparesis as a result of prior CVA
Ht pros W/ur oBst & otH luts
600.01
Use when documentation indicates enlargement of the prostate with lower urinary tract symptoms, prostate hyperplasia with lower urinary tract symptoms, enlargement/hyperplasia of the prostate with obstruction, enlargement/hyperplasia of the prostate with urinary retention, hypertrophy of the prostate with urinary retention/obstruction or hypertrophic prostate with lower urinary tract symptoms. Use additional code to identify symptoms such as frequency 788.41 etc. History of breast cancer, no active cancer, diagnosed by history
Enlargement/hyperplasia of the prostate with urinary retention.
HX of Breast maliGnancY
V10.3
This code is used when the documentation indicates that the patient has had breast cancer and has completed treatment (surgically, radiation, chemotherapy or any combination) when there is no indication that there is tumor still present. Patients undergoing treatment with tamoxifen or similar drugs should be coded as having active disease.
HX of toBacco use
V15.82
Used when the documentation indicates a history of tobacco use, prior tobacco use or history of cigarette smoking.
History of prior tobacco use, diagnosed by history CKD of any stage in the presence of essential (primary, not renovascular) HTN, but excluding malignant HTN (sudden and rapid development of extremely high blood pressure usually with a diastolic of > 125 and cardiac, renal, or cerebral manifestations) and also excluding acute or renal failure due to other (non HTN) causes
HYp cKD Ben cKD staGe i tHru iV/uns
403.10
Used when the documentation indicates benign hypertension with CKD stage 1-4 or benign hypertension with CKD, or hypertension with renal involvement, renal sclerosis with hypertension, or hypertension with glomerulosclerosis.
DX Description
Unspecified hypertensive renal disease
DX coDe de
Hcc
Hcc Description
clinical criteria
HYp cKD uns cKD staGe i tHru iV/uns
403.90
Used when documentation indicates hypertensive kidney disease, renovascular hypertension, arteriolar glomerulonephritis, arteriosclerotic glomerulonephritis, hypertension with chronic kidney disease (unspecified or Stage 1-4).
HYp KiD nos W cr KiD V
403.91
131
Renal Failure
This code is used when the documentation indicates that the patient has both Stage V CKD and hypertension. NOTE: Codes in the 403.X series are an exception to the rule that the physician must document a causal relationship between two diseases.
Hypertensive kidney disease with chronic kidney damage, such as albuminuria, proteinuria, hematuria, glomerulonephritis, abnormal creatinine or renal failure, characterized by GFR < 15, needing dialysis or transplantation High lipid state characterized by elevated LDL or triglyceride Refractive error of the eye leading to inability to focus on close objects often associated with aging, diagnosed clinically Blood test showing potassium is greater than upper limit of normal (5.0 mEq/L) Hypertension with SBP >140, DBP > 90 on 2 or more occasions Low potasium state, diagnosed by lab value
HYperlipiDemia nec/nos
272.4
When documentation only indicates hyperlipidemia, this is the correct code.
HYpermetropia
367.0
Used when documentation states hypermetropia, hyperopia, or farsightedness.
HYperpotassemia
276.7
Used when the documentation indicates hyperpotassemia, excess potassium, hyperkalemia, potassium overload or hyperkalemic.
HYpertension nos
401.9
When documentation only indicates hypertension, or uncontrolled hypertension, this is the correct code.
HYpopotassemia
276.8
Used when the documentation indicates hypopotassemia, potassium depletion, potassium deficiency, hypokalemia or hypokalemic.
HYposmolalitY
276.1
This code is used when the documentation indicates anhydration with hyponatremia, dehydration with hyponatremia, salt depletion, sodium depletion, sodium deficiency, fluid loss with hyponatremia, hyposmolality or sick cell. Nonspecific state of low blood pressure, diagnosed clinically
Low electrolyte state, frequently associated with dehydration and low sodium, diagnosed by laboratory values
HYpotension nos
458.9
Used when the documentation indicates low blood pressure, low pressure, arterial hypotension, hypotension, constitutional hypotension, or hyposystolic pressure.
HYpotHYroiDism nos
244.9 Lower than normal blood oxygen level.
Used when documentation indicates hypothyroidism, or post-surgical hypothyroidsm.
Low thyroid state characterized by low energy state, depression, weakness, edema, constipation, diagnosed by high TSH and usually low Total T3, Total T4
HYpoXemia
799.02
79
Used when the documentation indicates hypoxia, anoxia, anoxemia, pathological anoxia, or hypoxemia.
iDio peripH neurptHY nos
356.9
71
Polyneuropathy
This code is used when the documentation indicates interstitial hypertrophic progressive neuritis, hereditary neuropathy, interstitial hypertrophic neuropathy, multiple neuropathy, polyneuropathy, peripheral neuropathy, atrophic neuropathy, Peripheral progressive neuropathy, polyneuritis or trophoneurosis.
Nonspecific loss of sensation or movement due to idiopathic nerve damage, diagnosed clinically and/or by NCS/EMG
impacteD cerumen
380.4
This code is used when the documentation indicates impacted cerumen, impacted ear wax, abnormal cerumen production, wax in ear, or cerumen accumulation.
Ear wax impaction diagnosed by direct visualization
inGroWinG nail
703.0
Use when documentation states ingrown nail, onychocryptosis, onyxis, Unguis incarnatus or ingrowing nail.
Painful condition of the great toe in which the nail grows into the skin on either side, causing inflammation and/or infection, diagnosed clinically
DX Description
Inability or difficulty falling asleep or remaining asleep Presence of internal hemorrhoid, diagnosed clinically New onset angina (cardiac CP) or angina with increase in frequency or intensity, diagnosed clinically with T inversion on ECG and hypokinesis on echocardiogram
DX coDe de
Hcc
Hcc Description
clinical criteria
insomnia nos
780.52
This code is used when the documentation indicates insomnia, sleeplessness, agrypnia, disruption in sleep initiation or maintenance, or hyposomnia.
int HemorrHoiD W/o compl
455.0
This code is used when the documentation indicates internal hemorrhoids.
intermeD coronarY sYnD
411.1
82
Unstable Angina and Other Acute Ischemic Heart Disease
Used when the documentation indicates intermediate coronary syndrome, impending coronary syndrome, impending myocardial infarction, impending infarct, acute coronary syndrome, cornary insufficiency syndrome, unstable angina or intermediate coronary.
iron Defic anemia nos
280.9
Used when the diagnosis is iron deficiency anemia, Witts anemia, achlorhydic anemia, green sickness, sideropenia, Fabers disease, or Hayem-Faber disease.
Low RBC level (Hgb < 16 for men; Hgb < 14 for women) due to iron deficiency, characterized by low MCV, low ferritin, low iron, elevated TIBC Joint discomfort/pain involving ankle, diagnosed clinically Lower extremity pain involving the knee joint, diagnosed clinically Joint discomfort involving pelvic area, diagnosed clinically Joint discomfort involving shoulder, diagnosed clinically
Joint pain-anKle
719.47
Used when the documentation indicates pain in the ankle, foot or metatarsals.
Joint pain-l/leG
719.46
This code is used when the documentation indicates that the patient has knee pain, patellofemoral syndrome, or patellofemoral pain.
Joint pain-pelVis
719.45
Used when documentation states coxalagia, hip pain, or pelvic pain.
Joint pain-sHlDer
719.41
This code is used when the documentation indicates shoulder joint pain.
KeratoDerma, acquireD
701.1
This code is used when the documentation indicates acanthokeratodermia, acquired alligator skin disease, alligator skin, acquired fish skin, Kyrles syndrome, hyperkeratosis follicularis in cutem penetrans, or Lutz-Miescher syndrome. Status of knee replacement with prosthesis Performance of laboratory tests only Status post lens replacement Abnormal lipid metabolism, diagnosed clinically and by abnormal laboratory values
Skin disorder consisting of a growth that appears horny, diagnosed clinically
Knee Joint replacement otHer means
V43.65
Used when documentation indicates knee joint replacement, knee replacement, knee/knee joint prosthesis, knee joint device, or artificial knee joint.
laBoratorY eXamination unspecifieD
V72.60
This code is used when the documentation indicates that the patient had laboratory services done.
lens replacement nec
V43.1
Used when your note indicates that the lens of the eye has been replaced.
lipoiD metaBol Dis nos
272.9
Used when the documentation indicates abnormal lipids, congenital abnormal lipid metabolism, or abnormal cholesterol metabolism. (Note that metabolism must be mentioned. The term hyperlipidemia or dyslipidemia codes to 272.4).
loc prim osteoart-l/leG
715.16
This code is used when the documentation specifically states that osteoarthritis is present in the lower extremity (leg).
OA involving lower extremity, diagnosed clinically Status of using long term anticoagulation therapy
lonG-term use anticoaGul
V58.61
Used when the documentation indicates that the patient is on long-term anticoagulant therapy. The underlying condition (e.g., history of DVT or chronic atrial fibrillation) must also be documented and coded.
DX Description
Status of (current) medication use long term
DX coDe de
Hcc
Hcc Description
clinical criteria
lonG-term use meDs nec
V58.69
Used when the patient has long term medication use that does not have a specific code. For example there are specific codes for long term use of anticoagulants (V58.61), long term use of antibiotics (V58.62) and long term use of steroids (V58.65). Its appropriate to use this code for long term use of opioid pain medication. Status of long term use of insulin. OA involving lumbar and/or sacral area, diagnosed clinically Pain in the lumbar region diagnosed clinically Nonspecific inflammation of lumbarsacral nerve(s) leading to pain, numbness or tingling, diagnosed clinically and/or by EMG/NCS
lonG-term use of insulin
V58.67
19
Used when the documentation indicates current insulin use, long term insulin use, or ongoing insulin therapy.
lumB/lumBosac Disc DeGen
722.52
This code is assigned if the documentation states OA AND the location of the lumbar or sacral spine is specifically stated.
lumBaGo
724.2
Used when documentation says lumbago or low back pain.
lumBosacral neuritis nos
724.4
This code is used when the documentation indicates lumbar nerve root disorder, lumbosacral nerve root disorder, thoracic nerve root disorder, lumbosacral radicular pain, anterior crural radiculitis, leg radiculitis, lumbar, lumbosacral radiculitis, or lumbosacral radiculopathy.
lumBosacral sponDYlosis
721.3
Used when the documentation indicates lumbar spondylosis, lumbosacral spondylosis, or sacral spondylosis.
OA involving lumbar and/or sacral area, diagnosed clinically or by image studies
malaise anD fatiGue nec
780.79
Used when documentation indicates malaise, fatigue, asthenia, or chronic Epstein Barr.
Symptoms of malaise and fatique, diagnosed clinically Active malignant cancer of breasts diagnosed by + mamogram with + bx
maliGn neopl Breast nos
174.9
10
Breast, Prostate, Colorectal and Other Cancers and Tumors Diagnosis of lung cancer based upon postive biopsy result.
This code is used when the documentation indicates breast cancer or malignant neoplasm of the breast and the patient has not completed treatment aimed at eradicating the disease. After definitive treatment is complete, documentation should indicate history of breast cancer, and coded as V10.3.
maliGn neopl BroncHus & lunG uns site
162.9
Lung, Upper Digestive Tract, and Other Severe Cancers
Used when the documentation indicates lung cancer, bronchogenic cancer, pulmonary cancer, sub-pleural cancer, or bronchogenic carcinoma without indication of the specific site.
maliGn neopl prostate
185
10
Breast, Prostate, Colorectal and Other Cancers and Tumors
This code is used when prostate cancer is documented. This code can be used for patients on long-term Lupron therapy. Note that patients who have completed therapy for their cancer should be documented with a history of the malignancy and coded as V10.46.
Malignant cancer of the prostate gland diagnosed by biopsy
maliGn neopl sKin face nec
173.3
This code is used for malignancies on the skin of the face which do not have a specified code. If there is a specific code which describes the malignancy documented, use that code instead.
Malignant skin cancer on the face, diagnosed by biopsy
DX Description
Very elevated blood pressure resulting in eye, kidney, and cardiovascular damage, diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
maliGnant HYpertension
401.0
This code should only be used if the medical record indicates accelerating hypertension, necrotizing hypertension or malignant hypertension. This code should rarely be seen in a physician office setting. It is NOT synonmous with uncontrolled hypertension. Nonspecific psychiatric condition may include affective, paranoid and psychotic state, diagnosed clinically
mental Disor nec otH Dis
294.8
This code is used when the documentation indicates chronic brain infection, chronic intracranial infection, chronic brain trauma, mixed affective and paranoid state, mixed paranoid and affective pychosis or dementia. It is also used when a specified type of mental disorder does not have a more specific code.
mitral ValVe DisorDer
424.0
This code is used when the documentation indicates mitral valve disorder, ballooning posterior leaflet, Barlows prolapse, mitral valve prolapse, or floppy mitral valve.
Any disorder or damage involving mitral valve, including stenosis, regurgitation or prolapse diagnosed by echo, angiogram or other image studies Hyperlipidemia characterized by elevated LDL (>160mg/dL) and elevated triglyceride (>160mg/dL), diagnosed by lab values A reduction in the strength of one or more muscles.
miXeD HYperlipiDemia
272.2
Used when documentation states type II hyperlipoproteinemia, xanthoma, or beta disease.
muscle WeaKness (GeneraliZeD)
728.87
Use this code if the documentation indicates that the patient is myasthenic, or has muscle weakness.
mYalGia anD mYositis nos
729.1
Used when the documentation indicates myalgia, fibromyalgia, myositis, myofacial pain, fibromyositis, muscle pain, neuromuscular pain, or rheumatic muscular pain. Refractive error of the eye leading to inablility to focus farway objects, diagnosed clinically Symptoms of nausea and vomiting, diagnosed clinically
Nonspecific pain involving muscle, diagnosed clinically
mYopia
367.1
Used when documentation indicates myopia, nearsightedness, or shortsightedness.
nausea WitH VomitinG
787.01
Used when the documentation indicates the presence of both nausea and vomiting. For nausea w/o vomiting, use 787.02; for vomiting w/o nausea documented, use 787.03
neuropatHY in DiaBetes
357.2
71
Polyneuropathy
This code is used to describe diabetic neuropathy, neuropathy secondary to diabetes, or diabetes with neuropathy.
DM caused neurological manifestations including numbness, tingling, burning sensations, gastroparesis, erectile dysfunction, autonomic instability or positive finding on nerve conduction study, diagnosed clinically Decreased visual acuity or central vision loss due to aging, diagnosed clinically An inflammation of the stomach and intestine resulting in diarrhea, with vomiting and cramps with infectious workup being negative, diagnosed clinically Nonspecific raised, itchy, red-welts on the surface of the skin, usually due to allergic reaction to food, medication, etc, diagnosed clinically
noneXuDat macular DeGen
362.51
Used when the documentation states atrophic macula, dry macula, or nonexudative macular degeneration.
noninf Gastroenterit nec
558.9
This code is used when the documentation indicates chronic ileitis, non-infectious ilieitis, ileocolitis, bowel/colon inflammation, inflammatory bowel/colon, gastrointestinal inflammation, ileal inflammation, jejunitis, acute colitis or catarrhal colitis.
nonspecif sKin erupt nec
782.1
Used when the documentation indicates pustular rash, rash, rose rash, toxic rash, skin rash or exanthema.
DX Description
Characterized by 20% over ideal body weight or BMI of more than 30 Grade 3 overweight (morbid obesity) characterized by a BMI equal to or greater than 40 kg/m2. Chronic bronchitis with worsening cough, shortness of breath or hypoxia (pO2 < 60), diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
oBesitY nos
278.00
Use when the medical record indicates obesity.
oBesitY, morBiD
278.01
Used when the documentation indicates morbid obesity, morbidly obese, or severe obesity.
oBs cHr Bronc W(ac) eXac
491.21
108
Used when the documentation indicates exacerbation of chronic bronchitis or blue bloater with acute exacerbation.
oBstructiVe sleep apnea
327.23
This code is used when the documentation indicates obstructive sleep apnea or sleep apnea with obstruction.
Apnea, defined as a cessation of airflow for at least 10 seconds which occurs during sleep due to obstruction (non central). Stenosis or occlusion of carotid artery without CVA symptoms, diagnosed clinically and/or by imaging studies H/O MI as evident by Q waves on EKG or characteristic abnormal wall motion on echo
ocl crtD art Wo infrct
433.10
Used when the documentation indicates carotid stenosis, stenosis of carotid artery (common, internal), or carotid occlusion, without mention of infarct.
olD mYocarDial infarct
412
83
Use when a history of myocardial infarction is documented.
osteoartHros nos-l/leG
715.96
Use this code when the documentation states arthritis, nonpyogenic arthritis, arthropathy, joint inflammation, or rheumatism of the lower part of the leg is documented. Non-specific OA characterized by joint pain and stiffness, diagnosed clinically or by x-ray findings (narrow joint space, bone spurs, etc) Nonspecific decrease in bone mass or density, diagnosed clinically or by DEXA scan or other image studies Non-specific change in mental status, including delirium, drowsiness, hyporesponsive state, loss of consciousness, semi coma, semi consciousness or somnolence. Sudden, involuntary skeletal muscular contractions of cerebral or brain stem origin
Non-specific joint pain involving lower extremity, diagnosed clinically
osteoartHros nos-unspec
715.90
Used when documentation says arthritis or osteoarthrosis or degenerative joint disease and no site is described.
osteoporosis nos
733.00
Used when documentation says osteoporosis.
otHer alter consciousnes
780.09
Used when documentation states: delirium, drowsiness, hyporesponsive state, loss of consciousness, semi coma, semi consciousness or somnolence.
otHer conVulsions
780.39
74
Seizure Disorders and Convulsions
Use if the documentation indicates epileptiform attack, sensory and motor attack, toxic cerebral attack, eclamptic coma, convulsions, idiopathic convulsions, cerebral convulsions, cerebrospinal convulsions, eclamptic convulsions, ether convulsions, generalized convulsions, infantile convulsions, internal convulsions, recurrent convulsions, repetitive convulsions, spasmodic convulsions, epileptoid seizures, ether seizures, generalized seizures, or convulsive disorder.
otHer General sYmptoms
780.99
Used when documentation indicates rigors, subnormal temperature, functional activity decrease, or other general symptoms.
Nonspecific general symptoms, diagnosed clinically
DX Description
Lung disease including lung calcification, pulmolithiasis, etc
DX coDe de
Hcc
Hcc Description
clinical criteria
otHer lunG Disease nec
518.89
This code is used when the documented type of lung disease has no other classification. Documentation should indicate one of the following: honeycomb lung, bronchioliasis, pulmolithiasis, calcification of lung, or lung disease.
otHer sBorHeic Keratosis
702.19 Performance of specific preoperative examination
This code is used when the documentation indicates seborrheic keratosis, seborrhea, seborrheic wart or verruca seborrheica.
Painless benign skin wart-like growth, diagnosed clinically or by biopsy
otHer spcf preop eXam
V72.83
This code is used to indicate a specified pre-operative examination that does not have a more specific code, e.g. renal function studies in a patient with kidney disease, before undergoing surgery. N/A
otHer spec reHaBilitation proc otH
V57.89
Used when the documentation indicates multiple types of ongoing rehabilitation, or when there is no specific code for the type of rehabilitation that the patient is undergoing.
pain in limB
729.5
Pain in arm, leg, hand, foot, fingers or toes.
Pain in arm, leg, hand, foot, fingers or toes, diagnosed clinically Presence of palpitation, diagnosed clinically
palpitations
785.1
Use when documentation indicates palpitations, pulses in the neck, or you have recorded that the patient has an awareness of their heartbeat.
paralYsis aGitans
332.0
73
Parkinsons and Huntingtons Diseases
This code is used when the documentation indicates Parkinsons, Parkinsons disease, paralysis agitans, parkinsons, shaking palsy.
Progressive, degenerative disorder of the nervous system characterized by tremors, rigidity, bradykinesia, postural instability, and gait abnormalities; caused by a loss of neurons and a decrease of dopamine in the basal ganglia. Atheroclerosis involving peripheral arteries leading to pain, ulceration or gangrene, diagnosed clinically with ankle-brachial index or by angiogram
peripH Vascular Dis nos
443.9
105
Vascular Disease
This code is used when the documentation indicates peripheral vascular disease, Charcts syndrome, intermittent claudication, vasomotor dilatation, angiospasmodic disease, peripheral arterial disease, vascular disease or small vessel disease.
pers HX tia & ci W/o resiDl Deficts
V12.54
Use when documentation indicates old CVA or healed CVA, without mention of deficits, history of TIA, old or healed cerebral hemorrhage, TIA, transient ischemic attack or prolonged reversible ischemic neurologic deficit (PRIND). Patient with history of fall.
Patient with a personal history of CVA with residual deficit.
personal HistorY of fall
V15.88
Used when documentation indicates fall, at risk for falls, fall/ falling hazard, falling disorder, or falling risk.
pHYsical tHerapY nec
V57.1
This code should be used only when the patient presents for physical therapy, and this is noted in the medical record.
Used by the physical therapist for patients presenting for physical therapy Nonspecific pleural fluid in lung cavity, diagnosed clinically or by image studies
pleural effusion nos
511.9
Used when the description of the condition is pleural effusion without further characterization.
DX Description
Bacterial pneumonia caused by a nonspecified organism, diagnosed clinically and/or by image study
DX coDe de
Hcc
Hcc Description
clinical criteria
pneumonia, orGanism nos
486
This code is used when the documentation indicates pneumonia, lung inflammation; acute, bilateral, double, or septic Pleuropneumonia, or Pneumonia described as: acute, Alpenstich, benign, bilateral, brain, cerebral, circumscribed, congestive, creeping. Nonspecific or non cardiac chest discomfort other than angina, diagnosed clinically
precorDial pain
786.51
This code is used when the documentation states precordial pain, cardialgia, anginoid pain, midsternal pain, substernal pain, heart pain, pericardial pain, or retrosternal pain. If the documentation says angina, then the correct code is 413.9.
preop carDioVsclr eXam
V72.81
This code is used when the documentation indicates that the examination is for cardiovascular clearance preoperatively.
Performance of pre-operative cardiovascular evalution Performance of H & P prior to surgical procedure Refractive error of the eye leading to inability to focus on close objects due to aging, diagnosed clinically
preop eXam unspcf
V72.84
Use only when your documentation indicates you are doing a history and physical examination for a patient having a surgical procedure
presBYopia
367.4
Used when documentation indicates presbyopia or insufficient accomodation.
prim carDiomYopatHY nec
425.4
80
This code is used when the documenation indicates primary cardiomyopathy, idiopathic cardiomyopathy, idiopathic myocardial hypertrophy, myocardiopathy described as: congestive, constrictive, familial, hypertrophic nonobstructive, idiopathic or infiltrative cardiomyopathy.
Abnormal cardiac function where SOB, CP and peripheral edema are cardinal symptoms, including idiopathic, dilated, restrictive, constrictive and hypertrophic etiologies, diagnosed by echo, angiogram and other image studies Chronic increase in intraocular pressure causing optic nerve damage, leading to visual impairment diagnosed by tonometry and/or ophthalmoscopic exam Complete or partial collapse of a portion of the lung, diagnosed clinically and/or by image studies/bronchoscopy
prim open anGle Glaucoma
365.11
Use when the documentation indicates chronic glaucoma, simple glaucoma, or open angle glaucoma. NOTE: DO NOT USE this code if your note says only Glaucoma, which is coded 365.9.
pulmonarY collapse
518.0
Used when documentation indicates Brocks syndrome, atelectasis, right middle lobe syndrome, postinfective atelectasis, partial atelectasis, compression atelectasis, pulmonary atelectasis, complete atelectasis, pressure collapse or relaxation atelectasis.
pulmonarY conGest/ HYpostasis
514
This code is used when the documentation indicates chest congestion, pulmonary congestion, pulmonary hypostatis, hypostatic lung, chronic lung hypostasis, lung congestion, passive lung, Potains disease/sydrome, lung edema, or terminal lung.
Increase fluid within the lungs leading to cough and SOB, diagnosed clinically and or by image studies
pure HYpercHolesterolem
272.0
Used when documentation indicates hypercholesterolemia, Hyperbetalipoproteinemia, or cholesterolemia.
Condition characterized by elevated cholestrol (> 200) Bleeding from rectum and/or anus, diagnosed clinically and/or by endoscopy/image studies
rectal & anal HemorrHaGe
569.3
This code is used when the documentation indicates that the patient has rectal bleeding, anal bleeding, rectal hemorrhage, anal hemorrhage, BRBPR (bright red blood per rectum) or hemorrhage of anus.
DX Description
Nonspecified recurrent depression (depressed mood, loss of interest, change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate, or suicide thoughts) with delusion and/or hallucination Inflammation of esophagus caused by backflow of stomach fluid leading to acidic taste in the mouth, epigastric abdominal pain diagnosed clinically and/or by EGD Refractive error of the eye, excluding myopia and presbyopia, diagnosed clinically Refraction error of the eye characterized by an aspherical cornea leading to distorted image, diagnosed clinically Nonspecific renal and/or ureteral dysfunction, diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
recurr Depr psYcHos-unsp
296.30
55
Used when the documentation indicates a recurrent (this must be specified) episode of involutional depression, recurrent melancholia, recurrent depressive psychosis, intermittent recurrent melancholia, recurrent involutional melancolia or recurrent menopausal depression.
refluX esopHaGitis
530.11
This code is used when the documentation states reflux esophagitis, or esophageal reflux with esophagitis.
refraction DisorDer nos
367.9
This code is used when the documentation indicates ametropia, refraction error, refraction disorder, refractive error, subnormal accomodation or accomodation disorder.
reGular astiGmatism
367.21
Use this code when the documentation indicates astigmatism.
renal & ureteral Dis nos
593.9
Used when the documentation indicates impaired kidney function, kidney inaction, kidney inefficiency, kidney infiltrate, kidney disease, acute kidney disease, acute renal disease, salt syndrome, salt losing disease or salt wasting disease.
renal DialYsis status
V45.11
130
Dialysis Status
This code is used when the documentation indicates that the patient receives hemodialysis.
Patients undergoing renal dialysis. Loss of kidney function characterized by rise in creatinine, decreased GFR and/or inability to produce urine, diagnosed clinically or by lab values
renal failure nos
586
131
Renal Failure
This code is used when the documentation indicates uremia, renal failure, uremic coma, renal shutdown, kidney stasis, renal stasis, renal suppression, uremic toxemia, urinary toxemia, uremic absorption, uremic amaurosis, uremic amblyopia, or uremic aphasia.
respiratorY aBnorm nec
786.09
This code is used when the documentation says hypercapnia, hypoventilation, irregular breathing or labored breathing also dyspnea on exertion, respiratory distress and respiratory insufficiency.
Nonspecific pulmonary symptoms including shortness of breath, hypoventilation, dyspnea on exercise, hypercapnia, etc Chronic inflammatory disorder for more than 6 wks, diagnosed clinically with 4 out of the following: affecting 3 or more joints, morning stiffness, symmetrical joint pain, PIP/MCP joint involvement, rheumatoid nodules, erosion on x-ray and +RF or +CCP Performance of routine gynecological exam
rHeumatoiD artHritis
714.0
38
Rheumatoid Arthritis and Inflammatory Connective Tissue Disease
This code is used when the documentation states rheumatoid arthritis, rheumatic arthritis, chronic polyarthritis, rheumatoid torticollis, primary progressive arthritis, proliferative arthritis, or atrophic arthritis.
routine GYn eXamination
V72.31
Used only when the documentation indicates that the patient presented for a routine gynecological examination. This code is not to be used for patients with a known gynecological condition.
routine meDical eXam
V70.0
Used to indicate that the patient is seen for a routine (e.g., preventive) service.
Performance of routine medical examination
DX Description
Irritation of sciatic nerve leading to pain and tingling sensation radiating down lower extremities, diagnosed clinically Performance of pap smear for cervical cancer screening Performance of colon cancer screening, including colonoscopy, checking stool for occult blood, or barium enema Performance of mammogram for breast cancer screening Elevated PTH level secondary to renal disease. Age related opacification of lens leading to impaired vision, diagnosed clinically Loss of intellectual functions due to old age leading to interference of daily function, diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
sciatica
724.3
This code is used when the documentation indicates Cotungos disease, Cotungos syndrome, Ischialgia, sacroiliac joint neuralgia, sciatic neuralgia, sciatic pain, infectional sciatica or sciatica.
screen maliG neop-cerViX
V76.2
This code is used when the patient presents for a screening Pap smear.
screen maliG neop-colon
V76.51
Use this code when the patient has no symptoms and you are performing a colonoscopy or stool for occult blood.
screen mammoGram nec
V76.12
Used by the screening mammography center or interpreting radiologist when the patient is seen for a screening mammogram.
seconDarY HYperparatHYroiDism
588.81
This code is used when the documentation indicates secondary hyperparathyroidism.
senile cataract nos
366.10
This code is used when the documentation indicates senile cataract, or cataracta senilis is documented.
senile Dementia uncomp
290.0
Used when the documentation indicates dementia, dementia of old age, senile dementia, senile anergasia, idiopathic senility, senile or senile exhaustion.
senile nuclear cataract
366.16 Decrease in bone mass or density due to old age diagnosed clinically by DEXA scan and/or image studies Severe sepsis is an administrative diagnosis, which is defined as sepsis with associated organ dysfunction. Symptom of shortness of breath Disease and/or Dysfunction of SA node leading to non-sinus rhythm, bradycardia diagnosed by ECG or rhythm monitor Nonspecific skin disorder, including inflammation, discoloration, infection, growth, irritation, etc, diagnosed clinically and/or by biopsy Narrowing of the spinal canal leading to the compression of the spinal cord and nerves leading to pain and/or abnormal sensation, diagnosed clinically and/or by image studies Pacemaker placement, diagnosed clinically or by imaging study Swelling in a limb including digits, diagnosed clinically
Used when the documentation states senile cataract, cataracta brunecens cataracta nigra or nuclear cataract.
Age related cataract, diagnosed clinically
senile osteoporosis
733.01
This code is used when the documentation indicates osteoporosis, senile osteoporosis or post-menopausal osteoporosis.
seVere sepsis
995.91
Use when documentation indicates severe sepsis, generalized sepsis, or SIRS due to infection.
sHortness of BreatH
786.05
Used when the documentation says shortness of breath.
sinoatrial noDe DYsfunct
427.81
92
Used when the documentation indicates chronic sinus bradycardia, sino-atrial (SA) bradycardia (with or without paroxysmal tachycardia) NOTE: Acute sinus bradycardia is 427.89.
sKin DisorDer nos
709.9
Used when the documentation indicates dermatosis, skin disease, perineal irritation, or skin sores.
spinal stenosis-lumBar
724.02
This code is used when the documentation indicates lumbar spinal stenosis or lumbosacral stenosis.
status carDiac pacemaKer
V45.01
This code is used when the documentation indicates that the patient has a cardiac pacemaker in place.
sWellinG of limB
729.81
Used when the documentation indicates swelling in a limb, including digits.
DX Description
Loss of consciousness due to inadequate blood flow to the brain, diagnosed clinically
DX coDe de
Hcc
Hcc Description
clinical criteria
sYncope anD collapse
780.2
This code should be used when the docmentation indicates syncope (without underlying cause), collapse, unconsciousness, vaso-vagal attack, vagal syncope, vasomotor attack, blackout, fainting, Gowers syndrome, vascular hyperreactor, or vasomotor instability. Insufficient tear secretion with symptoms of eye irritation, injection, diagnosed clinically and/or by Schirmer test Current tobacco user, diagnosed by history Transient alteration of consciousness, diagnosed clinically Sudden brief or transient focal brain neuro deficit, lasting less than 24 hrs diagnosed clinically A noncancerous, rapidly growing skin tumor that usually occurs on sun-exposed areas of the skin that can go away without treatment. Unspecified debility. Excludes asthenia, nervous debility, neurasthenia and senile asthenia
tear film insuffic nos
375.15
Used when the documentation indicates dry eye syndrome, insufficient tears, insufficient tear secretion, deficient lacrimal fluid, tear film deficiency or dry eye.
toBacco use DisorDer
305.1
Used when the documentation indicates that the patient is a current smoker. Past history of smoking is coded as V15.89 (personal history of tobacco use).
trans alter aWareness
780.02
Used when the documentation indicates alteration of consciousness, transient alteration of awareness or transient alteration of consciousness.
trans cereB iscHemia nos
435.9
Used when documentation indicates transient ischemic attack, or TIA.
unc BeHaV neo sKin
238.2
Used when the documentation indicates Keratoacanthoma or bathing trunk nevus.
unspecifieD DeBilitY
799.3
This code is used when the documentation states general(ized) debility, debility, or general decline are documented.
unspecifieD retention of urine
788.20
This code is used when the documentation indicates urinary retention, bladder retention, urine stoppage, or urine stasis.
Incomplete emptying of the bladder For these purposes, the term septicemia is an adminstrative term. Septicemia is defined as systemic disease associated with the presence of pathological microorganisms or toxins in the bloodstream.
unspecifieD septicemia
038.9
Septicemia/Shock
Used if the documentation indicates pyemia, pyemic fever, pyemic infection, nadir sepsis, septicemia, septicemic, septic toxemia, or blood poisoning. NOTE: This code should not be used in a physicians office setting. Patients with sepsis are treated in a hospital setting. If this is a follow up visit for a recently discharged patient who had sepsis, the correct code is V12.09, history of other infectious and parasitic disease. Vitamin D 25 Hydroxy Level of less than 50 ng/mL Unspecified loss of control of urine, diagnosed clinically
unspecifieD Vitamin D DeficiencY
268.9
Use when the documentation indicates Vitamin D deficiency, calciferol deficiency, ergosterol deficiency, or vioesterol deficiency.
urinarY incontinence nos
788.30
This code is used when the documentation only states that the patient has urinary incontinence without stating the etiology or type.
urinarY tract infection nos
599.0
Used when documentation says UTI.
Condition characterized with symptoms of urinary frequency, dysuria, hematuria, diagnosed clinically and/or positive UA Performance of influenza vaccination Administration of pneumococcal vaccination
Vaccin for influenZa
V04.81
Used to indicate that the patient is seen for influenza vaccine.
Vaccin strptcs pneumni B
V03.82
This code is used when the documentation indicates the patient received streptococcus pneumoniae [pneumococcus] vaccine.
DX Description
DX coDe de
Hcc
Hcc Description
clinical criteria
Diagnoses by ICD-9 Code
DiAGnoSeS by ICD-9 CODE

CliniCal Criteria
For these purposes, the term septicemia is an adminstrative term. Septicemia is defined as systemic disease associated with the presence of pathological microorganisms or toxins in the bloodstream.
DX CoDe
DX Description
HCC
HCC DesCription
DoCumentation requirements for CoDe use
038.9
UNSPECIFIED SEPTICEMIA
Septicemia/ Shock
Used if the documentation indicates pyemia, pyemic fever, pyemic infection, nadir sepsis, septicemia, septicemic, septic toxemia, or blood poisoning. NOTE: This code should not be used in a physicians office setting. Patients with sepsis are treated in a hospital setting. If this is a follow up visit for a recently discharge patient who had sepsis, the correct code is V12.09, history of other infectious and parasitic disease.
110.1
DERMATOPHYTOSIS OF NAIL
Used when the documentation indicates dermatophytosis of nail, fungus of nail, toenail fungus, or fingernail fungus.
Fungal infection of the nail, diagnosed clinically or by biopsy Diagnosis of lung cancer based upon postive biopsy result.
162.9
MALIGN NEOPL BRONCHUS 8 & LUNG UNS SITE
Used when the documentation indicates lung cancer, bronchogenic cancer, pulmonary cancer, sub-pleural cancer, or bronchogenic carcinoma without indication of the specific site.
173.3
MALIGN NEOPL SKIN FACE NEC
This code is used for malignancies on the skin of the face which do not have a specified code. If there is a specific code which describes the malignancy documented, use that code instead.
Malignant skin cancer on the face, diagnosed by biopsy
DX CoDe
Active malignant cancer of breasts diagnosed by + mamogram with + bx
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
174.9
MALIGN NEOPL BREAST NOS
10
Breast, Prostate, Colorectal and Other Cancers and Tumors Malignant cancer of the prostate gland diagnosed by biopsy
This code is used when the documentation indicates breast cancer or malignant neoplasm of the breast and the patient has not completed treatment aimed at eradicating the disease. After definitive treatment is complete, documentation should indicate history of breast cancer, and coded as V10.3.
185
MALIGN NEOPL PROSTATE
10
This code is used when prostate cancer is documented. This code can be used for patients on long-term Lupron therapy. Note that patients who have completed therapy for their cancer should be documented with a history of the malignancy and coded as V10.46.
211.3
BENIGN NEOPLASM LG BOWEL
Used when the documentation indicates adenomatosis, Cronkhite-Canada syndrome, colon polyp, appendix polyp, caput coli polyp, cecum polyp, ileocecal polyp, hepatic flexure polyp or familial adenomatous polyp.
Non-cancerous lesion in colon, diagnosed by colonoscopy and/or radiologic studies
238.2
UNC BEHAV NEO SKIN
Used when the documentation indicates Keratoacanthoma or bathing trunk nevus.
A noncancerous, rapidly growing skin tumor that usually occurs on sunexposed areas of the skin that can go away without treatment. Low thyroid state characterized by low energy state, depression, weakness, edema, constipation, diagnosed by high TSH and usually low Total T3, Total T4 DM 2 without complication, not stated as uncontrolled, diagnosed clinically
244.9
HYPOTHYROIDISM NOS
Used when documentation indicates hypothyroidism, or post-surgical hypothyroidsm.
250.00
DMII WO CMP NT ST UNCNTRLD
19
Diabetes without If diagnosis indicates DM, diabetes mellitus or diabetes, this is Complication the correct code. When unspecified in the medical record, diabetes is assumed to be type II based on ICD-9 guidelines.
250.01
DMI WO CMP NT ST UNCNTRLD
19
Diabetes without This code should be used when you have documented Complication DM 1 or juvenile diabetes is documented.
Controlled DM 1 without complication Uncontrolled DM 2 without end-organ complication. Micro albumin/Cr ratio<299
250.02
DMII WO CMP UNCNTRLD
19
Diabetes without This code is used when the documentation indicates that the patient has DM II (or Complication the type is not stated) and the physician specifically states that the diabetes is uncontrolled or out of control. NOTE: poor/poorly control is not acceptable. Controlled DM 2 with renal manifestations caused by the diabetes (renal manifestation included albuminuria, proteinuria, decreased GFR, Cr, etc) Diabetic Neuropathy MA/CR>299
250.40
DMII RENL NT ST UNCNTRLD
15
Diabetes with Renal or Peripheral Circulatory Manifestation Diabetes with abnormal blood glucose values and proteinuria or other evidence of kidney damage.
Use only when documentation indicates the patient has renal disease that is secondary to diabetes, or diabetic renal disease. The ICD-9 does not assume a causal relationship, so you must include it in your documentation. You must also code the renal disease.
250.42
DMII W/RENAL UNS/ UNCNTRLD
15
Use when the documentation indicates uncontrolled or out of control diabetes(either type II or no type stated) with renal manifestations or complications.
250.50
DMII OPHTH NT ST UNCNTRLD
18
Used when the documentation indicates that ophthalmological conditions are secondary to, or caused by diabetes. The documentation must indicate the causal relationship. This code is not used when an eye condition simply co-exists (i.e., comorbid) with diabetes.
Controlled DM 2, which has caused eye findings such as Macula edema, vision change, retinopathy, cataract, retinal edema, vitreous hemorrhage, microaneurysms, and blindness, diagnosed clinically and/or by ophthalmoscopic exam
DX CoDe
Controlled DM 2, with neurological manifestations 2 DM including numbness, tingling, burning sensations, gastroparesis, erectile dysfunction, autonomic instability or positive finding on nerve conduction study or failed monofilament test of foot DM 2, not stated as uncontrolled, and vascular findings including claudication, ulcers, gangrene, atherosclerosis (i.e. peripheral vascular disease, erectile dysfunction, CVA, CAD) or positive findings on ABI, ultrasound, CT angiogram, MRA or angiogram
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
250.60
DMII NEURO NT ST UNCNTRLD
16
Use this code when the documentation indicates that the patient has a neurological complication of their diabetes. The documentation must indicate that the complication is secondary to the diabetes. The neurological complication must be specified.
250.70
DMII CIRC NT ST UNCNTRLD
15
This code is used when the documentation indicates that circulatory disorders are secondary to or caused by diabetes mellitus. For example, diabetic angiopathy, gangrene 2 diabetes, peripheral circulatory disease 2 diabetes, or diabetic microangiopathy.
250.80
DMII OTH NT ST UNCNTRLD 16
This code is used when the documentation indicates that there is a diabetic complication (i.e., a condition CAUSED by the diabetes) that is not included in a more specific diabetes complication code. For example: diabetic bone changes, diabetic dermatitis.
Controlled DM 2 with other complications caused by the diabetes such as skin findings, infections, etc, not stated as uncontrolled
268.9
UNSPECIFIED VITAMIN D DEFICIENCY
Use when the documentation indicates Vitamin D deficiency, calciferol deficiency, ergosterol deficiency, or vioesterol deficiency.
Vitamin D 25 Hydroxy Level of less than 50 ng/ml Condition characterized by elevated cholestrol (> 200) Hyperlipidemia characterized by elevated LDL (>160mg/dL) and elevated triglyceride (>160mg/dL), diagnosed by lab values
272.0
PURE HYPERCHOLESTEROLEM
Used when documentation indicates hypercholesterolemia, Hyperbetalipoproteinemia, or cholesterolemia.
272.2
MIXED HYPERLIPIDEMIA
Used when documentation states type II hyperlipoproteinemia, xanthoma, or beta disease.
272.4
HYPERLIPIDEMIA NEC/NOS
When documentation only indicates hyperlipidemia, this is the correct code.
High lipid state characterized by elevated LDL or triglyceride Abnormal lipid metabolism, diagnosed clinically and by abnormal laboratory values
272.9
LIPOID METABOL DIS NOS
Used when the documentation indicates abnormal lipids, congenital abnormal lipid metabolism, or abnormal cholesterol metabolism. (Note that metabolism must be mentioned. The term hyperlipidemia or dyslipidemia codes to 272.4). Condition caused by the accumulation of uric acid crystals, may deposit in joints (arthritis), kidney (stone), gallbladder (stone), dignosed clinically with/without elevated uric acid Low electrolyte state, frequently associated with dehydration and low sodium, diagnosed by laboratory values Loss of fluid from the body leading to weakness, thirst, fast heartbeat, poor skin turgor, hypernatremia, etc, diagnosed clinically
274.9
GOUT NOS
Used when documentation indicates gout, urate thesaurismosis, uric acid diasthesis, gouty diasthesis or podagra.
276.1
HYPOSMOLALITY
This code is used when the documentation indicates anhydration with hyponatremia, dehydration with hyponatremia, salt depletion, sodium depletion, sodium deficiency, fluid loss with hyponatremia, hyposmolality or sick cell.
276.51
DEHYDRATION
This code is used when documentation says Luetschers syndrome, Luetschers dehydration, dehydration or anhydration.
276.7
HYPERPOTASSEMIA
Used when the documentation indicates hyperpotassemia, excess potassium, hyperkalemia, potassium overload or hyperkalemic.
Blood test showing potassium is greater than upper limit of normal (5.0 mEq/L) Low potasium state, diagnosed by lab value Characterized by 20% over ideal body weight or BMI of more than 30 Grade 3 overweight (morbid obesity) characterized by a BMI equal to or greater than 40 kg/m2.
276.8
HYPOPOTASSEMIA
Used when the documentation indicates hypopotassemia, potassium depletion, potassium deficiency, hypokalemia or hypokalemic.
278.00
OBESITY NOS
Use when the medical record indicates obesity.
278.01
OBESITY, MORBID
Used when the documentation indicates morbid obesity, morbidly obese, or severe obesity.
DX CoDe
Low RBC level (Hgb < 16 for men; Hgb < 14 for women) due to iron deficiency, characterized by low MCV, low ferritin, low iron, elevated TIBC Anemia in chronic kidney disease
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
280.9
IRON DEFIC ANEMIA NOS
Used when the diagnosis is iron deficiency anemia, Witts anemia, achlorhydic anemia, green sickness, sideropenia, Fabers disease, or Hayem-Faber disease.
285.21
ANEMIA IN CHRONIC KIDNEY DISEASE Nonspecific Low RBC level (Hgb < 16 for men; Hgb < 14 for women), diagnosed by laboratory values Loss of intellectual functions due to old age leading to interference of daily function, diagnosed clinically A progressive, neurodegenerative disease characterized by loss of function and death of nerve cells in several areas of the brain leading to loss of cognitive function such as memory and language. Nonspecific psychiatric condition may include affective, paranoid and psychotic state, diagnosed clinically
This code is used when the documentation indicates that the patient has anemia of chronic kidney disease, or ESRD or EPO resistant anemia. The underlying chronic condition (e.g., ESRD 585.6) should also be coded.
285.9
ANEMIA NOS
Used when the documentation says anemia, erythrocytopenia or low hematocrit.
290.0
SENILE DEMENTIA UNCOMP
Used when the documentation indicates dementia, dementia of old age, senile dementia, senile anergasia, idiopathic senility, senile or senile exhaustion.
294.10
DEMENTIA CCE W/O BEHAV DISTURB
This code is only used as a secondary code. In any disease that may have dementia as a symptom, the primary disease (e.g., Huntingtons Chorea, Alzheimers disease, Picks Disease, etc.), and dementia without mention of behavioral disturbance is mentioned, this code should be used in addition to the code for the primary disease.
294.8
MENTAL DISOR NEC OTH DIS
This code is used when the documentation indicates chronic brain infection, chronic intracranial infection, chronic brain trauma, mixed affective and paranoid state, mixed paranoid and affective pychosis or dementia. It is also used when a specified type of mental disorder does not have a more specific code.
296.20
DEPRESSIVE PSYCHOSIS-UNSPEC
55
Used when the documentation indicates an episode of involutional depression, melancholia, depressive psychosis, melancholia, involutional melancolia, menopausal melancholia, stuporous melancholia, agitated depression, psychotic depression, or melancholy.
Nonspecific depression (depressed mood, loss of interest, change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate, or suicide thoughts) with delusion and/or hallucination
296.30
RECURR DEPR PSYCHOS-UNSP
55
Used when the documentation indicates a recurrent (this must be specified) episode of involutional depression, recurrent melancholia, recurrent depressive psychosis, intermittent recurrent melancholia, recurrent involutional melancolia or recurrent menopausal depression.
Nonspecified recurrent depression (depressed mood, loss of interest, change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate, or suicide thoughts) with delusion and/or hallucination
300.00
ANXIETY STATE NOS
Use when documentation says anxiety, neurosis, neurotic state, abnormal apprehension, apprehensiveness, psychogenic anxiety, anxiety state, psychoneurotic anxiety, asphyctic anxiety or anxiety disorder.
Condition characterized by a pattern of frequent worry and anxiety about several different events/activities, diagnosed clinically Current tobacco user, diagnosed by history Depressive disorder not elsewhere classified, may have some symptoms of depressed mood and loss of interest, change in appetite, sleep disturbance, behavior change, decrease in energy, guilt, inability to concentrate but not MDD Apnea, defined as a cessation of airflow for at least 10 seconds which occurs during sleep due to obstruction (non central). Dementia characterized by impairment in memory, thinking and behavior, diagnosed clinically and by mini-mental state examination 0 minimum cog
305.1
TOBACCO USE DISORDER
Used when the documentation indicates that the patient is a current smoker. Past history of smoking is coded as V15.89 (personal history of tobacco use).
311
DEPRESSIVE DISORDER NEC
Use this code when the documentation indicates depression or depressive disorder with no further description.
327.23
OBSTRUCTIVE SLEEP APNEA
This code is used when the documentation indicates obstructive sleep apnea or sleep apnea with obstruction.
331.0
ALZHEIMERS DISEASE
Use when documentation indicates Alzheimers disease, atrophic brain degeneration, or Alzheimers type dementia.
DX CoDe
Progressive, degenerative disorder of the nervous system characterized by tremors, rigidity, bradykinesia, postural instability, and gait abnormalities; caused by a loss of neurons and a decrease of dopamine in the basal ganglia. Nonspecific loss of sensation or movement due to idiopathic nerve damage, diagnosed clinically and/or by NCS/EMG
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
332.0
PARALYSIS AGITANS
73
This code is used when the documentation indicates Parkinsons, Parkinsons disease, paralysis agitans, parkinsons, shaking palsy.
356.9
IDIO PERIPH NEURPTHY NOS
71
Polyneuropathy
This code is used when the documentation indicates interstitial hypertrophic progressive neuritis, hereditary neuropathy, interstitial hypertrophic neuropathy, multiple neuropathy, polyneuropathy, peripheral neuropathy, atrophic neuropathy, Peripheral progressive neuropathy, polyneuritis or trophoneurosis.
357.2
NEUROPATHY IN DIABETES
71
Polyneuropathy
This code is used to describe diabetic neuropathy, neuropathy secondary to diabetes, or diabetes with neuropathy.
DM caused neurological manifestations including numbness, tingling, burning sensations, gastroparesis, erectile dysfunction, autonomic instability or positive finding on nerve conduction study, diagnosed clinically Decreased visual acuity or central vision loss due to aging, diagnosed clinically Decrease visual acuity or central vision loss due to aging diagnosed clinically. Should be based on prior or concurrent exam by ophthalmologist. Chronic increase in intraocular pressure causing optic nerve damage, leading to visual impairment diagnosed by tonometry and/or ophthalmoscopic exam
362.51
NONEXUDAT MACULAR DEGEN
Used when the documentation states atrophic macula, dry macula, or nonexudative macular degeneration.
362.52
EXUDATV SENL MACULR DEGENRAT-RET
Used when the documentation indicates Kuhnt-Junius disease, disciform macula, exudative macular degeneration, wet macular degeneration, KuhntJunias retina, Kuhnt-Junias degeneration or disciformis retinitis.
365.11
PRIM OPEN ANGLE GLAUCOMA
Use when the documentation indicates chronic glaucoma, simple glaucoma, or open angle glaucoma. NOTE: DO NOT USE this code if your note says only Glaucoma, which is coded 365.9.
365.9
GLAUCOMA NOS
Used when documentation only states glaucoma with no further information.
Increase in intraocular pressure causing optic nerve damage, leading to visual impairment diagnosed by tonometry and/or ophthalmoscopic exam Age related opacification of lens leading to impaired vision, diagnosed clinically Age related cataract, diagnosed clinically Opacification of lens leading to impaired vision, diagnosed clinically Refractive error of the eye leading to inability to focus on close objects often associated with aging, diagnosed clinically Refractive error of the eye leading to inablility to focus farway objects, diagnosed clinically Refraction error of the eye characterized by an aspherical cornea leading to distorted image, diagnosed clinically Refraction error of the eye characterized by an aspherical cornea leading to distorted image, diagnosed clinically Refractive error of the eye leading to inability to focus on close objects due to aging, diagnosed clinically Refractive error of the eye, excluding myopia and presbyopia, diagnosed clinically
366.10
SENILE CATARACT NOS
This code is used when the documentation indicates senile cataract, or cataracta senilis is documented.
366.16
SENILE NUCLEAR CATARACT
Used when the documentation states senile cataract, cataracta brunecens cataracta nigra or nuclear cataract.
366.9
CATARACT NOS
Used when documentation indicates cataract, lens changes, intumescent lens, or lens opacity without further description.
367.0
HYPERMETROPIA
Used when documentation states hypermetropia, hyperopia, or farsightedness.
367.1
MYOPIA
Used when documentation indicates myopia, nearsightedness, or shortsightedness.
367.20
ASTIGMATISM NOS
Used when the documentation indicates astigmatism, acquired astigmatism, congenital astigmatism, refractive astigmatism or congenital astigmatism.
367.21
REGULAR ASTIGMATISM
Used this code when the documentation indicates astigmatism.
367.4
PRESBYOPIA
Used when documentation indicates presbyopia or insufficient accomodation.
367.9
REFRACTION DISORDER NOS
This code is used when the documentation indicates ametropia, refraction error, refraction disorder, refractive error, subnormal accomodation or accomodation disorder.
DX CoDe
Insufficient tear secretion with symptoms of eye irritation, injection, diagnosed clinically and/or by Schirmer test Ear wax impaction diagnosed by direct visualization Nonspecific loss of hearing, diagnosed clinically or by audiology
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
375.15
TEAR FILM INSUFFIC NOS
Used when the documentation indicates dry eye syndrome, insufficient tears, insufficient tear secretion, deficient lacrimal fluid, tear film deficiency or dry eye.
380.4
IMPACTED CERUMEN
This code is used when the documentation indicates impacted cerumen, impacted ear wax, abnormal cerumen production, wax in ear, or cerumen accumulation.
389.9
HEARING LOSS NOS
Used when the documentation indicates hearing loss, deafness, auditory deafness, impaired hearing, auditory imperception, hereditary deafness, congenital deafness, or acquired deafness with no description of the etiology of the impairment.
401.0
MALIGNANT HYPERTENSION
This code should only be used if the medical record indicates accelerating hypertension, Very elevated blood pressure resulting in eye, kidney, and necrotizing hypertension or malignant hypertension. This code should rarely be seen cardiovascular damage, diagnosed clinically in a physician office setting. It is NOT synonmous with uncontrolled hypertension. HTN (SBP >140, DBP > 90 on 2 occasions) without any end organ (eye, kidney, or cardiovascular) damage, diagnosed clinically Hypertension with SBP >140, DBP > 90 on 2 or more occasions Any cardiac condition due to HTN, including cardiomegaly, cardiomyopathy, cardiovascular disease without CHF, diagnosed clinically
401.1
BENIGN HYPERTENSION
Documentation must indicate benign or benign essential hypertension. If documentation only indicates hypertension, see 401.9, below.
401.9
HYPERTENSION NOS
When documentation only indicates hypertension, or uncontrolled hypertension, this is the correct code.
402.10
BENIGN HYP HT DIS W/O HF
Used when the documentation indicates benign hypertensive heart disease, hypertensive heart disease or heart disease secondary to hypertension.
403.10
HYP CKD BEN CKD STAGE I THRU IV/UNS
Used when the documentation indicates benign hypertension with CKD stage 1-4 or benign hypertension with CKD, or hypertension with renal involvement, renal sclerosis with hypertension, or hypertension with glomerulosclerosis. Unspecified hypertensive renal disease
CKD of any stage in the presence of essential (primary, not renovascular) HTN, but excluding malignant HTN (sudden and rapid development of extremely high blood pressure usually with a diastolic of > 125 and cardiac, renal, or cerebral manifestations) and also excluding acute or renal failure due to other (non HTN) causes
403.90
HYP CKD UNS CKD STAGE I THRU IV/UNS
Used when documentation indicates hypertensive kidney disease, renovascular hypertension, arteriolar glomerulonephritis, arteriosclerotic glomerulonephritis, hypertension with chronic kidney disease (unspecified or Stage 1-4).
403.91
HYP KID NOS W CR KID V
131
Renal Failure
This code is used when the documentation indicates that the patient has both Stage V CKD and hypertension. NOTE: Codes in the 403.X series are an exception to the rule that the physician must document a causal relationship between two diseases.
Hypertensive kidney disease with chronic kidney damage, such as albuminuria, proteinuria, hematuria, glomerulonephritis, abnormal creatinine or renal failure, characterized by GFR < 15, needing dialysis or transplantation
411.1
INTERMED CORONARY SYND
82
New onset angina (cardiac CP) or angina with increase in frequency or intensity, Used when the documentation indicates intermediate coronary syndrome, impending coronary syndrome, impending myocardial infarction, impending infarct, acute coronary diagnosed clinically with T inversion on ECG and hypokinesis on echocardiogram syndrome, cornary insufficiency syndrome, unstable angina or intermediate coronary. H/O MI as evident by Q waves on EKG or characteristic abnormal wall motion on echo
412
OLD MYOCARDIAL INFARCT 83
Use when a history of myocardial infarction is documented.
413.9
ANGINA PECTORIS NEC/NOS
83
Use when documentation says angina, angina pectoris, Heberdens syndrome, Likoffs syndrome, Schaufenster krankheit, anginosus, stenocardia, sternalgia, or stable angina.
Nonspecific atypical cardiac chest pain, diagnosed clinically
DX CoDe
Atherosclerosis of coronary arteries defined by positive stress test or positive cardiac cath without specification of whether native or graft vessel is involved in a patient with graft vessels Atherosclerosis of coronary arteries defined by positive stress test or positive cardiac catheterization Nonspecific chronic ischemic heart disease, diagnosed clinically and/or cardiac testing
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
414.00
CRNRY ATH UNSP VSL NTV/GFT
Use when documentation indicates coronary atherosclerosis or arteriosclerosis AND you have stated that the patient has both native and non-native vesselsbut you have not indicated which type of vessel is affected.
414.01
CRNRY ATHRSCL NATVE VSSL
Use only when atherosclerosis or arteriosclerosis is stated to be of native vessel or there is no documentation of a prior CABG.
414.9
CHRONIC ISCHEMIC HRT DIS NOS
This code is used when the documentation indicates ischemic coronary changes, coronary damage, ischemic heart, coronary disease, ischemic heart disease, cardiac ischemia, coronary ischemia, or acquired coronary ischemia and no additional information is given.
424.0
MITRAL VALVE DISORDER
This code is used when the documentation indicates mitral valve disorder, ballooning posterior leaflet, Barlows prolapse, mitral valve prolapse, or floppy mitral valve.
Any disorder or damage involving mitral valve, including stenosis, regurgitation or prolapse diagnosed by echo, angiogram or other image studies
424.1
AORTIC VALVE DISORDER
Used when the documentation indicates acquired aortic valve disorder, aortic deformity, Disorder or damage involving aortic valve, stenosis or insufficiency endocarditis with aortic valve involvement, arteriosclerotic aortic valve, aortic valve regurgitation, diagnosed by echo, angiogram or other image studies insufficiency, aortic valve obstruction, aortic valve stenosis, or aortic murmur. Abnormal cardiac function where SOB, CP and peripheral edema are cardinal symptoms, including idiopathic, dilated, restrictive, constrictive and hypertrophic etiologies, diagnosed by echo, angiogram and other image studies
425.4
PRIM CARDIOMYOPATHY NEC
80
This code is used when the documenation indicates primary cardiomyopathy, idiopathic cardiomyopathy, idiopathic myocardial hypertrophy, myocardiopathy described as: congestive, constrictive, familial, hypertrophic nonobstructive, idiopathic or infiltrative cardiomyopathy.
427.31 Disease and/or Dysfunction of SA node leading to non-sinus rhythm, bradycardia diagnosed by ECG or rhythm monitor Nonsinus rhythm diagnosed by ECG or rhythm monitor
ATRIAL FIBRILLATION
92
Used when documentation states atrial fibrillation. Be sure to also document and code long term or current use of anticoagulant V58.61.
Rapid irregular heartbeat diagnosed by exam, ECG or rhythm monitor
427.81
SINOATRIAL NODE DYSFUNCT
92
Used when the documentation indicates chronic sinus bradycardia, sino-atrial (SA) bradycardia (with or without paroxysmal tachycardia) NOTE: Acute sinus bradycardia is 427.89.
427.89
CARDIAC DYSRHYTHMIAS NEC
Used when the documentation indicates cardiac arrhythmia, cardiac dysrythmia, gallop rhythm, nodal rhythm disorder, alternating pulse, bigeminy, bigeminal rhythm, trigeminy, trigeminal rhythm, pulsus alternans, a-v nodal rhythm or ectopic rhythm.
427.9
CARDIAC DYSRHYTHMIA NOS
Used when the documentation indicates only arrythmia, cardiac dysrhythmia or cardiac arrythmia. When the type of arrythmia is known, it should be documented and coded appropriately.
Nonspecific non-sinus rhythm diagnosed by EKG or rhythm monitor
428.0
CHF NOS
80
Used when documentation says Bernheims syndrome, CHF or heart failure.
Cardinal symptoms include SOB, edema, or CP, diagnosed by clinical findings and +PVC on CXR...echo may reveal low EF (<50%) and/or normal EF with diastolic dysfunction Enlarged heart, diagnosed clinically or by image studies
429.3
CARDIOMEGALY
This code is used when the documentation states only cardiomegaly, without any indication of the underlying disease. If documentation indicates it is due to HTN use codes 402.0-402.9.
433.10
OCL CRTD ART WO INFRCT
Used when the documentation indicates carotid stenosis, stenosis of carotid artery (common, internal), or carotid occlusion, without mention of infarct.
Stenosis or occlusion of carotid artery without CVA symptoms, diagnosed clinically and/or by imaging studies
DX CoDe
Development of blood clot in the cerebral arteries with brain tissue damage leading to motor, sensory, and/or speech deficit, diagnosed clinically and/or by image studies Sudden brief or transient focal brain neuro deficit, lasting less than 24 hrs diagnosed clinically Unspecified acute cerebrovascular disease other than CVA
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
434.91
CRBL ART OCL NOS W INFRC
96
This code is used when the documentation indicates CVA, Cerebral accident, cerebrovascular accident, acute cerebrovascular disease, ischemic CVA, brain stem infarct(ion), lacunar infarction, cerebellar infarction, cortical infarction, or stroke.
435.9
TRANS CEREB ISCHEMIA NOS
Used when documentation indicates transient ischemic attack, or TIA.
436
ACUTE, ILL DEFINED CEREBROVASCULAR DISEASE Hemiplegia/Hemiparesis as a result of prior CVA
96
Use only when unspecified cerebrovascular disease is documented. Coding Clinic comments indicate this code should rarely be used. It is not the correct code for CVA. The correct series of codes for CVAs is 434.1X.
438.20
HEMIPL AFFCT UNS SIDE-CEREBRVASC DZ
100
Hemiplegia/ Hemiparesis
Used when the documentation indicates hemiplegia/hemiparesis following (or status post) CVA, hemiplegia as a late effect of CVA or CVA with hemiplegia or hemiparesis. NOTE: Per Coding Clinic, Q1 2005, weakness status post CVA is coded as 438.89, Other late effects of cerebrovascular disease and code 728.87, Muscle weakness, for residual muscle weakness secondary to late effect of cerebrovascular accident.
440.0
AORTIC ATHEROSCLEROSIS 105
Vascular Disease
This code is used when the documentation indicates sclerotic aorta, arteriosclerotic aorta, calcified aorta or atherosclerosis of the aorta.
Condition where fatty material is deposited in the walls of aorta leading to narrowing, hardening and/or blockage, diagnosed clinically or by angiogram/image studies Atheroclerosis involving peripheral arteries leading to pain, ulceration or gangrene, diagnosed clinically with ankle-brachial index or by angiogram
443.9
PERIPH VASCULAR DIS NOS
105
Vascular Disease
This code is used when the documentation indicates peripheral vascular disease, Charcts syndrome, intermittent claudication, vasomotor dilatation, angiospasmodic disease, peripheral arterial disease, vascular disease or small vessel disease.
453.40 Presence of internal hemorrhoid, diagnosed clinically Nonspecific state of low blood pressure, diagnosed clinically Acute infection or inflammation of sinus, often diagnosed clinically and/or by x-ray, CT findings Acute infection or inflammation of pharynx, diagnosed clinically
AC VNUS EMB & THRMB UNS DP VES LW EXT
105
Vascular Disease
Used when the documentation indicates deep venous thrombus of the leg, acute deep venous thrombus of the leg, or deep venous thrombosis of the leg.
Thrombus of lower extremity, confirmed by ultrasound or venogram.
455.0
INT HEMORRHOID W/O COMPL
This code is used when the documentation indicates internal hemorrhoids.
458.9
HYPOTENSION NOS
Used when the documentation indicates low blood pressure, low pressure, arterial hypotension, hypotension, constitutional hypotension, or hyposystolic pressure.
461.9
ACUTE SINUSITIS NOS
Use this code when the documentation indicates acute sinusitis.
462
ACUTE PHARYNGITIS
This code is used when the documentation indicates pharyngitis, acute pharyngitis, sore throat, adenopharyngitis, catarrhal angina, fauces, hypopharyngitis, or phlegmonous pharyngitis.
465.9
ACUTE URI NOS
Used when documentation indicates respiratory infection, URI, or viral respiratory infection.
Nonspecific acute viral infection of upper repiratory tract, involving nose and throat characterized by runny nose, sore throat, headache and ill-feeling, diagnosed clinically Acute infection/inflammation of bronchus often leading to productive cough and/or sputum production diagnosed clinically Nonspecific allergic inflammation of nose, leading to sneezing, congestion, a runny/itchy nose, diagnosed clinically and/or by rhinoscope Bacterial pneumonia caused by a nonspecified organism, diagnosed clinically and/or by image study
466.0
ACUTE BRONCHITIS
Used when documentation states acute bronchitis.
477.9
ALLERGIC RHINITIS NOS
Used when the documentation indicates allergic rhinitis, Bostocks disease, febris aestiva, hay fever, allergic rhinitis, vasomotor rhinitis, paroxysmal rhinorrhea, or spasmodic rhinorrhea.
486
PNEUMONIA, ORGANISM NOS
This code is used when the documentation indicates pneumonia, lung inflammation; acute, bilateral, double, or septic Pleuropneumonia, or Pneumonia described as: acute, Alpenstich, benign, bilateral, brain, cerebral, circumscribed, congestive, creeping.
DX CoDe
Infection or inflammation of bronchus charaterized by cough and/ or CXR normal (no infiltrate) diagnosed clinically Chronic bronchitis with worsening cough, shortness of breath or hypoxia (pO2 < 60), diagnosed clinically
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
490
BRONCHITIS NOS
This code is used when bronchitis is the only description in medical record. In diseases where there is both a chronic and acute form of the disease, its important to note which form of the disease is present.
491.21
OBS CHR BRONC W(AC) EXAC
108
Used when the documentation indicates exacerbation of chronic bronchitis or blue bloater with acute exacerbation.
492.8
EMPHYSEMA NEC
108
Used when the documentation indicates emphysema, atrophic, centriacinar, centrilobular, chronic, diffuse, essential, hypertrophic, interlobular, lung, obstructive, panlobular, paracicatricial, paracinar, postural, pulmonary, senile, subpleural, or traction pulmonary disease.
Damage to alveoli frequently diagnosed by smoking history, wheezing, CXR finding and obstructive PFT (FEV1/FVC < 70%)
493.90
ASTHMA NOS
Used when documentation indicates asthma, and there is no indication of an exacerbation.
Reversible reactive airway disease resulting from an allergic reaction to foreign substances such as vapor, pollen, etc. diagnosed clinically and/or by PFT showing obstructive pattern (FEV1/FVC < 80%) and reversibility Chronic obstructive lung disease often diagnosed with smoking hx, wheezing, PFT showing obstructive pattern (FEV1/FVC < 80%)
496
CHRONIC AIRWAY OBSTRUCT NEC
108
Used when documentation indicates COPD. When known, the type of airway obstruction should be documented and coded (e.g., chronic bronchitis).
511.9 Increase fluid within the lungs leading to cough and SOB, diagnosed clinically and or by image studies
PLEURAL EFFUSION NOS
Used when the description of the condition is pleural effusion without further characterization.
Nonspecific pleural fluid in lung cavity, diagnosed clinically or by image studies
514
PULMONARY CONGEST/ HYPOSTASIS
This code is used when the documentation indicates chest congestion, pulmonary congestion, pulmonary hypostatis, hypostatic lung, chronic lung hypostasis, lung congestion, passive lung, Potains disease/sydrome, lung edema, or terminal lung.
518.0
PULMONARY COLLAPSE
Used when documentation indicates Brocks syndrome, atelectasis, right middle lobe Complete or partial collapse of a portion of the lung, diagnosed clinically and/or by mage studies/bronchoscopy syndrome, postinfective atelectasis, partial atelectasis, compression atelectasis, pulmonary atelectasis, complete atelectasis, pressure collapse or relaxation atelectasis. Acute pulmonary failure as defined by severe hypoxia (pO2 < 60) or hypercapnia (pCO2>40) often needing emergent intervention such as intubation
518.81
ACUTE RESPIRATRY FAILURE
79
CardioRespiratory Failure and Shock
This code is used when the documenation indicates respiratory failure, pulmonary failure, or acute respiratory failure.
518.83
CHRONIC RESPIRATORY FAILURE
79
CardioRespiratory Failure and Shock
This code is used when the documentation indicates chronic respiratory failure, or chronic respiration failure.
Clinical markers of chronic hypoxemia, such as polycythemia or cor pulmonale, suggest a long-standing disorder. May manifest as CO2 retention resulting in a respiratory acidosis. Chronic respiratory acidosis results in a metabolic alkalosis with elevated serum bicarbonate level. Lung disease including lung calcification, pulmolithiasis, etc
518.89
OTHER LUNG DISEASE NEC
This code is used when the documented type of lung disease has no other classification. Documentation should indicate one of the following: honeycomb lung, bronchioliasis, pulmolithiasis, calcification of lung, or lung disease.
530.11
REFLUX ESOPHAGITIS
This code is used when the documentation states reflux esophagitis, or esophageal reflux with esophagitis.
Inflammation of esophagus caused by backflow of stomach fluid leading to acidic taste in the mouth, epigastric abdominal pain diagnosed clinically and/or by EGD
DX CoDe
Backflow of stomach fluid to esophagus leading to acidic taste in the mouth, epigastric abdominal pain diagnosed clinically and/or by EGD Nonbleeding inflammation of stomach or duodenum diagnosed clinically and/or by endoscopy/image studies Protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm, diagnosed by EGD and/or image studies
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
530.81
ESOPHAGEAL REFLUX
Used when documentation indicates GERD or reflux.
535.50
GASTR/DDNTS NOS W/O HMRHG
Used when the documentation indicates gastritis, gastroduodenitis, gastrohepatitis, gastrojejunitis or pyloritis and there is no mention in the documentation of hemorrhage or bleeding.
553.3
DIAPHRAGMATIC HERNIA
Used when the documentation indicates hiatus hernia, diaphragmatic hernia, sliding diaphragmatic hernia, Bochdalek hernia, Morgagni(an) hernia, hiatal hernia, paraesophageal hernia, Saint triad, or Saints hernia.
558.9
NONINF GASTROENTERIT NEC
An inflammation of the stomach and intestine resulting in diarrhea, with vomiting This code is used when the documentation indicates chronic ileitis, non-infectious ilieitis, ileocolitis, bowel/colon inflammation, inflammatory bowel/colon, gastrointestinal and cramps with infectious workup being negative, diagnosed clinically inflammation, ileal inflammation, jejunitis, acute colitis or catarrhal colitis. Non-bleeding colon diverticulosis diagnosed by colonoscopy or other image studies Nonspecific constipation, diagnosed by history Bleeding from rectum and/or anus, diagnosed clinically and/or by endoscopy/image studies
562.10
DVRTCLO COLON W/O HMRHG
Used when documentation states diverticulosis.
564.00
CONSTIPATION NOS
Use when documentation states constipation.
569.3
RECTAL & ANAL HEMORRHAGE
This code is used when the documentation indicates that the patient has rectal bleeding, anal bleeding, rectal hemorrhage, anal hemorrhage, BRBPR (bright red blood per rectum) or hemorrhage of anus,.
578.9
GASTROINTEST HEMORR NOS Sudden rise in Creatinine level (>1.4mg/dL) or decrease in urine output (<30 cc/hr), diagnosed clinically or by lab findings Chronic renal dysfunction characterized by GFR of 60-89 Chronic renal dysfunction characterized by GFR of 30-59 Chronic renal dysfunction characterized by GFR of 15-29 3 mos or with signs of kidney damage (e.g., microalbuminuria, proteinuria, etc.)
Used when the documentation indicates gastric bleeding, gastrointestinal bleeding, stomach bleeding, enterorrhagia, bowel hemorrhage, cecal bleeding, gastric hemorrhage or gastroenteric hemorrhage.
Nonspecific bleeding involving GI tract, diagnosed clinically and or by endoscopies or radiological studies
584.9
ACUTE RENAL FAILURE NOS
131
Renal Failure
Used when documentation indicates renal failure or acute renal failure. Chronic Renal Failure is never assumed, it must be explicitly stated.
585.2
CHRONIC KIDNEY DIS STAGE II (MILD)
131
Renal Failure
Used when documentation indicates that the patient has CKD stage 2 and there is a documented GFR of 60-89.
585.3
CHRONIC KIDNEY DIS STAGE III
131
Renal Failure
This code is used only when the documentation indicates Stage III Chronic Kidney Disease AND there is a documented GFR from 30-59.
585.4
CHRONIC KIDNEY DIS STAGE IV (SEVERE)
131
Renal Failure
Used when documentation indicates that the patient has stage 4 CKD and there is a documented GFR of 15-29
585.6
END STAGE RENAL DISEASE
131
Renal Failure
This code is used when the documation indicates end stage renal disease, ESRD, or kidney disease requiring dialysis.
End-stage renal disease (ESRD) is an administrative term based on the conditions for payment for health care by the Medicare ESRD Program. This term denotes kidney disease at a level that requires dialysis or transplantation. Nonspecific chronic renal dysfunction characterized by impaired GFR.
585.9
CHRONIC KIDNEY DIS NOS
131
Renal Failure
Use when the documentation indicates chronic kidney disease, chronic renal failure, chronic kidney disease or chronic uremia. Note that chronic kidney disease coding should include a diagnostic statement of the stage of kidney disease whenever possible.
DX CoDe
Loss of kidney function characterized by rise in creatinine, decreased GFR and/or inability to produce urine, diagnosed clinically or by lab values
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
586
RENAL FAILURE NOS
131
Renal Failure
This code is used when the documentation indicates uremia, renal failure, uremic coma, renal shutdown, kidney stasis, renal stasis, renal suppression, uremic toxemia, urinary toxemia, uremic absorption, uremic amaurosis, uremic amblyopia, or uremic aphasia. Elevated PTH level secondary to renal disease. Nonspecific renal and/or ureteral dysfunction, diagnosed clinically
588.81
SECONDARY HYPERPARATHYROIDISM
This code is used when the documentation indicates secondary hyperparathyroidism.
593.9
RENAL & URETERAL DIS NOS
Used when the documentation indicates impaired kidney function, kidney inaction, kidney inefficiency, kidney infiltrate, kidney disease, acute kidney disease, acute renal disease, salt syndrome, salt losing disease or salt wasting disease.
599.0
URINARY TRACT INFECTION NOS
Used when documentation says UTI.
Condition characterized with symptoms of urinary frequency, dysuria, hematuria, diagnosed clinically and/or positive UA Blood in the urine, diagnosed clinically or by UA (+blood or +RBC)
599.70
HEMATURIA UNSPECIFIED
Used when the documentation indicates hematuria, blood in the urine, Tommasellis disease, bloody urine, idiopathic hematuria, intermittent hematuria, paroxysmal hematuria or sulfonamide hematuria (if correct drug administered properly).
600.00
BPH W/O URINARY OBS/LUTS
Used when documentation states BPH.
Enlargement of prostate without obstructive sxs (urinary retention, dripping or hesitancy), diagnosed clinically
600.01
HT PROS W/UR OBST & OTH LUTS
Use when documentation indicates enlargement of the prostate with lower urinary tract symptoms, prostate hyperplasia with lower urinary tract symptoms, enlargement/hyperplasia of the prostate with obstruction, enlargement/hyperplasia of the prostate with urinary retention, hypertrophy of the prostate with urinary retention/obstruction or hypertrophic prostate with lower urinary tract symptoms. Use additional code to identify symptoms such as frequency 788.41 etc. Nonspecific infection of the skin leading to warmth, erythema, swelling, diagnosed clinically and/or by image studies Nonspecific infection of the skin leading to warmth, erythema, swelling, diagnosed clinically and/or by image studies
Enlargement/hyperplasia of the prostate with urinary retention.
682.6
CELLULITIS & ABSCESS LEG EXCEPT FOOT
Used when the documentation indicates abscess of leg/ankle, cellulitis of leg/ ankle, abscess/cellulitis of hip, femoral abscess/cellulitis of knee, popliteal abscess/ cellulitis, pre-patellar abscess/cellulitis, or abscess/cellulitis of the thigh.
682.9
CELLULITIS NOS
This code is used when the documentation indicates cellulitis, diffuse cellulitis, chronic cellulitis, phlegmonous cellulitis or when multiple sites of cellulitis are documented.
692.9
DERMATITIS NOS
Used when the documentation indicates dermatitis, venenata dermatitis, contact dermatitis, allergic dermatitis, occupational dermatitis, acneiform dermatitis, anaphylactic dermatitis, allergic agent (unspecified) or eczematoid dermatitis (unspecified).
Inflammation of the skin leading to erythema, swelling, itchiness, diagnosed clinically
701.1
KERATODERMA, ACQUIRED
This code is used when the documentation indicates acanthokeratodermia, acquired alligator skin disease, alligator skin, acquired fish skin, Kyrles syndrome, hyperkeratosis follicularis in cutem penetrans, or Lutz-Miescher syndrome.
Skin disorder consisting of a growth that appears horny, diagnosed clinically
702.0
ACTINIC KERATOSIS
Used when the documentation indicates actinic keratosis, AK, senile keratosis, senile hyperkeratosis, senile keratoma, keratosis senilis, solar keratosis, senile wart, verruca senilis, or senile wart.
Precancerous skin growth usually caused by sun-exposure, diagnosed clinically and by skin biopsy
DX CoDe
Painless benign skin wart-like growth, diagnosed clinically or by biopsy Painful condition of the great toe in which the nail grows into the skin on either side, causing inflammation and/or infection, diagnosed clinically Specified lesion or process involving the nail, including deformity, discoloration, abnormal growth, etc, diagnosed clinically Nonspecific skin disorder, including inflammation, discoloration, infection, growth, irritation, etc, diagnosed clinically and/or by biopsy Chronic inflammatory disorder for more than 6 wks, diagnosed clinically with 4 out of the following: affecting 3 or more joints, morning stiffness, symmetrical joint pain, PIP/MCP joint involvement, rheumatoid nodules, erosion on x-ray and +RF or +CCP
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
702.19
OTHER SBORHEIC KERATOSIS
This code is used when the documentation indicates seborrheic keratosis, seborrhea, seborrheic wart or verruca seborrheica.
703.0
INGROWING NAIL
Use when documentation states ingrown nail, onychocryptosis, onyxis, Unguis incarnatus or ingrowing nail.
703.8
DISEASES OF NAIL NEC
This code is used when the documentation indicates achromia unguium, acquired anonychia, atrophia unguium, Beaus lines, brittle nails, clubnail, defluvium unguium, nail discoloration, eggshell nails, fragilitas unguium, fragile nails or furrowing nails.
709.9
SKIN DISORDER NOS
Used when the documentation indicates dermatosis, skin disease, perineal irritation, or skin sores.
714.0
RHEUMATOID ARTHRITIS
38
This code is used when the documentation states rheumatoid arthritis, rheumatic arthritis, chronic polyarthritis, rheumatoid torticollis, primary progressive arthritis, proliferative arthritis, or atrophic arthritis.
715.00
GENERAL OSTEOARTHROSIS
Used when the documentation indicates generalized osteoarthrosis or generalized arthritis. This code should not be used when the medical record indicates arthritis, which is coded 715.9not stated whether localized or generalized.
Generalized OA involving multiple joints, diagnosed clinically or by image studies
715.09
GEN OSTEOARTHROSIS INVLV MX SITES OA involving lower extremity, diagnosed clinically Non-specific OA characterized by joint pain and stiffness, diagnosed clinically or by x-ray findings (narrow joint space, bone spurs, etc) Non-specific joint pain involving lower extremity, diagnosed clinically
Use this code when the documentation indicates generalized osteoarthritis/ osteoarthrosis, polyarticular osteoarthrosis, idiopathic general osteoarthosis/ arthritis, polyarticular arthrosis, generalized joint disease, or generalized arthritis.
Pain in multiple joints without inflammation.
715.16
LOC PRIM OSTEOART-L/LEG
This code is used when the documentation specifically states that osteoarthritis is present in the lower extremity (leg).
715.90
OSTEOARTHROS NOS-UNSPEC
Used when documentation says arthritis or osteoarthrosis or degenerative joint disease and no site is described.
715.96
OSTEOARTHROS NOS-L/LEG Nonspeicific joint pain diagnosed clinically
Use this code when the documentation states arthritis, nonpyogenic arthritis, arthropathy, joint inflammation, or rheumatism of the lower part of the leg is documented.
716.90
ARTHROPATHY NOS-UNSPEC
Use this code when the documentation states arthritis, nonpyogenic arthritis, arthropathy, joint inflammation, or rheumatism and no area of the body is mentioned.
719.41
JOINT PAIN-SHLDER
This code is used when the documentation indicates shoulder joint pain.
Joint discomfort involving shoulder, diagnosed clinically Joint discomfort involving pelvic area, diagnosed clinically Lower extremity pain involving the knee joint, diagnosed clinically Joint discomfort/pain involving ankle, diagnosed clinically Difficulty walking, diagnosed clinically.
719.45
JOINT PAIN-PELVIS
Used when documentation states coxalagia, hip pain, or pelvic pain.
719.46
JOINT PAIN-L/LEG
This code is used when the documentation indicates that the patient has knee pain, patellofemoral syndrome, or patellofemoral pain.
719.47
JOINT PAIN-ANKLE
Used when the documentation indicates pain in the ankle, foot or metatarsals.
719.7
DIFFICULTY WALKING
Used when documentation indicates that the patient has difficulty in walking, but no cause is described.
DX CoDe
OA involving lumbar and/or sacral area, diagnosed clinically or by image studies OA involving lumbar and/or sacral area, diagnosed clinically Symptoms of neck pain/discomfort, diagnosed clinically Narrowing of the spinal canal leading to the compression of the spinal cord and nerves leading to pain and/or abnormal sensation, diagnosed clinically and/or by image studies Pain in the lumbar region diagnosed clinically Irritation of sciatic nerve leading to pain and tingling sensation radiating down lower extremities, diagnosed clinically Nonspecific inflammation of lumbarsacral nerve(s) leading to pain, numbness or tingling, diagnosed clinically and/or by EMG/NCS
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
721.3
LUMBOSACRAL SPONDYLOSIS
Used when the documentation indicates lumbar spondylosis, lumbosacral spondylosis, or sacral spondylosis.
722.52
LUMB/LUMBOSAC DISC DEGEN
This code is assigned if the documentation states OA AND the location of the lumbar or sacral spine is specifically stated.
723.1
CERVICALGIA
This code is used when the documentation indicates cervicalgia, neck pain or cervical pain and no cause of the pain is documented.
724.02
SPINAL STENOSIS-LUMBAR
This code is used when the documentation indicates lumbar spinal stenosis or lumbosacral stenosis.
724.2
LUMBAGO
Used when documentation says lumbago or low back pain.
724.3
SCIATICA
This code is used when the documentation indicates Cotungos disease, Cotungos syndrome, Ischialgia, sacroiliac joint neuralgia, sciatic neuralgia, sciatic pain, infectional sciatica or sciatica.
724.4
LUMBOSACRAL NEURITIS NOS
This code is used when the documentation indicates lumbar nerve root disorder, lumbosacral nerve root disorder, thoracic nerve root disorder, lumbosacral radicular pain, anterior crural radiculitis, leg radiculitis, lumbar, lumbosacral radiculitis, or lumbosacral radiculopathy. Nonspecific back pain
724.5
BACKACHE NOS
Used when documentation states backache, or vertebrogenic syndrome.
728.87 Nonspecific pain involving muscle, diagnosed clinically Pain in arm, leg, hand, foot, fingers or toes, diagnosed clinically Swelling in a limb including digits, diagnosed clinically Nonspecific decrease in bone mass or density, diagnosed clinically or by DEXA scan or other image studies Decrease in bone mass or density due to old age diagnosed clinically by DEXA scan and/or image studies Nonspecific abnormality involving bone and cartilage, diagnosed clinically
MUSCLE WEAKNESS (GENERALIZED)
Use this code if the documentation indicates that the patient is myasthenic, or has muscle weakness.
A reduction in the strength of one or more muscles.
729.1
MYALGIA AND MYOSITIS NOS
Used when the documentation indicates myalgia, fibromyalgia, myositis, myofacial pain, fibromyositis, muscle pain, neuromuscular pain, or rheumatic muscular pain.
729.5
PAIN IN LIMB
Pain in arm, leg, hand, foot, fingers or toes.
729.81
SWELLING OF LIMB
Used when the documentation indicates swelling in a limb, including digits.
733.00
OSTEOPOROSIS NOS
Used when documentation says osteoporosis.
733.01
SENILE OSTEOPOROSIS
This code is used when the documentation indicates osteoporosis, senile osteoporosis or post-menopausal osteoporosis.
733.90
BONE & CARTILAGE DIS NOS
Used when the documentation indicates bone lesion, osteolytic lesion, bone mass, osteocopic pain, osteodynia, osteopenia, bone pain, cartilage pain, tibia pain, xyphoid pain, scapulalgia, xiphoidenia, xiphoidalgia or bone changes.
780.02
TRANS ALTER AWARENESS
Used when the documentation indicates alteration of consciousness, transient alteration of awareness or transient alteration of consciousness.
Transient alteration of consciousness, diagnosed clinically Non-specific change in mental status, including delirium, drowsiness, hyporesponsive state, loss of consciousness, semi coma, semi consciousness or somnolence.
780.09
OTHER ALTER CONSCIOUSNES
Used when documentation states: delirium, drowsiness, hyporesponsive state, loss of consciousness, semi coma, semi consciousness or somnolence.
DX CoDe
Loss of consciousness due to inadequate blood flow to the brain, diagnosed clinically
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
780.2
SYNCOPE AND COLLAPSE
This code should be used when the docmentation indicates syncope (without underlying cause), collapse, unconsciousness, vaso-vagal attack, vagal syncope, vasomotor attack, blackout, fainting, Gowers syndrome, vascular hyperreactor, or vasomotor instability.
780.39
OTHER CONVULSIONS
74
Use if the documentation indicates epileptiform attack, sensory and motor attack, toxic cerebral attack, eclamptic coma, convulsions, idiopathic convulsions, cerebral convulsions, cerebrospinal convulsions, eclamptic convulsions, ether convulsions, generalized convulsions, infantile convulsions, internal convulsions, recurrent convulsions, repetitive convulsions, spasmodic convulsions, epileptoid seizures, ether seizures, generalized seizures, or convulsive disorder. Symptoms of feeling dizzy, imbalanced, diagnosed clinically
Sudden, involuntary skeletal muscular contractions of cerebral or brain stem origin
780.4
DIZZINESS AND GIDDINESS
This code is used when the documentation indicates dizziness, giddiness, dysequilibrium, lightheadedness, swimming in the head, Mal de Debarquement or vertigo.
780.52
INSOMNIA NOS
This code is used when the documentation indicates insomnia, sleeplessness, agrypnia, disruption in sleep initiation or maintenance, or hyposomnia.
Inability or difficulty falling asleep or remaining asleep Presence of fever without further detail; generally >= 99.5 F or 37.5 C
780.60
FEVER UNSPECIFIED
Used when the documentation indicates fever, chills with fever, pyrexia, fever of unknown origin, ephemeral fever, or febricula.
780.79
MALAISE AND FATIGUE NEC
Used when documentation indicates malaise, fatigue, asthenia, or chronic Epstein Barr. Symptoms of malaise and fatique, diagnosed clinically
780.97 Nonspecific general symptoms, diagnosed clinically Abnormal pattern of walking, diagnosed clinically Nonspecific raised, itchy, red-welts on the surface of the skin, usually due to allergic reaction to food, medication, etc, diagnosed clinically Accumulation of fluid, usually in the lower extremities and dependent area, diagnosed clinically
ALTERED MENTAL STATUS
This code is used when the documentation indicates altered mental status, alteration of mental status or changes in mental status.
A loss or decrease in the level of awareness of self and environment combined with markedly reduced responsiveness to environmental stimuli
780.99
OTHER GENERAL SYMPTOMS
Used when documentation indicates rigors, subnormal temperature, functional activity decrease, or other general symptoms.
781.2
ABNORMALITY OF GAIT
Used when the documentation indicates ataxic gait, gait abnormality, gait disturbance, paralytic gait, scissor gait, spastic gait, staggering gait or imbalance.
782.1
NONSPECIF SKIN ERUPT NEC
Used when the documentation indicates pustular rash, rash, rose rash, toxic rash, skin rash or exanthema.
782.3
EDEMA
Use this code when the documentation indicates anasarca, Secretans edema, infectious edema, pitting edema, or edema.
783.21
ABNORM LOSS OF WEIGHT
Used when the documentation indicates abnormal weight loss, or weight loss of unknown cause.
Losing more than 10% of the usual weight over 3-6 months, diagnosed clinically Symptoms of headache or head discomfort, diagnosed clinically Presence of palpitation, diagnosed clinically Symptom of shortness of breath Nonspecific pulmonary symptoms including shortness of breath, hypoventilation, dyspnea on exercise, hypercapnia, etc
784.0
HEADACHE
Used when the documentation indicates headache, cephalgia, vascular headache, face or facial pain or head pain.
785.1
PALPITATIONS
Use when documentation indicates palpitations, pulses in the neck, or you have recorded that the patient has an awareness of their heartbeat.
786.05
SHORTNESS OF BREATH
Used when the documentation says shortness of breath.
786.09
RESPIRATORY ABNORM NEC
This code is used when the documentation says hypercapnia, hypoventilation, irregular breathing or labored breathing also dyspnea on extertion, respiratory distress and respiratory insufficiency.
DX CoDe
Symptom of cough, diagnosed clinically Nonspecific or non cardiac chest pain / discomfort, diagnosed clinically Nonspecific or non cardiac chest discomfort other than angina, diagnosed clinically
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
786.2
COUGH
This code is used when the documentation indicates cough, laryngeal syncope or tussive syncope.
786.50
CHEST PAIN NOS
Used when documentation indicates chest pain or rib pain.
786.51
PRECORDIAL PAIN
This code is used when the documentation states precordial pain, cardialgia, anginoid pain, midsternal pain, substernal pain, heart pain, pericardial pain, or retrosternal pain. If the documentation says angina, then the correct code is 413.9.
786.59
CHEST PAIN NEC
Used when the documentation states chest pain, chest discomfort, atypical chest pain, musculoskeletal chest pain or noncardiac chest pain.
Nonspecific noncardiac chest pain/discomfort, diagnosed clinically Symptoms of nausea and vomiting, diagnosed clinically Difficulty swallowing, diagnosed clinically or by radiological studies. Diagnosed generally clinically, x-rays only if patient is aphasic. Symptoms of diarrhea (frequeuent stool: > 3 daily), diagnosed clinically. Also diagnosed based on stool appearance (watery)
787.01
NAUSEA WITH VOMITING
Used when the documentation indicates the presence of both nausea and vomiting. For nausea w/o vomiting, use 787.02; for vomiting w/o nausea documented, use 787.03
787.20
DYSPHAGIA UNSPECIFIED
Used when the documentation indicates dysphagia, or difficulty swallowing.
787.91
DIARRHEA
This code was used when the documentation indicates diarrhea, acute diarrhea, autumn diarrhea, bilious diarrhea, bloody diarrhea, catarrhal diarrhea, choleraic diarrhea, chronic diarrhea, diarrhea gravis, green diarrhea, infantile diarrhea, or lienteric diarrhea.
788.20
UNSPECIFIED RETENTION OF URINE
This code is used when the documentation indicates urinary retention, bladder retention, urine stoppage, or urine stasis.
Incomplete emptying of the bladder
788.30 Non-specific abdominal pain, diagnosed clinically Epigastric pain/discomfort, diagnosed clinically Generalized abdominal pain/discomfort, diagnosed clinically Abdominal pain/discomfort, diagnosed clinically
URINARY INCONTINENCE NOS
This code is used when the documentation only states that the patient has urinary incontinence without stating the etiology or type.
Unspecified loss of control of urine, diagnosed clinically
789.00
ABDMNAL PAIN UNSPCF SITE
Used when documentation states abdominal pain and a quadrant is not specified.
789.06
ABDMNAL PAIN EPIGASTRIC
This code is used when the documentation indicates that the patient has epigastric abdominal pain.
789.07
ABDMNAL PAIN GENERALIZED
This code is used when the documentation indicates generalized abdominal pain.
789.09
ABDMNAL PAIN OTH SPCF ST
This code is used when the documentation describes abdominal pain in an area of the abdomen that does not have a specific code. This includes descriptive terms such as abdominalgia, or colic.
790.6
ABNORM BLOOD CHEMISTRY NEC
This code is assigned when the documentation indicates an abnormal (blood) laboratory test, but the significance or related diagnosis is not determined or documented.
Abnormal blood test value, diagnosed based on lab value
790.93
ELVTD PRSTATE SPCF ANTGN
This code is to be used when you have documented that the patient has an elevated PSA. If you only note the lab value, you cannot code thisyou must state that it is elevated.
Elevated PSA level, diagnosed based on lab value
793.1
ABNORM FINDINGSLUNG FIELD
Used when the documentation indicates lung shadow, abnormal radiology finding in lung, lung infiltrate, or lung coin.
Abnormal lesions in the lungs, including infiltrate, mass/ nodules, abcess, etc, diagnosed by image studies Abnormal ECG findings,
794.31
ABNORM ELECTROCARDIOGRAM
This code is only used when the documentation indicates that the EKG is abnormal but the nature of the abnormality is unknown or unstated.
DX CoDe
Lower than normal blood oxygen level.
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
799.02
HYPOXEMIA
79
CardioRespiratory Failure and Shock Unspecified debility. Excludes asthenia, nervous debility, neurasthenia and senile asthenia Fracture of femur, diagnosed by x-ray. Severe sepsis is an administrative diagnosis, which is defined as sepsis with associated organ dysfunction. Accident at home Used to indicate the cause of an injury
Used when the documentation indicates hypoxia, anoxia, anoxemia, pathological anoxia, or hypoxemia.
799.3
UNSPECIFIED DEBILITY
This code is used when the documentation states general(ized) debility, debility, or general decline are documented.
820.8
CLOS FRACTURE UNSPEC PART NECK FEM
158
Hip Fracture/ Dislocation
Use this code when the documentation indicates fracture of the neck of femur, fracture of the femur, upper end of the femur, or hip.
995.91
SEVERE SEPSIS
Use when documentation indicates severe sepsis, generalized sepsis, or SIRS due to infection.
E849.0
ACCIDENT IN HOME
This is a supplemental code, and should never be used alone. Use this code when the documentation indicates that the patient suffered an injury in their home.
E888.9
FALL NOS
This code is used when the documentation indicates that the patient fell, without further information. The code series E888.X has very specific codes for falls, based on how or where they occurred. When this information is available, it should be documented.
V03.82
VACCIN STRPTCS PNEUMNI B
This code is used when the documentation indicates the patient received streptococcus pneumoniae [pneumococcus] vaccine.
Administration of pneumococcal vaccination
V04.81 History of breast cancer, no active cancer, diagnosed by history
VACCIN FOR INFLUENZA
Used to indicate that the patient is seen for influenza vaccine.
Performance of influenza vaccination
V10.3
HX OF BREAST MALIGNANCY
This code is used when the documentation indicates that the patient has had breast cancer and has completed treatment (surgically, radiation, chemotherapy or any combination) when there is no indication that there is tumor still present. Patients undergoing treatment with tamoxifen or similar drugs should be coded as having active disease. Patient with a personal history of CVA with residual deficit.
V12.54
PERS HX TIA & CI W/O RESIDL DEFICTS History of prior tobacco use, diagnosed by history Patient with history of fall. Status post lens replacement Status of knee replacement with prosthesis
Use when documentation indicates old CVA or healed CVA, without mention of deficits, history of TIA, old or healed cerebral hemorrhage, TIA, transient ischemic attack or prolonged reversible ischemic neurologic (PRIND).
V15.82
HX OF TOBACCO USE
Used when the documentation indicates a history of tobacco use, prior tobacco use or history of cigarette smoking.
V15.88
PERSONAL HISTORY OF FALL
Used when documentation indicates fall, at risk for falls, fall/ falling hazard, falling disorder, or falling risk.
V43.1
LENS REPLACEMENT NEC
Used when your note indicates that the lens of the eye has been replaced.
V43.65
KNEE JOINT REPLACEMENT OTHER MEANS
Used when documentation indicates knee joint replacement, knee replacement, knee/knee joint prosthesis, knee joint device, or artificial knee joint.
V45.01
STATUS CARDIAC PACEMAKER
This code is used when the documentation indicates that the patient has a cardiac pacemaker in place.
Pacemaker placement, diagnosed clinically or by imaging study Patients undergoing renal dialysis.
V45.11
RENAL DIALYSIS STATUS
130
Dialysis Status
This code is used when the documentation indicates that the patient receives hemodialysis.
DX CoDe
s/p CABG
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
V45.81
AORTOCORONARY BYPASS
This code is used when the documentation indicates that the patient is status post coronary bypass surgery. If there is residual disease, this should be fully described and coded. Used by the physical therapist for patients presenting for physical therapy N/A
V57.1
PHYSICAL THERAPY NEC
This code should be used only when the patient presents for physical therapy, and this is noted in the medical record.
V57.89
OTHER SPEC REHABILITATION PROC OTH Status of using long term anticoagulation therapy
Used when the documentation indicates multiple types of ongoing rehabilitation, or when there is no specific code for the type of rehabilitation that the patient is undergoing.
V58.61
LONG-TERM USE ANTICOAGUL Status of long term use of insulin. Status of (current) medication use long term
Used when the documentation indicates that the patient is on long-term anticoagulant therapy. The underlying condition (e.g., history of DVT or chronic atrial fibrillation) must also be documented and coded.
V58.67
LONG-TERM USE OF INSULIN
19
Diabetes without Used when the documentation indicates current insulin use, Complication long term insulin use, or ongoing insulin therapy.
V58.69
LONG-TERM USE MEDS NEC
Used when the patient has long term medication use that does not have a specific code. For example there are specific codes for long term use of anticoagulants (V58.61), long term use of antibiotics (V58.62) and long term use of steroids (V58.65). Its appropriate to use this code for long term use of opioid pain medication.
V70.0
ROUTINE MEDICAL EXAM
Used to indicate that the patient is seen for a routine (e.g., preventive) service.
Performance of routine medical examination
V72.0 Performance of routine gynecological exam
EYE & VISION EXAMINATION
Used to indicate a patient seen for eye examination
Performance of eye and vision examination
V72.31
ROUTINE GYN EXAMINATION Performance of laboratory tests only
Used only when the documentation indicates that the patient presented for a routine gynecological examination. This code is not to be used for patients with a known gynecological condition.
V72.60
LABORATORY EXAMINATION UNSPECIFIED Performance of pre-operative cardiovascular evalution Performance of specific preoperative examination
This code is used when the documentation indicates that the patient had laboratory services done.
V72.81
PREOP CARDIOVSCLR EXAM
This code is used when the documentation indicates that the examination is for cardiovascular clearance preoperatively.
V72.83
OTHER SPCF PREOP EXAM
This code is used to indicate a specified pre-operative examination that does not have a more specific code, e.g. renal function studies in a patient with kidney disease, before undergoing surgery.
V72.84
PREOP EXAM UNSPCF
Use only when your documentation indicates you are doing a history and physical examination for a patient having a surgical procedure
Performance of H & P prior to surgical procedure Performance of mammogram for breast cancer screening Performance of pap smear for cervical cancer screening Performance of colon cancer screening, including colonoscopy, checking stool for occult blood, or barium enema
V76.12
SCREEN MAMMOGRAM NEC
Used by the screening mammography center or interpreting radiologist when the patient is seen for a screening mammogram.
V76.2
SCREEN MALIG NEOP-CERVIX
This code is used when the patient presents for a screening Pap smear.
V76.51
SCREEN MALIG NEOP-COLON
Use this code when the patient has no symptoms and you are performing a colonoscopy or stool for occult blood.
DX CoDe
DX DesCription
HCC
HCC DesCription
CliniCal Criteria
Appendices
Appendix 1. CMS-HCC RiSk AdjuStMent ModelCoMMunity And inStitutionAl FACtoRS

institutional FaCtors
Variable
Disease Group
Community FaCtors
Female 0.950 0.950 0.950 1.031 1.031 1.131 1.025 0.900 0.772 0.700 0.576
Female 0-34 Years
0.210
Female 35-44 Years
0.217
Female 45-54 Years
0.276
Female 55-59 Years
0.343
Female 60-64 Years
0.415
Female 65-69 Years
0.279
Female 70-74 Years
0.337
Female 75-79 Years
0.426
Female 80-84 Years
0.525
Female 85-89 Years
0.651
Female 90-94 Years
0.786
Variable
institutional FaCtors 0.447
Disease Group
Community FaCtors
Female 95+ Years
0.822
male 1.089 0.960 0.960 1.020 1.082 1.281 1.178 1.178 1.104 1.041 0.883
Male 0-34 Years
0.117
Male 35-44 Years
0.133
Male 45-54 Years
0.193
Male 55-59 Years
0.272
Male 60-64 Years
0.337
Male 65-69 Years
0.283
Male 70-74 Years
0.346
Male 75-79 Years
0.436
Male 80-84 Years
0.534
Male 85-89 Years
0.656
Male 90-94 Years
0.824
Male 95+ Years
0.993
0.796
meDiCaiD & oriGinally DisableD interaCtions with aGe anD sex 0.096 0.096 0.096 0.096
Medicaid Female, Aged
0.202
Medicaid Female, Disabled
0.103
Medicaid Male, Aged
0.232
Medicaid Male, Disabled
0.099
Originally Disabled, Female
0.228
Originally Disabled, Male
0.160
Disease CoeFFiCients 1.732 0.796 0.471 0.910 0.576 0.413
HCC1
HIV/AIDS
0.458
HCC2
Septicemia/Shock
0.766
HCC5
Opportunistic Infections
0.465
HCC7
Metastatic Cancer and Acute Leukemia
2.175
HCC8
0.919
HCC9
Lymphatic, Head and Neck, Brain, and Other Major Cancers
0.706
Variable
institutional FaCtors 0.240 0.413 0.413 0.413 0.413 0.173 0.358 0.937 0.350 0.350 0.352 0.374 0.283
Disease Group
Community FaCtors
HCC10
0.187
HCC15
0.371
HCC16
0.371
HCC17
Diabetes with Acute Complications
0.371
HCC18
0.371
HCC19
0.127
HCC21
Protein-Calorie Malnutrition
0.745
HCC25
End-Stage Liver Disease
1.006
HCC26
Cirrhosis of Liver
0.413
HCC27
Chronic Hepatitis
0.262
HCC31
Intestinal Obstruction/Perforation
0.310
HCC32
Pancreatic Disease
0.362
HCC33
Inflammatory Bowel Disease
0.302
HCC37 0.304 0.600 0.533 0.407 0.301 0.518 0.480 0.238 0.277 0.157
Bone/Joint/Muscle Infections/Necrosis
0.585
0.670
HCC38
0.361
HCC44
Severe Hematological Disorders
1.129
HCC45
Disorders of Immunity
0.945
HCC51
Drug/Alcohol Psychosis
0.373
HCC52
Drug/Alcohol Dependence
0.373
HCC54
Schizophrenia
0.517
HCC55
0.360
HCC67
Quadriplegia, Other Extensive Paralysis
1.147
HCC68
Paraplegia
1.061
HCC69
Spinal Cord Disorders/Injuries
0.491
HCC70
Muscular Dystrophy
0.464
HCC71
Polyneuropathy
0.321
HCC72
Multiple Sclerosis
0.516
Variable
institutional FaCtors 0.138 0.192 0.060 2.129 1.121 0.485 0.228 0.439 0.439 0.331 0.245 0.151 0.151
Disease Group
Community FaCtors
HCC73
0.643
HCC74
0.278
HCC75
Coma, Brain Compression/Anoxic Damage
0.580
HCC77
Respirator Dependence/Tracheostomy Status
1.767
HCC78
Respiratory Arrest
1.117
HCC79
0.531
HCC80
0.346
HCC81
Acute Myocardial Infarction
0.294
HCC82
0.274
HCC83
Angina Pectoris/Old Myocardial Infarction
0.170
HCC92
0.289
HCC95
Cerebral Hemorrhage
0.359
HCC96
0.265
HCC100 0.470 0.138 0.378 0.378 0.605 0.197 0.440 2.228 0.353 0.353 0.517 0.291
Hemiplegia/Hemiparesis
0.534
0.069
HCC101
Cerebral Palsy and Other Paralytic Syndromes
0.131
HCC104
Vascular Disease with Complications
0.594
HCC105
Vascular Disease
0.302
HCC107
Cystic Fibrosis
0.385
HCC108
0.340
HCC111
Aspiration and Specified Bacterial Pneumonias
0.734
HCC112
Pneumococcal Pneumonia, Emphysema, Lung Abscess
0.206
HCC119
Proliferative Diabetic Retinopathy and Vitreous Hemorrhage
0.236
HCC130
Dialysis Status
1.348
HCC131
Renal Failure
0.297
HCC132
Nephritis
0.116
HCC148
Decubitus Ulcer of Skin
1.165
HCC149
Chronic Ulcer of Skin, Except Decubitus
0.476
HCC150
Extensive Third-Degree Burns
1.246
Variable
institutional FaCtors 0.060 0.154 0.266 0.325 0.925 0.861 0.266
Disease Group
Community FaCtors
HCC154
Severe Head Injury
0.580
HCC155
Major Head Injury
0.171
HCC157
Vertebral Fractures without Spinal Cord Injury
0.467
HCC158
Hip Fracture/Dislocation
0.435
HCC161
Traumatic Amputation
0.793
HCC164
Major Complications of Medical Care and Trauma
0.311
HCC174
Major Organ Transplant Status
1.084
HCC176
Artificial Openings for Feeding or Elimination
0.659
HCC177
Amputation Status, Lower Limb / Amputation Complications
0.793
DisableD/Disease interaCtions 0.633 0.284
D_HCC5
Disabled, Opportunistic Infections
0.597
D_HCC44
Disabled, Severe Hematological Disorders
1.340
D_HCC51
Disabled, Drug/Alcohol Psychosis
0.383
D_HCC52
Disabled, Drug/Alcohol Dependence
0.105
0.284
D_HCC107
Disabled, Cystic Fibrosis
2.556
Disease interaCtions 0.111 0.051 0.248 0.118 0.373
INT1
Diabetes Mellitus+Congestive Heart Failure
0.150
INT2
Diabetes Mellitus+Cerebrovascular Disease
0.150
INT3
Congestive Heart Failure+Chronic Obstructive Pulmonary Disease
0.278
INT4
Chronic Obstructive Pulmonary Disease+Cerebrovascular Disease+Coronary Artery Disease
0.233
INT5
Renal Failure+Congestive Heart Failure
0.262
INT6
Renal Failure+Congestive Heart Failure+Diabetes Mellitus
0.600
Variable
institutional FaCtors
Disease Group
Community FaCtors
Appendix 2. DiSeASe HieRARCHieS foR tHe CMS-HCC MoDel

tHen drop tHe associated disease group(s) listed in tHis column
HierarcHical condition category (Hcc)

112 8, 9, 10 9, 10 10 16, 17, 18, 19 17, 18, 19 18, 19 19 26, 27 27
if tHe disease group is listed in tHis column
disease group label
Opportunistic Infections
Metastatic Cancer and Acute Leukemia
Lung, Upper Digestive Tract and Other Severe Cancers
Lymphatic, Head and Neck, Brain and Other Major Cancers
15
Diabetes with Renal Manifestations or Peripheral Circulatory Manifestation
16
17
Diabetes with Acute Complications
18
Diabetes with Ophthalmologic or Unspecified Manifestations
25
End-Stage Liver Disease
26
Cirrhosis of Liver

52 55 68, 69, 100, 101, 157 69, 100, 101, 157 157 78, 79 79 82, 83 83 96 101 105, 149
disease group label
51
Drug/Alcohol Psychosis
54
Schizophrenia
67
Quadriplegia/Other Extensive Paralysis
68
Paraplegia
69
Spinal Cord Disorders/Injuries
77
Respirator Dependence/Tracheostomy Status
78
Respiratory Arrest
81
Acute Myocardial Infarction
82
95
Cerebral Hemorrhage
100
Hemiplegia/Hemiparesis
104
Vascular Disease with Complications
107 112 131, 132 132 149 75, 155 177
Cystic Fibrosis
108
111
Aspiration and Specified Bacterial Pneumonias
130
Dialysis Status
131
Renal Failure
148
Decubitus Ulcer of Skin
154
Severe Head Injury
161
Traumatic Amputation
How payments are Made with a disease HierarchyEXAMPLE: If a beneficiary triggers HCCs 148 (Decubitus Ulcer of the Skin) and 149 (Chronic Ulcer of Skin, Except Decubitus), then HCC 149 will be dropped. In other words, payment will always be associated with the HCC in column 1 if a HCC in column 3 also occurs during the same collection period. Therefore, the MA organizations payment will be based on HCC 148 rather than HCC 149.
disease group label
Appendix 3. CMS-HCC Model RelAtive FACtoRS FoR AGed And diSAbled new enRolleeS
Variable
NoN-Medicaid & NoNorigiNally disabled
Medicaid & NoNorigiNally disabled
NoN-Medicaid & origiNally disabled
Medicaid & origiNally disabled
FeMale
034 Years
0.545
0.919
3544 Years
0.723
1.097
4554 Years
0.881
1.255
5559 Years
0.957
1.331
6064 Years
1.094
1.468
65 Years
0.504
1.085
1.108
1.689
66 Years
0.506
0.920
1.043
1.457
67 Years
0.506
0.920
1.043
1.457
68 Years
0.543
0.957
1.080
1.494
69 Years
0.569
0.983
1.106
1.520
7074 Year
0.660
0.991
1.274
1.605
7579 Year
0.864
1.165
1.478
1.779
Variable
8084 Year
1.057
1.358
1.671
1.972
8589 Year
1.264
1.565
1.878
2.179
9094 Year
1.264
1.565
1.878
2.179
95 Years or Over
1.264
1.565
1.878
2.179
Male
034 Years
0.233
0.788
3544 Years
0.510
1.065
4554 Years
0.754
1.309
5559 Years
0.885
1.440
6064 Years
0.951
1.506
65 Years
0.517
1.248
0.931
1.662
66 Years
0.532
1.135
1.083
1.686
67 Years
0.579
1.182
1.130
1.733
68 Years
0.617
1.220
1.168
1.771
69 Years
0.657
1.260
1.208
1.811
7074 Years
0.784
1.249
1.481
1.946
7579 Years
1.046
1.445
1.743
2.142
8084 Years
1.249
1.648
1.946
2.345
8589 Years
1.424
1.823
2.121
2.520
9094 Years
1.424
1.823
2.121
2.520
95 Years or Over
1.424
1.823
2.121
2.520
Variable
Appendix 4. AppRoved pHySiCiAn SpeCiAltieS foR RiSk AdjuStMent

Code
67 68 72* 76* 77 78 79 80 81 82 83 84 Cardiac Surgery Addiction Medicine Licensed Clinical Social Worker Critical Care (Intensivist) Hematology Hematology/Oncology Preventive Medicine Vascular Surgery Peripheral Vascular Disease Pain Management Clinical Psychologist Occupational Therapist
Code
SpeCialty
Code
SpeCialty
SpeCialty
01
General Practice
25
Physical Medicine and Rehabilitation
02
General Surgery
26
Psychiatry
03
Allergy/Immunology
27
Geriatric Psychiatry
04
Otolaryngology
28
Colorectal Surgery
05
Anesthesiology
29
Pulmonary Disease
06
Cardiology
33*
Thoracic Surgery
07
Dermatology
34
Urology
08
Family Practice
35
Chiropractic
09
Interventional Pain Management
36
Nuclear Medicine
10
Gastroenterology
37
Pediatric Medicine
11
Internal Medicine
38
Geriatric Medicine
12
Osteopathic Manipulative Therapy
39
Nephrology
Code
85 86 89* 90 91 92 93 94 97* 98 99 C0 Physician Assistant Gynecologist/Oncologist Unknown Physician Specialty Sleep Medicine Interventional Radiology Emergency Medicine Radiation Oncology Surgical Oncology Medical Oncology Certified Clinical Nurse Specialist Neuropsychiatry Maxillofacial Surgery
SpeCialty
Code
SpeCialty
Code
SpeCialty
13
Neurology
40
Hand Surgery
14
Neurosurgery
41
Optometry (specifically means Optometrist)
15
Speech Language Pathologist
42
Certified Nurse Midwife
16
Obstetrics/Gynecology
43
Certified Registered Nurse Anesthetist
17
Hospice and Pallative Care
44
Infectious Disease
18
Ophthalmology
46*
Endocrinology
19
Oral Surgery (Dentist only)
48*
Podiatry
20
Orthopedic Surgery
50*
Nurse Practitioner
21
Electrophysiology
62*
Psychologist
22
Pathology
64*
Audiologist
23
Sports Medicine
65
Physical Therapist
24
Plastic and Reconstructive Surgery
66
Rheumatology
note: Qualified physician data for risk adjustment requires a face-to-face visit with the exception of pathology services (professional component only). * Indicates that a number has been skipped
Appendix 5. CliniCAl AbbReviAtionS foR tHe MediCAl ReCoRd
AAA AbdoMinAl AoRtiC AneURYSM
Abi AnKel-bRACHiAl indeX
Abn AbnoRMAl
AK ACtiniC KeRAtoSiS
ARt ARteRY
ASHd AtHeRoSCleRotiC HeARt diSeASe
AtH AtHeRoSCleRoSiS
bKA beloW Knee AMPUtAtion
bMi bodY MASS indeX
bPH beniGn PRoStAtiC HYPeRtRoPHY
bRbPR bRiGHt Red blood PeR ReCtUM
bRon bRonCHitiS
CA CAnCeR
CAbG CoRonARY ARteRY bYPASS GRAft
CAd CoRonARY ARteRY diSeASe
CAGe CUt-doWn, AnnoYed, GUiltY, eYe oPeneR teSt
CCP CYCliC CitRUllinAted PePtide
CHf ConGeStive HeARt fAilURe
CKd CHRoniC KidneY diSeASe
CoPd CHRoniC obStRUCtive PUlMonARY diSeASe
CoR CoRonARY
CP CHeSt PAin oR CeRebRAl PAlSY
CR CReAtinine
CRbl CeRebRAl
Ct CoMPUteRiZed toMoGRAPHY
Cv CARdiovASCUlAR
CvA CeRebRovASCUlAR ACCident
CXR CHeSt X-RAY
dbP diAStoliC blood PReSSURe
deXA dUAl eneRGY X-RAY AbSoRPtioMetRY
diS diSeASe
dl deCiliteR
dM diAbeteS MellitUS
dvt deeP vein tHRoMboSiS
eCG eleCtRoCARdioGRAM
ef eJeCtion fRACtion
eGd eSoPHAGoGAStRodUodenoSCoPY
eKG eleCtRoCARdioGRAM
eMG eleCtRoMYoGRAM
eSR eRYtHRoCYte SediMentAtion RAte
eSRd end-StAGe RenAl diSeASe
fvC foRCed vitAl CAPACitY
GeRd GAStRoeSoPHAGeAl ReflUX diSeASe
GfR GloMeRUlAR filtRAtion RAte
H&P HiStoRY And PHYSiCAl
Hf HeARt fAilURe
Hgb or Hb HeMoGlobin
Hiv HUMAn iMMUnodefiCienCY viRUS
Htn HYPeRtenSion
Hx HiStoRY
idio idioPAtHiC
int inteRnAl
ivP intRAvenoUS PYeloGRAM
Kg KiloGRAM
Kid KidneY
KUb KidneYS, UReteRS, blAddeR
l left
le loWeR eXtReMitY
lG lARGe
ln lYMPH node
lUtS loWeR URinARY tRACt SYMPtoMS
MA MiCRoAlbUMin
MAl MAliGnAnt
MCP MetACARPoPHAlAnGeAl
MCv MeAn Cell volUMe
mg MilliGRAM
Mi MYoCARdiAl infARCtion
MRA MAGnetiC ReSonAnCe AnGioGRAPHY
nCS neRve CondUCtion StUdieS
neo neoPlASM
neURo neURoloGiCAl
oCd obSeSSive-CoMPUlSive diSoRdeR
Pft PUlMonARY fUnCtion teSt
PvC PReMAtURe ventRiCUlAR ContRACtion
Pvd PeRiPHeRAl vASCUlAR diSeASe
RA RHeUMAtoid ARtHRitiS
RbC Red blood Cell
SA SinoAtRiAl
Sle SYSteMiC lUPUS eRYtHeMAtoSUS
SoAP SUbJeCtive, obJeCtive, ASSeSSMent, PlAn
Sob SHoRtneSS of bReAtH
Sx SYMPtoMS
tiA tRAnSient iSCHeMiC AttACK
tibC totAl iRon bindinG CAPACitY
tSH tHYRoid StiMUlAtinG HoRMone
UA URinAlYSiS
URi UPPeR ReSPiRAtoRY infeCtion
US UltRASoUnd
Uti URinARY tRACt infeCtion
Appendix 6. MediCARe PReventive SeRviCeS

WHO IS COVERED
All Medicare beneficiaries whose first Part B coverage began on or after 1/1/05.
SERVICE
HCPCS/CPT CODES
ICD-9-CM CODES
FREQUENCY
Once in a lifetime benefit per beneficiary. Must be furnished no later than 12 months after the effective date of the first Medicare Part B coverage.
Initial Preventive Physical Examination (IPPE) Also known as the Welcome to Medicare Visit
G0402IPPE G0403ECG for IPPE G0404ECG tracing for IPPE G0405ECG interpret & report
No specific diagnosis code Contact the local Medicare Contractor for guidance.
importantThe screening EKG is an optional service that may be performed as a result of a referral from an IPPE Once in a lifetime for G0438. Annually for G0439.
Annual Wellness Visit (AWV). This is a new benefit beginning for dates of service on and after 1/1/11. As of 1/1/12, the AWV includes an HRA.
G0438First visit. G0439Subsequent visit.
No specific diagnosis code.
Contact the local Medicare Contractor for guidance.
All Medicare beneficiaries who are no longer within 12 months after the effective date of their first Medicare Part B coverage period and who have not received an IPPE or AWV within the past 12 months.
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
G0389Ultrasound exam AAA screen
No specific diagnosis code.
Contact the local Medicare Contractor for guidance.
Medicare beneficiaries with certain risk factors for abdominal aortic aneurysm. Important Eligible beneficiaries must receive a referral for an AAA ultrasound screening as a result of an IPPE.
Once in a lifetime benefit per eligible beneficiary.
SERVICE
All Medicare beneficiaries without apparent signs or symptoms of cardiovascular disease. 12-hour fast is required prior to testing. Medicare beneficiaries with certain risk factors for diabetes or diagnosed with pre-diabetes. Beneficiaries previously diagnosed with diabetes are not eligible for this benefit. Every 5 years
HCPCS/CPT CODES
ICD-9-CM CODES
WHO IS COVERED
FREQUENCY
Cardiovascular Disease Screenings
80061Lipid Panel 82465Cholesterol 83718Lipoprotein 84478Triglycerides
Report one or more of the following codes: V81.0, V81.1, V81.2
Diabetes Screening Tests
82947Glucose, quantitative, blood (except reagent strip)
V77.1
2 screening tests per year for beneficiaries diagnosed with pre-diabetes. 1 screening per year if previously tested, but not diagnosed with pre-diabetes, or if never tested.
82950Glucose, post-glucose dose (includes glucose)
82951Glucose Tolerance Test (GTT), three specimens (includes glucose) Medicare beneficiaries diagnosed with diabetes. Must be ordered by the physician or qualified non-physician practitioner treating the beneficiarys diabetes. Up to 10 hours of initial training within a continuous 12-month period. Subsequent years: Up to 2 hours of follow-up training each year after the initial year. 1st year: 3 hours of one-on-one counseling. Subsequent years: 2 hours.
Diabetes Self-Management Training (DSMT)
G0108DSMT, individual session, per 30 minutes.
No specific diagnosis code. Contact the local Medicare Contractor for guidance.
G0109DSMT, group session (2 or more), per 30 minutes.
Medical Nutrition Therapy (MNT)
97802, 97803, 97804, G0270, G0271. Services must be provided by a registered dietitian or nutrition professional.
No specific diagnosis code. Contact the local Medicare Contractor for guidance.
Certain Medicare beneficiaries diagnosed with diabetes, renal disease, or who have received a kidney transplant within the last three years.
Screening Pap Tests
G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 Every 24 months for all other women. All female Medicare beneficiaries.
Report one of the following codes: V76.2, V76.47, V76.49, V15.89, V72.31
All female Medicare beneficiaries.
Annually if at high-risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within past 3 years.
Screening Pelvic Exam
G0101Cervical or vaginal cancer screening; pelvic and clinical breast examination
Report one of the following codes: V76.2, V76.47, V76.49, V15.89, V72.31
Annually if at high-risk for developing cervical or vaginal cancer, or childbearing age with abnormal Pap test within past 3 years. Every 24 months for all other women.
Screening Mammography
77052, 77057, G0202
Report one of the following codes: V76.11 or V76.12
All female Medicare beneficiaries aged 35 and older.
Aged 35 through 39: One baseline. Aged 40 and older: Annually.
SERVICE
Certain Medicare beneficiaries that fall into at least one of the following categories: Women determined by their physician or qualified non-physician practitioner to be estrogen deficient and at clinical risk for osteoporosis; Individuals with vertebral abnormalities; Individuals receiving (or expecting to receive) glucocorticoid therapy for more than three months; Individuals with primary hyperparathyroidism; or Individuals being monitored to assess response to FDA-approved osteoporosis drug therapy. Every 24 months. More frequently if medically necessary.
HCPCS/CPT CODES
ICD-9-CM CODES
WHO IS COVERED
FREQUENCY
Bone Mass Measurements
76977, 77078, 77079, 77080, 77081, 77083, G0130
Use the appropriate diagnosis code. Contact the local Medicare Contractor for guidance.
Colorectal Cancer Screening
G0104Flexible Sigmoidoscopy
G0105Colonoscopy (high risk) At high risk of developing colorectal cancer.*
Use appropriate diagnosis code Contact the local Medicare Contractor for guidance
All Medicare beneficiaries aged 50 and older who are: At normal risk of developing colorectal cancer; or
G0106Barium Enema (alternative to G0104)
G0120Barium Enema (alternative to G0105) *High risk for developing colorectal cancer is defined in 42 CFR 410.37(a) (1). See http://www.gpo.gov/fdsys/pkg/ CFR-2010-title42-vol2/pdf/CFR-2010title42-vol2-sec410-37.pdf on the Internet.
G0121Colonoscopy (not high risk)
G0122Barium Enema (non-covered)
G0328Fecal Occult Blood Test (FOBT) (alternative to 82270)
82270FOBT
normal risk: Fecal Occult Blood Test (FOBT) every year; Flexible Sigmoidoscopy once every 4 years (unless a screening colonoscopy has been performed and then Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months); Screening Colonoscopy every 10 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months); and Barium Enema (as an alternative to a covered screening flexible sigmoidoscopy). High risk: FOBT every year; Flexible Sigmoidoscopy once every 4 years; Screening Colonoscopy every 2 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months); and Barium Enema (as an alternative to a covered screening colonoscopy). Annually
Prostate Cancer Screening
G0102Digital Rectal Exam (DRE)
V76.44
G0103Prostate Specific AntigenTest (PSA)
All male Medicare beneficiaries aged 50 and older (coverage begins the day after 50th birthday)
SERVICE
Medicare beneficiaries with diabetes mellitus, family history of glaucoma, African-Americans aged 50 and older, or Hispanic-Americans aged 65 and older. All Medicare beneficiaries. Annually for beneficiaries in one of the high risk groups.
HCPCS/CPT CODES
ICD-9-CM CODES
WHO IS COVERED
FREQUENCY
Glaucoma Screening
G0117By an optometrist or ophthalmologist
V80.1
G0118Under the direct supervision of an optometrist or ophthalmologist
Seasonal Influenza Virus Vaccine
90655, 90656, 90657, 90660, 90662, Q2035, Q2036, Q2037, Q2038, Q2039Influenza Virus Vaccine
Report one of the following codes: V04.81
G0008Administration All Medicare beneficiaries.
V06.6 When purpose of visit was to receive both seasonal influenza virus and pneumococcal vaccines
Once per influenza season in the fall or winter. Medicare may provide additional flu shots if medically necessary.
Pneumococcal Vaccine
90669Pneumococcal Conjugate Vaccine
Report one of the following codes: V03.82
90670Pneumococcal Conjugate Vaccine, 13 valent, for intramuscular use
90732Pneumococcal Polysaccharide Vaccine
V06.6When purpose of visit was to receive both pneumococcal and seasonal influenza virus vaccines
Once in a lifetime. Medicare may provide additional vaccinations based on risk and provided that at least 5 years have passed since receipt of a previous dose.
G0009Administration Certain Medicare beneficiaries at intermediate or high risk. Medicare beneficiaries that are currently positive for antibodies for hepatitis B are not eligible for this benefit. Scheduled dosages required.
Hepatitis B (HBV) Vaccine
90740, 90743, 90744, 90746, 90747 Hepatitis B Vaccine G0010Administration
V05.3
Counseling to Prevent Tobacco Use
This is a new benefit beginning for dates of service on and after 08/25/10
G0436Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes
Report one of the following codes: 305.1 or V15.82
G0437Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes Beneficiaries who are at increased risk for HIV infection or pregnant.**
Outpatient and hospitalized beneficiaries who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease; are competent and alert at the time that counseling is provided; and whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.
2 cessation attempts per year; Each attempt includes maximum of 4 intermediate or intensive sessions; up to 8 sessions in a 12-month period.
Human Immunodeficiency Virus (HIV) Screening
G0432Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening
Report one of the following codes: V73.89Primary
Annually for beneficiaries at increased risk. Three times per pregnancy for beneficiaries who are pregnant: a. When woman is diagnosed with pregnancy; b. During the 3rd trimester; and c. At labor, if ordered by the womans clinician.
This is a new benefit beginning for dates of service on and after 12/08/09 **Increased risk for HIV infection is defined in the National Coverage Determinations (NCD) Manual, Publication 100-03, Sections 190.14 (diagnostic) and 210.7 (screening). See http:// www.cms.gov/manuals/downloads/ncd103c1_ Part3.pdf and http://www.cms.gov/manuals/ downloads/ncd103c1_Part4.pdf on the Internet.
G0433Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening
V22.0, V22.1, V69.8, or V23.9 Secondary, as appropriate
G0435Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening
SERVICE
Medicare beneficiaries with obesity (BMI 30 kg/m2). One face-to-face visit every week for the first month; One face-to-face visit every other week for months 26; and one face-to-face visit every month for months 712 if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement during the first 6 months.
HCPCS/CPT CODES
ICD-9-CM CODES
WHO IS COVERED
FREQUENCY
Counseling for Obesity
This is a new benefit beginning for dates of service on and after 11/29/11
G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes.
Report a code from one of the following ranges:
V85.30-V85.39, V85.41-V85.45
SCAN Health Plan is a not-for-profit organization focused exclusively on helping to make life better for Medicare beneficiaries in California and Maricopa and Pima counties in Arizona. For 35 years SCAN has demonstrated a unique passion for finding innovative ways to enhance seniors ability to manage their own health and continue to control how and where they live. SCAN is committed to partnering with our physician providers in offering high-quality geriatric care to our members. A significant part of that effort is to assist our providers in the provision of accurate documentation and coding that will contribute to the quality of care and support the expected revenue from the Medicare program. To this end, we developed Accuracy in Documentation and Coding: A Guide to Risk Adjustment and the CMS-HCC Model for all the physicians and groups providing care to our members.
G5885 06/2012 2012 SCAN Health Plan. All Rights Reserved.

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Accuracy in Documentation and Coding:

A Guide to Risk Adjustment and the CMS-HCC Model 20122013 Edition

CLiniCAL PEEr PAnEL:

A Guide to Risk Adjustment and the CMS-HCC Model | 1

A Guide to Risk Adjustment and the CMS-HCC Model | 3

4 | A Guide to Risk Adjustment and the CMS-HCC Model

Chapter 1. IntRoduCtIon CMS-hCC riSk adjuStMent Capitation payMent SySteM

A Guide to Risk Adjustment and the CMS-HCC Model | 5

iCd-9 Coding SySteM

Basic Structure of an ICD-9-CM Code

ChallengeS to the phySiCian CoMMunity

general approaCh to proper Coding

8 | A Guide to Risk Adjustment and the CMS-HCC Model

Chapter 2. GeneRAl PRinCiPleS of DoCuMentAtion AnD iCD-9-CM CoDinG

10 | A Guide to Risk Adjustment and the CMS-HCC Model

a. seleCtIOn Of fIrst-lIsted COndItIOn

b. COdes frOM 001.0 thrOugh v91.99

C. aCCurate repOrtIng Of ICd-9-CM dIagnOsIs COdes

d. seleCtIOn Of COdes 001.0 thrOugh 999.9

e. COdes that desCrIbe syMptOMs and sIgns

f. enCOunters fOr CIrCuMstanCes Other than a dIsease Or Injury

g. level Of detaIl In COdIng 1. ICd-9-CM COdes wIth 3, 4, Or 5 dIgIts

2. use Of full nuMber Of dIgIts requIred fOr a COde

A Guide to Risk Adjustment and the CMS-HCC Model | 13

k. COde all dOCuMented COndItIOns that COexIst

l. patIents reCeIvIng dIagnOstIC servICes Only

M. patIents reCeIvIng therapeutIC servICes Only

n. patIents reCeIvIng preOperatIve evaluatIOns Only

14 | A Guide to Risk Adjustment and the CMS-HCC Model

p. rOutIne OutpatIent prenatal vIsIts

Iv. keys tO suCCessful dOCuMentatIOn and COdIng fOr MedICare patIents

A Guide to Risk Adjustment and the CMS-HCC Model | 15

16 | A Guide to Risk Adjustment and the CMS-HCC Model

Psychiatry Making the specific diagnosis is the key to appropriate documentation.

A Guide to Risk Adjustment and the CMS-HCC Model | 17

18 | A Guide to Risk Adjustment and the CMS-HCC Model

A Guide to Risk Adjustment and the CMS-HCC Model | 19

20 | A Guide to Risk Adjustment and the CMS-HCC Model

Chapter 3. AvoidinG ERRoRS in doCuMEntAtion

22 | A Guide to Risk Adjustment and the CMS-HCC Model

A Guide to Risk Adjustment and the CMS-HCC Model | 23

problem: using a general term to support a specific disease. example: depression

24 | A Guide to Risk Adjustment and the CMS-HCC Model

26 | A Guide to Risk Adjustment and the CMS-HCC Model

A Guide to Risk Adjustment and the CMS-HCC Model | 27

Create processes to carry out RAdV that include quality assurance.

28 | A Guide to Risk Adjustment and the CMS-HCC Model

Chapter 5. EMR WHitE PAPER: A PRiMER foR tHE PRACtiCAl-MindEd CliniCiAn

how thIs prImer works

the very, very basICs

30 | A Guide to Risk Adjustment and the CMS-HCC Model

welCome to the world oF dIgItal ClInICal reCords objeCtIves:

32 | A Guide to Risk Adjustment and the CMS-HCC Model

Is It tIme to move Into the world oF dIgItal ClInICal reCords?

why all the push For emrs now?

34 | A Guide to Risk Adjustment and the CMS-HCC Model

Chart II-1 Health Care Spending per Capita in 2004

Adjusted for Differences in Cost of Living

36 | A Guide to Risk Adjustment and the CMS-HCC Model

plannIng the FIrst small steps

readIng lIst (all avaIlable Free)

38 | A Guide to Risk Adjustment and the CMS-HCC Model

Chapter 6. DiAGnoStiC AnD CoDinG CRiteRiA of CoMMon GeRiAtRiC ConDitionS