FY10 ICD-9-CM Diagnosis Code Updates

FY10 ICD-9-CM
Diagnosis Code Updates
Audio Seminar/Webinar
September 10, 2009
Practical Tools for Seminar Learning
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AHIMA 2009 Audio Seminar Series • http://campus.ahima.org/audio i

American Health Information Management Association • 233 N. Michigan Ave., 21st Floor, Chicago, Illinois
Faculty
Lizabeth Fisher, RHIA
Lizabeth Fisher is a medical systems specialist at the National Center for Health
Statistics (NCHS), Centers for Disease Control and Prevention (CDC) in Hyattsville,
MD. NCHS is responsible for maintenance of Volumes 1 and 2 of ICD-9-CM as well
as development and preparation for implementation of ICD-10-CM. Ms. Fisher has
over 25 years experience in the HIM field.
AHIMA 2009 Audio Seminar Series ii

Table of Contents
Disclaimer ..................................................................................................................... i
Faculty ......................................................................................................................... ii
Objectives ..................................................................................................................... 1
ICD-9-CM Maintenance Cycle .......................................................................................... 1
The International Classification of Diseases – 9th Revision illustration .................................. 2
Highlights of October 1, 2009 (FY10) ICD-9-CM Diagnosis Code Changes
Highlights of Diagnosis Changes ...................................................................................... 3
Additional Changes......................................................................................................... 3
Influenza Due to Certain Indentified Influenza Viruses....................................................... 4
Influenza Due to Certain Indentified Influenza Viruses Category 488 – Tabular Changes ...... 4
Chapter 2 – Neoplasms ................................................................................................... 5
Chapter 3 – Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders ......... 6-7
Chapter 4 – Diseases of the Blood and Blood-forming Organs ............................................ 7
Case Study .................................................................................................................... 8
Chapter 6 – Neurology.................................................................................................... 8
Chapter 6 – Neurology (Eye and Adnexa) ......................................................................... 9
Chapter 7 – Diseases of the Circulatory System ............................................................9-10
Case Study ...................................................................................................................11
Chapter 9 – Digestive System.........................................................................................11
Chapter 10 – Diseases of the Genitourinary System..........................................................12
Chapter 11 – Pregnancy, Childbirth, and the Puerperium ............................................. 12-13
Chapter 14 – Certain Conditions Originating in the Perinatal Period............................... 13-15
Chapter 16 – Signs and Symptoms ............................................................................ 15-16
Chapter 17 – Injury and Poisoning ............................................................................. 16-18
Case Study .............................................................................................................. 18-19
Chapter 17 – Injury and Poisoning ..................................................................................19
Supplementary Classification of Factors ...........................................................................20
Case Study ...................................................................................................................20
E Codes and the Federal Register ...................................................................................21
Supplementary Classification of External Causes of Injury and Poisoning (E Codes).............21
E Codes – New in 2009 ..................................................................................................22
Index Change to Note ...................................................................................................23
Resource/Reference List ........................................................................................... 23-24
Audio Seminar Discussion ..............................................................................................24

Become an AHIMA Member Today! .................................................................................25
Audio Seminar Information Online ..................................................................................25
Upcoming Audio Seminars ............................................................................................26
Thank You/Evaluation Form and CE Certificate (Web Address) ..........................................26
Appendix ..................................................................................................................27
Resource/Reference List .......................................................................................28
(CONTINUED)
AHIMA 2009 Audio Seminar Series
Table of Contents
Revised Diagnosis Code Titles
New Diagnosis Codes
Invalid Diagnosis Codes
CE Certificate Instructions
AHIMA 2009 Audio Seminar Series

FY10 ICD-9-CM Diagnosis Code Updates Notes/Comments/Questions
Goals
Review ICD-9-CM maintenance process

Highlight October 1, 2009 diagnosis
code changes including rationale for
changes
Review appropriate clinical
documentation to use the code changes
Illustrate code updates through case
scenarios
Provide further resources
1
ICD-9-CM Maintenance Cycle
ICD-9-CM Coordination and Maintenance

Committee
• Joint chair by NCHS and CMS
• Open public meetings twice per year
• Proposals and summaries posted online
Public comment period following meetings
Changes published in Federal Register
• Proposed Rule – April 30, 2009
• Final Rule – August 27, 2009
Complete addenda posted – see references
at end
2
AHIMA 2009 Audio Seminar Series 1

Highlights of
October 1, 2009 (FY10)
ICD-9-CM
Diagnosis Code Changes

Highlights of Diagnosis Changes
Effective October 1, 2009

143 new diagnosis and V-codes
23 invalid codes
• Invalid codes are not “deleted” but “expanded”
• Important if you maintain a superbill
45 revised code titles
140 New external cause of injury codes
(E codes)
• New E-codes for activity status at time of injury
• New E-codes for wrong patient/wrong site
5
Additional Changes
Index changes - ~ 1800

• New codes indexed
• Existing index entries revised
• Requests to add or revise existing entries
• Additions/revisions to Table of Drugs and
Chemicals
Review all addenda documents
• Other than in “your clinical chapter”
• Conversion table if you do studies
• Guidelines updated
6

Influenza Due to Certain

Identified Influenza Viruses
Influenza due to H1N1 influenza virus
(swine flu)
http://www.cdc.gov/h1n1flu
Influenza due to identified avian influenza

virus (bird flu)
CDC influenza website: http://www.cdc.gov/flu/avian/
Code only confirmed cases based on the provider’s
diagnostic statement of the patient having the
specific type of influenza
If “suspected”, “possible” or “probable” is used with
this diagnosis then a code from category 488
should NOT be assigned
7
Influenza Due to Certain

Identified Influenza Viruses
Category 488 – Tabular changes
488 Influenza Due to Certain Identified Influenza
Viruses
Excludes: influenza caused by unspecified influenza
viruses (487.0-487.8)
488.0 Influenza due to identified avian influenza virus
Avian influenza
Bird flu
Influenza A/H5N1
488.1 Influenza due to identified novel H1N1 influenza
virus
2009 H1N1 [swine] influenza virus
Novel 2009 influenza H1N1
Novel H1N1 influenza
Novel influenza A/H1N1
Swine flu
8

Chapter 2 – Neoplasms
Merkel Cell Carcinoma

Aggressive neuroendocrine skin cancer;
rising incidence
About 1500 new cases per year
33% disease specific mortality higher
than melanoma
Most common sites affected have unique
codes
Face, scalp/neck, limbs, trunk areas with
sun exposure
9
Chapter 2 – Neoplasms
Secondary neuroendocrine tumors

Continuation of neuroendocrine tumor codes
implementation last year
• 209.7x Secondary neuroendocrine
tumors
Also V code for personal history of
neuroendocrine tumors
• V10.91 Personal history of malignant
neuroendocrine tumor
10

Chapter 3 – Endocrine, Nutritional and

Metabolic Diseases, and Immunity
Disorders
274.0x Gouty arthropathy
Urate (uric acid) crystals deposit in joints
and soft tissues
Inflammation and degenerative changes
4 progressive stages of gout:
Asymptomatic urate deposition or
accumulation
Acute gout
Intercritical gout
Chronic tophaceous gout
11

Disorders
274.0x Gouty arthropathy
First changes to the category 274 in 30 years
Codes created to recognize acute vs. chronic
Chronic codes are split between with and
without tophi
274.00 Gouty arthropathy, unspecified
274.01 Acute gouty arthropathy
274.02 Chronic gouty arthropathy without
mention of tophus (tophi)
274.03 Chronic gouty arthropathy with tophus
(tophi)
12


Disorders
Tumor lysis syndrome
Serious/life-threatening complication of cancer
therapy
Metabolic complications that can occur after
treatment of cancer
Complications caused by breakdown products of
dying cancer cells
Pretreatment spontaneous tumor lysis syndrome is
different
Previous coding advice – use code 584.8, with E-
code for adverse effect of chemotherapy
New code 277.88 Tumor lysis syndrome
13
Chapter 4 – Diseases of the Blood

and Blood-forming Organs
285.3 Antineoplastic chemotherapy induced
anemia
Chemotherapy induced anemia – one of most
common side effects (20%-60% patients)
Rarely a hemolytic process and is not usually an
aplastic process
Patients usually have fatigue and inability to
perform everyday activities
Different than 285.22, Anemia in neoplastic disease
Both 285.3 and 285.22 can be used on one
admission/encounter
14

Case Study
Q: A patient presents to the oncologist for follow- up care and
the diagnosis listed is anemia of chemotherapy. What code
do you assign and what is the principal diagnosis, the anemia
code or the code for the malignancy?
A: Use code 285.3, Antineoplastic chemotherapy induced
anemia.
Additional, secondary code(s) would also be assigned for the
malignancy.
ICD-9-CM Official Guidelines for Coding and Reporting,
revised and effective October 1, 2009, I.C.2.c.2 Anemia
associated with chemotherapy, immunotherapy and radiation
therapy:
“When the admission/encounter is for management of an
anemia associated with chemotherapy, immunotherapy or
radiotherapy and the only treatment is for the anemia, the
anemia is sequenced first. The appropriate neoplasm code
should be assigned as an additional code.” 15
Chapter 6 – Neurology
Temporal Sclerosis 348.81

Localization related epilepsy can be an
acquired condition
Largest number of focal seizures arise from
temporal lobes
Often due to structural change in brain such as:
• Tumors, vascular malformations, developmental
malformations, scarring
• Structures in this region prone to traumatic or
hypoxic injury resulting in sclerosis
• Most common is mesial temporal sclerosis
• Often, surgical removal reduces or eliminates
seizures
16

Chapter 6 – Neurology
(Eye and Adnexa)
Chemical conjunctivitis
Can result when a substance enters the eye
Differentiating this type of “pink eye” from
“serous”
Common cause is that due to chlorine in pool
New code 372.06, Acute chemical conjunctivitis
• Not the same as burn due to chemicals
• Use category 940, Burn confined to eye and
adnexa
17
Chapter 7 – Diseases of the

Circulatory System
Changes related to venous embolism and
thrombosis
Increased use of PICC lines, central catheters,
tunnel dialysis catheters and wired cardiac devices
Deep vein thrombosis of major veins in thorax and
upper extremities more common
Chronic pulmonary embolism – in patients receiving
anticoagulation treatment but no longer in initial
episode
Patients with these conditions often require
subsequent hospital admission for:
• Extension of the initial thrombosis
• Anticoagulant related bleeding
18


Circulatory System
Goals of new codes:
Create codes for venous thrombosis of vessels
in thorax, neck and upper extremities
Create codes for superficial thromboses of
lower extremities similar to those for deep
vessels of lower extremity
Track patients with acute or chronic DVT or
chronic pulmonary embolism
• Receiving anticoagulation treatment
• No longer in initial care
Need to track patients
• High risk for recurrence of thrombosis or embolism
• Especially 1-3 months after initial diagnosis
19

Circulatory System
Many changes and new codes to review and
be aware of in category 453:
453.4 Acute venous embolism and thrombosis of
deep vessels of lower extremity
453.5 Chronic venous embolism and thrombosis
of deep vessels of lower extremity
453.6 Venous embolism and thrombosis of
superficial vessels of lower extremity
453.7 Chronic venous embolism and thrombosis
of other specified vessels
453.8 Acute venous embolism and thrombosis of
other specified veins 20

Case Study
Q: A patient is admitted with deep vein thrombosis

following a 15 hour flight. What code do you
assign for this?
A: DVT, or deep vein thrombosis is indexed to
default to code 453.40, Acute venous embolism
and thrombosis of unspecified deep vessels of
lower extremity. If the physician does not state
acute or chronic for this condition the default is to
this acute code.
You can also assign code V58.61, Long-term
(current) use of anticoagulants if the patient is
prescribed this medication to prevent future
occurrence of this condition.
21
Chapter 9 – Digestive System

569.71 Pouchitis
Internal ileoanal pouch created following
proctocolectomy
Proctocolectomy often treatment of ulcerative
colitis or familial adenomatous polyposis
Pouch means patient does not need
permanent ileostomy, and can have preserved
continence
Pouchitis (inflammation) common
complication
Usually be treated successfully with
antibiotics
Cause of pouchitis is not well understood 22


Genitourinary System
Benign endometrial hyperplasia (621.34) and
Endometrial intraepithelial neoplasia [EIN] (621.35)
Both endometrial hormonal responses and
localized premalignant lesions have been lumped
to “endometrial hyperplasia”
No uniform meaning to modifiers mild, moderate,
severe, and atypical
Pathologists and gynecologists increasingly
distinguishing
• Benign hormonal effects of unopposed estrogens
(benign hyperplasia)
• Emergent precancerous lesions (endometrial
intraepithelial neoplasia [EIN])
Non-overlapping terminology and discrete criteria
23
Chapter 11 – Pregnancy, Childbirth,

and the Puerperium
670.0 Major puerperal infection
Needed improved specificity – contained over
100 index entries
• Needed to define deep vein thrombosis
• Needed to show pulmonary embolism in pregnancy
and postpartum
Venous thrombosis and septic pelvic
thrombophlebitis were together under 671.4x
Septic pelvic thrombophlebitis - inflammatory
condition affecting adnexa in the pelvis
• Infectious complication following delivery, especially
C-section
• New code for septic pelvic thrombophlebitis was
requested to separate from postpartum DVT
24

Chapter 11 – Pregnancy, Childbirth,

and the Puerperium
Coding changes:
671.3x Deep phlebothrombosis, antepartum
671.4x Deep phlebothrombosis, postpartum
Added: Use additional code to identify the deep
vein thrombosis (DVT) (453.40-453.42, 453.50-
453.52, 453.72-453.79, 453.82-453.89)
670 Major puerperal infection (5th digits 0, 2, 4
apply)
670.1x Puerperal endometritis
670.2x Puerperal sepsis
670.3x Puerperal septic thrombophlebitis
670.8x Other major puerperal infection
25
Chapter 14 – Certain Conditions

Originating in the Perinatal Period
Anomalies of the abdominal wall:
756.72 Omphalocele
Ventral wall defect
Intestines usually covered by
membranous sac intestine
Intestines are exposed if the sac ruptures
1-2 per 10,000 births
Frequently being associated with other
structural and chromosomal anomalies
26


Anomalies of the abdominal wall:
786.73 Gastroschisis
Congenital ventral body wall defect
Adjacent and usually to the right of the
umbilical cord insertion
Results from failure of developing
abdominal wall to close completely
Allows the extrusion of the fetal intestines
from the defect
2-5 per 10,000 births with higher incidence
in younger mothers 27

768.7 Hypoxic-ischemic encephalopathy (HIE)
This was added to ICD-9-CM on Oct 1, 2006
This condition has well defined clinical definitions
• Mild, moderate, severe
Difficult to track specific clinical conditions due to
lack of specific diagnostic terms in the
classification
Expanded 768.7 to 5th digits to show these stages
Clinical presentation and imaging findings
determines staging
28


779.3 Feeding problems in newborn
Expanded this code to 5th digits for more specificity
779.32 Bilious vomiting in newborn
Excludes: bilious vomiting in child over 28
days old (787.04)
779.33 Other vomiting in newborn
779.34 Failure to thrive in newborn
Related change:
Subcategory 787.0 Nausea and vomiting
Excludes new code 569.87 Vomiting of fecal
matter 29
Chapter 16 – Signs and Symptoms
Dysphonia (784.42)
• Dysphonia is a disorder of phonation
Hypernasality (784.43)
Hyponasality (784.44)
• Disorders of resonance
Inconclusive mammogram (793.82)
• Dense breasts – included here
30

Chapter 16 – Signs and Symptoms

799.82 Apparent life threatening event (ALTE)
NIH definition - combination of:
• Apnea (central or obstructive),
• Color change (cyanotic, pallid, erythematous or
plethoric)
• Change in muscle tone (usually diminished), and
• Choking or gagging
Cause - variety of congenital or acquired conditions
• 50% no concrete cause is determined despite
workup
Previously used terminology
• Near-miss sudden infant death syndrome (SIDS)
• Aborted crib death
Additional code(s) should be reported for
associated signs and symptoms 31
Chapter 17 – Injury and Poisoning

Traumatic Brain Injury (TBI) – tabular changes:
800-804, Fracture of Skull and
850-854, Intracranial injury, excluding those with
skull fracture
Added inclusion term for traumatic brain injury
854, Intracranial injury of other and unspecified
nature
Includes traumatic brain injury NOS
New codes –
V15.52 History of traumatic brain injury
V80.01 Screening for traumatic brain injury
32


Traumatic Brain Injury (TBI) – tabular changes:
799.2 Signs and symptoms involving emotional
state
Expanded to 5th digits for symptoms associated
with TBI
799.21 Nervousness
799.22 Irritability
799.23 Impulsiveness
799.24 Emotional lability
799.25 Demoralization and apathy
799.29 Other signs and symptoms involving
emotional state
Review exclusion terms at memory loss (780.93),
and alteration of consciousness (780.0) 33
Traumatic Brain Injury (TBI) – index changes

Injury 959.9
- brain (traumatic) NEC (see also Injury,
intracranial) 854.0
- due to fracture of skull - see Fracture, skull, by
site
-- intracranial (traumatic) 854.0
TBI (traumatic brain injury) (see also Injury,
intracranial) 854.0
- with skull fracture - see Fracture, skull, by site
Traumatic - see also condition
- brain injury (TBI) (see also Injury, intracranial)
854.0
-- with skull fracture - see Fracture, skull, by site
34

Current injury
• Use injury codes and external cause codes
Subsequent treatment following initial
injury treatment
• Code symptom codes such as nervousness
• V codes for history of TBI
• Sequelae/late effects
907.0 Late effect of intracranial injury without
mention of skull fracture
905.0 Late effect of fracture of skull and face
bones
35
Case Study
Q: Patient is admitted and final diagnosis is
traumatic brain injury due to a closed
fracture of the base of the skull from being
hit by fragments of roadside IEDs. There
was no documented loss of consciousness.
A: Assign codes:
801.41 Closed with intracranial injury of
other and unspecified nature,
with no loss of consciousness
E991.7 Injury due to fragments from
other improvised explosive device
[IED] 36

Case Study
Q: Patient is seen to be assessed for possible

TBI because of being stationed in Iraq. He
has no symptoms but documentation
indicates that the screening is mandatory,
following the end of deployment, for all
soldiers who were stationed in Iraq.
A: Assign code:
V80.01, Special screening for traumatic
brain injury
Note: If there were any symptoms
documented they should also be coded. 37
Additional changes to review in Chapter 17:

813.4x Torus fractures of radius and ulna
832.2 Nursemaid’s elbow
Expansion of codes -
969.0 Poisoning by antidepressents
969.7 Poisoning by psychostimulants
caffeine vs. amphetamines
995.24 Failed moderate sedation during
procedure
• Related to that change –
V15.80 History of failed conscious sedation
38

Supplementary Classification of Factors

Influencing Health Status and Contact
with Health Services (V Codes)
V20.3 Newborn health supervision
• Age of infant is important here now
V26.42 Encounter for fertility preservation
counseling
V26.82 Encounter for fertility preservation
procedure
• Prior to cancer therapy
V53.51 Fitting and adjustment of gastric lap
band
V60 and V61 Numerous new codes
• For family disruption and parent/child problems
V87.4x Personal history of drug therapy 39
Case Study
Q: A 10 day old baby is seen in the

pediatrician’s office for a weight check
and is noted also to have feeding
problems. What are the appropriate
diagnosis codes?
A: Assign code V20.32, Health supervision
for newborn 8 to 28 days old, for the first
listed diagnosis. Assign code 779.31,
Feeding problems in newborn, as an
additional diagnosis.
40

E Codes and the Federal Register

Frequently asked question:
Q: Why don’t new and revised E codes appear in the Federal Register
notice that has the Inpatient Prospective Payment System (IPPS)
changes with the new and revised code tables (Tables 6A-6E)?
A: Since E codes are not used in the IPPS they do not appear in this
notice. They DO always appear in the diagnosis addenda (tabular and
index changes) each year. Comments regarding these codes and all
other proposed changes to ICD-9-CM can be made during the open
comment period following an ICD-9-CM Coordination and
Maintenance Committee meeting. This year because there are
numerous changes to the E codes (including 140 new E-codes) a
separate Federal Register, under the CDC, will be published with
these changes.
You can also find these codes listed at the CMS website given as a
reference at the end of this presentation. This is another good
reason to always check the full addenda, posted on the NCHS web
site, in addition to the new and revised code lists in the Federal
Register. 41
Supplementary Classification of External

Causes of injury and Poisoning (E Codes)
Never Events
Wrong procedure/wrong patient/wrong part or side
of body
E876.5 – Performance of wrong operation
(procedure) correct patient
• Example: replaced the right hip on Mrs. Jones but she was
scheduled for a hysterectomy
E876.6 – Performance of operation (procedure) on
a patient not scheduled for surgery
• Example: replaced right hip on Mrs. Smith, but this procedure
should have been done on Mrs. Jones
E876.7 – Performance of operation (procedure) on
wrong side/body part
• Example: replaced the right hip on Mrs. Jones it but should have
been the left hip
42

E Codes – New in 2009
E000 – External cause status

Indicates status of the person at the time
the (injury) event occurred
E001-E030 – Activity
To indicate what activity the person was
doing at the time of the injury
Extensive list of categories here
• Athletics, household maintenance, hobbies, etc.
43
E Codes – New in 2009
E830-E838 Water Transport Accidents

Fourth digit .7 added for “occupant of
military watercraft”
Additions and expansion to external
cause of injury for –
Injury due to war operations
44

Index Change to Note
Epilepsy, epileptic (idiopathic) 345.9

Note: use the following fifth-digit subclassifications
with categories 345.0, 345.1, 345.4-345.9
0 without mention of intractable epilepsy
1 with intractable epilepsy
Add pharmacoresistant (pharmacologically
resistant)
Add poorly controlled
Add treatment resistant
Add refractory (medically)
45
Resources/References
ICD-9-CM Diagnosis Coding Changes
10/01/2009
NCHS Classification of Diseases and Functioning &
Disability web site includes Diagnosis (Volumes 1
&2) addenda:
http://www.cdc.gov/nchs/icd9.htm
Link to FY10 CD-ROM published by Government
Printing Office:
http://bookstore.gpo.gov/actions/GetPublication.do?stocknumber=
017-022-01611-7
ICD-9-CM Coordination and Maintenance
Committee (background about changes)
http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm
46

Resources/References
ICD-9-CM Diagnosis Coding Changes
10/01/2009
Tables 6A-6F: New/Revised/Invalid codes (CMS
web site):
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_s
ummarytables.asp
Federal Register scheduled to publish August 27,
2009, Final Rule FY 2010 Inpatient Prospective
Payment System (including new code lists and DRG
changes):
Link to rule on display as of August 4, 2009:
http://www.federalregister.gov/inspection.aspx#spec_C
47
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Appendix
Resource/Reference List .......................................................................................27

Revised Diagnosis Code Titles
New Diagnosis Codes
Invalid Diagnosis Codes
CE Certificate Instructions

Appendix
Resource/Reference List
http://www.cdc.gov/nchs/icd9.htm
http://bookstore.gpo.gov/actions/GetPublication.do?stocknumber=017-022-01611-7
http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp
http://www.federalregister.gov/inspection.aspx#spec_C

REVISED DIAGNOSIS CODE TITLES
The final addendum providing complete information on changes to the diagnosis part of ICD-9-CM
is posted on CDC’s webpage at: www.cdc.gov/nchs/icd9.htm
Diagnosis Description
Code
008.65 Enteritis due to calicivirus
041.3 Klebsiella pneumoniae
041.86 Helicobacter pylori [H. pylori]
453.2* Other venous embolism and thrombosis of inferior vena cava
453.40 Acute venous embolism and thrombosis of unspecified deep vessels of lower
extremity
453.41 Acute venous embolism and thrombosis of deep vessels of proximal lower
extremity
453.42 Acute venous embolism and thrombosis of deep vessels of distal lower extremity
572.2 Hepatic encephalopathy
584.5 Acute kidney failure with lesion of tubular necrosis
584.6 Acute kidney failure with lesion of renal cortical necrosis
584.7** Acute kidney failure with lesion of renal medullary [papillary] necrosis
584.8 Acute kidney failure with other specified pathological lesion in kidney
584.9 Acute kidney failure, unspecified
639.3 Kidney failure following abortion and ectopic and molar pregnancies
669.30 Acute kidney failure following labor and delivery, unspecified as to episode of
care or not applicable
669.32 Acute kidney failure following labor and delivery, delivered, with mention of
postpartum complication
669.34 Acute kidney failure following labor and delivery, postpartum condition or
complication
670.00 Major puerperal infection, unspecified, unspecified as to episode of care or not
applicable
670.02 Major puerperal infection, unspecified, delivered, with mention of postpartum
complication
670.04 Major puerperal infection, unspecified, postpartum condition or complication
757.6 Specified congenital anomalies of breast
772.0 Fetal blood loss affecting newborn
776.9 Unspecified hematological disorder specific to newborn
784.40 Voice and resonance disorder, unspecified
784.49 Other voice and resonance disorders
793.0 Nonspecific (abnormal) findings on radiological and other examination of skull
and head
793.1 Nonspecific (abnormal) findings on radiological and other examination of lung
field
793.2 Nonspecific (abnormal) findings on radiological and other examination of other
intrathoracic organs
793.3 Nonspecific (abnormal) findings on radiological and other examination of biliary
tract
1
REVISED DIAGNOSIS CODE TITLES
Code
793.4 Nonspecific (abnormal) findings on radiological and other examination of
gastrointestinal tract
genitourinary organs
abdominal area, including retroperitoneum
musculoskeletal system
793.89 Other (abnormal) findings on radiological examination of breast
793.99 Other nonspecific (abnormal) findings on radiological and other examination of
body structure
813.45 Torus fracture of radius (alone)
996.43 Broken prosthetic joint implant
E876.5 Performance of wrong operation (procedure) on correct patient
V15.06 Allergy to insects and arachnids
V15.84 Personal history of contact with and (suspected) exposure to asbestos
V15.85 Personal history of contact with and (suspected) exposure to potentially hazardous
body fluids
V15.86 Personal history of contact with and (suspected) exposure to lead
V57.3 Care involving speech-language therapy
V61.29 Other parent-child problems
V65.11 Pediatric pre-birth visit for expectant parent(s)
Notes:
*
This diagnosis code was discussed at the March 11-12, 2009 ICD-9-CM Coordination and
Maintenance Committee meeting and was not finalized in time to include in the proposed rule.
However, it will be implemented on October 1, 2009.
** The code title has changed from the proposed rule.
2
NEW DIAGNOSIS CODES
Code
209.31 Merkel cell carcinoma of the face
209.32 Merkel cell carcinoma of the scalp and neck
209.33 Merkel cell carcinoma of the upper limb
209.34 Merkel cell carcinoma of the lower limb
209.35 Merkel cell carcinoma of the trunk
209.36 Merkel cell carcinoma of other sites
209.70 Secondary neuroendocrine tumor, unspecified site
209.71 Secondary neuroendocrine tumor of distant lymph nodes
209.72 Secondary neuroendocrine tumor of liver
209.73 Secondary neuroendocrine tumor of bone
209.74 Secondary neuroendocrine tumor of peritoneum
209.75* Secondary Merkel cell carcinoma
209.79 Secondary neuroendocrine tumor of other sites
239.81 Neoplasms of unspecified nature, retina and choroid
239.89 Neoplasms of unspecified nature, other specified sites
274.00 Gouty arthropathy, unspecified
274.01 Acute gouty arthropathy
274.02 Chronic gouty arthropathy without mention of tophus (tophi)
274.03 Chronic gouty arthropathy with tophus (tophi)
277.88 Tumor lysis syndrome
279.41 Autoimmune lymphoproliferative syndrome
279.49 Autoimmune disease, not elsewhere classified
285.3 Antineoplastic chemotherapy induced anemia
348.81 Temporal sclerosis
348.89 Other conditions of brain
359.71 Inclusion body myositis
359.79 Other inflammatory and immune myopathies, NEC
372.06 Acute chemical conjunctivitis
416.2 Chronic pulmonary embolism
438.13 Late effects of cerebrovascular disease, dysarthria
438.14 Late effects of cerebrovascular disease, fluency disorder
453.50 Chronic venous embolism and thrombosis of unspecified deep vessels of lower
extremity
453.51 Chronic venous embolism and thrombosis of deep vessels of proximal lower
extremity
453.52 Chronic venous embolism and thrombosis of deep vessels of distal lower
extremity
453.6 Venous embolism and thrombosis of superficial vessels of lower extremity
453.71 Chronic venous embolism and thrombosis of superficial veins of upper extremity
453.72 Chronic venous embolism and thrombosis of deep veins of upper extremity
1
NEW DIAGNOSIS CODES
Code
453.73 Chronic venous embolism and thrombosis of upper extremity, unspecified
453.74** Chronic venous embolism and thrombosis of axillary veins
453.75 Chronic venous embolism and thrombosis of subclavian veins
453.76 Chronic venous embolism and thrombosis of internal jugular veins
453.77 Chronic venous embolism and thrombosis of other thoracic veins
453.79 Chronic venous embolism and thrombosis of other specified veins
453.81 Acute venous embolism and thrombosis of superficial veins of upper extremity
453.82 Acute venous embolism and thrombosis of deep veins of upper extremity
453.83 Acute venous embolism and thrombosis of upper extremity, unspecified
453.84 Acute venous embolism and thrombosis of axillary veins
453.85 Acute venous embolism and thrombosis of subclavian veins
453.86 Acute venous embolism and thrombosis of internal jugular veins
453.87 Acute venous embolism and thrombosis of other thoracic veins
453.89 Acute venous embolism and thrombosis of other specified veins
488.0*** Influenza due to identified avian influenza virus
488.1*** Influenza due to identified novel H1N1 influenza virus
569.71 Pouchitis
569.79 Other complications of intestinal pouch
569.87 Vomiting of fecal matter
621.34 Benign endometrial hyperplasia
621.35 Endometrial intraepithelial neoplasia [EIN]
670.10 Puerperal endometritis, unspecified as to episode of care or not applicable
670.12 Puerperal endometritis, delivered, with mention of postpartum complication
670.14 Puerperal endometritis, postpartum condition or complication
670.20 Puerperal sepsis, unspecified as to episode of care or not applicable
670.22 Puerperal sepsis, delivered, with mention of postpartum complication
670.24 Puerperal sepsis, postpartum condition or complication
670.30 Puerperal septic thrombophlebitis, unspecified as to episode of care or not
applicable
670.32 Puerperal septic thrombophlebitis, delivered, with mention of postpartum
complication
670.34 Puerperal septic thrombophlebitis, postpartum condition or complication
670.80 Other major puerperal infection, unspecified as to episode of care or not applicable
670.82 Other major puerperal infection, delivered, with mention of postpartum
complication
670.84 Other major puerperal infection, postpartum condition or complication
756.72 Omphalocele
756.73 Gastroschisis
768.70 Hypoxic-ischemic encephalopathy, unspecified
768.71 Mild hypoxic-ischemic encephalopathy
768.72 Moderate hypoxic-ischemic encephalopathy
768.73 Severe hypoxic-ischemic encephalopathy
2
NEW DIAGNOSIS CODES
Code
779.32 Bilious vomiting in newborn
779.33 Other vomiting in newborn
779.34 Failure to thrive in newborn
784.42 Dysphonia
784.43 Hypernasality
784.44 Hyponasality
784.51 Dysarthria
784.59 Other speech disturbance
787.04 Bilious emesis
789.7 Colic
793.82 Inconclusive mammogram
799.21 Nervousness
799.22 Irritability
799.23 Impulsiveness
799.24 Emotional lability
799.25 Demoralization and apathy
799.29 Other signs and symptoms involving emotional state
799.82 Apparent life threatening event in infant
813.46 Torus fracture of ulna (alone)
813.47 Torus fracture of radius and ulna
832.2 Nursemaid's elbow
969.00 Poisoning by antidepressant, unspecified
969.01 Poisoning by monoamine oxidase inhibitors
969.02 Poisoning by selective serotonin and norepinephrine reuptake inhibitors
969.03 Poisoning by selective serotonin reuptake inhibitors
969.04 Poisoning by tetracyclic antidepressants
969.05 Poisoning by tricyclic antidepressants
969.09 Poisoning by other antidepressants
969.70 Poisoning by psychostimulant, unspecified
969.71 Poisoning by caffeine
969.72 Poisoning by amphetamines
969.73 Poisoning by methylphenidate
969.79 Poisoning by other psychostimulants
995.24 Failed moderate sedation during procedure
E000.0 Civilian activity done for income or pay
E000.1 Military activity
E000.8 Other external cause status
E000.9 Unspecified external cause status
E001.0 Activities involving walking, marching and hiking
E001.1 Activities involving running
E002.0 Activities involving swimming
E002.1 Activities involving springboard and platform diving
E002.2 Activities involving water polo
3
NEW DIAGNOSIS CODES
Code
E002.3 Activities involving water aerobics and water exercise
E002.4 Activities involving underwater diving and snorkeling
E002.5 Activities involving rowing, canoeing, kayaking, rafting and tubing
E002.6 Activities involving water skiing and wake boarding
E002.7 Activities involving surfing, windsurfing and boogie boarding
E002.8 Activities involving water sliding
E002.9 Other activity involving water and watercraft
E003.0 Activities involving ice skating
E003.1 Activities involving ice hockey
E003.2 Activities involving snow (alpine) (downhill) skiing, snow boarding, sledding,
tobogganing and snow tubing
E003.3 Activities involving cross country skiing
E003.9 Other activity involving ice and snow
E004.0 Activities involving mountain climbing, rock climbing and wall climbing
E004.1 Activities involving rappelling
E004.2** Activities involving BASE jumping
E004.3** Activities involving bungee jumping
E004.4 Activities involving hang gliding
E004.9 Other activity involving climbing, rappelling and jumping off
E005.0 Activities involving dancing
E005.1 Activities involving yoga
E005.2 Activities involving gymnastics
E005.3 Activities involving trampoline
E005.4 Activities involving cheerleading
E005.9 Other activity involving dancing and other rhythmic movements
E006.0 Activities involving roller skating (inline) and skateboarding
E006.1 Activities involving horseback riding
E006.2 Activities involving golf
E006.3 Activities involving bowling
E006.4 Activities involving bike riding
E006.5** Activities involving jumping rope
E006.6 Activities involving non-running track and field events
E006.9 Other activity involving other sports and athletics played individually
E007.0 Activities involving american tackle football
E007.1 Activities involving american flag or touch football
E007.2 Activities involving rugby
E007.3 Activities involving baseball
E007.4 Activities involving lacrosse and field hockey
E007.5 Activities involving soccer
E007.6 Activities involving basketball
E007.7 Activities involving volleyball (beach) (court)
E007.8 Activities involving physical games generally associated with school recess,
summer camp and children
4
NEW DIAGNOSIS CODES
Code
E007.9 Other activity involving other sports and athletes played as a team or group
E008.0 Activities involving boxing
E008.1 Activities involving wrestling
E008.2 Activities involving racquet and hand sports
E008.3 Activities involving frisbee
E008.4 Activities involving martial arts
E008.9** Other specified sports and athletics activity
E009.0 Activity involving exercise machines primarily for cardiorespiratory conditioning
E009.1 Activity involving calisthenics
E009.2 Activity involving aerobic and step exercise
E009.3 Activity involving circuit training
E009.4 Activity involving obstacle course
E009.5 Activity involving grass drills
E009.9 Other activity involving cardiorespiratory exercise
E010.0 Activity involving exercise machines primarily for muscle strengthening
E010.1 Activity involving push-ups, pull-ups, sit-ups
E010.2 Activity involving free weights
E010.3 Activity involving pilates
E010.9 Other activity involving other muscle strengthening exercises
E011.0 Activities involving computer keyboarding
E011.1 Activities involving hand held interactive electronic device
E011.9 Other activity involving computer technology and electronic devices
E012.0 Activities involving knitting and crocheting
E012.1 Activities involving sewing
E012.2 Activities involving furniture building and finishing
E012.9 Activity involving other arts and handcrafts
E013.0 Activities involving personal bathing and showering
E013.1 Activities involving laundry
E013.2 Activities involving vacuuming
E013.3 Activities involving ironing
E013.4 Activities involving floor mopping and cleaning
E013.5 Activities involving residential relocation
E013.8 Other personal hygiene activity
E013.9 Other household maintenance
E014.0 Caregiving involving bathing
E014.1 Caregiving involving lifting
E014.9 Other activity involving person providing caregiving
E015.0 Activities involving food preparation and clean up
E015.1 Activities involving grilling and smoking food
E015.2 Activities involving cooking and baking
E015.9 Other activity involving cooking and grilling
E016.0 Activities involving digging, shoveling and raking
E016.1 Activities involving gardening and landscaping
5
NEW DIAGNOSIS CODES
Code
E016.2 Activities involving building and construction
E016.9 Other activity involving property and land maintenance, building and construction
E017.0 Activities involving roller coaster riding
E017.9 Other activity involving external motion
E018.0 Activities involving piano playing
E018.1 Activities involving drum and other percussion instrument playing
E018.2 Activities involving string instrument playing
E018.3 Activities involving winds and brass instrument playing
E019.0 Activities involving walking an animal
E019.1 Activities involving milking an animal
E019.2 Activities involving grooming and shearing an animal
E019.9 Other activity involving animal care
E029.0 Refereeing a sports activity
E029.1 Spectator at an event
E029.2 Rough housing and horseplay
E029.9 Other activity
E030 Unspecified activity
E830.7 Accident to watercraft causing submersion, occupant of military watercraft, any
type
E831.7 Accident to watercraft causing other injury, occupant of military watercraft, any
type
E832.7 Other accidental submersion or drowning in water transport accident, occupant of
military watercraft, any type
E833.7 Fall on stairs or ladders in water transport, occupant of military watercraft, any
type
E834.7 Other fall from one level to another in water transport, occupant of military
watercraft, any type
E835.7 Other and unspecified fall in water transport, occupant of military watercraft, any
type
E836.7 Machinery accident in water transport, occupant of military watercraft, any type
E837.7 Explosion, fire, or burning in watercraft, occupant of military watercraft, any type
E838.7 Other and unspecified water transport accident, occupant of military watercraft,
any type
E876.6 Performance of operation (procedure) on patient not scheduled for surgery
E876.7 Performance of correct operation (procedure) on wrong side/body part
E928.7 Environmental and accidental causes, mechanism or component of firearm and air
gun
E990.1 Injury due to war operations from flamethrower
E990.2 Injury due to war operations from incendiary bullet
E990.3 Injury due to war operations from fire caused indirectly from conventional weapon
E991.4 Injury due to war operations by fragments from munitions
E991.5** Injury due to war operations by fragments from person-borne improvised
explosive device [IED]
6
NEW DIAGNOSIS CODES
Code
E991.6** Injury due to war operations by fragments from vehicle-borne improvised
explosive device [IED]
E991.7** Injury due to war operations by fragments from other improvised explosive device
[IED]
E991.8 Injury due to war operations by fragments from weapons
E992.0 Injury due to torpedo
E992.1 Injury due to depth charge
E992.2 Injury due to marine mines
E992.3 Injury due to sea-based artillery shell
E992.8 Injury due to war operations by other marine weapons
E992.9 Injury due to war operations by unspecified marine weapon
E993.0 Injury due to war operations by aerial bomb
E993.1 Injury due to war operations by guided missile
E993.2 Injury due to war operations by mortar
E993.3** Injury due to war operations by person-borne improvised explosive device [IED]
E993.4** Injury due to war operations by vehicle-borne improvised explosive device [IED]
E993.5** Injury due to war operations by other improvised explosive device [IED]
E993.6 Injury due to war operations by unintentional detonation of own munitions
E993.7 Injury due to war operations by unintentional discharge of own munitions launch
device
E993.8 Injury due to war operations by other specified explosion
E993.9 Injury due to war operations by unspecified explosion
E994.0 Injury due to war operations by destruction of aircraft due to enemy fire or
explosives
E994.1 Injury due to war operations by unintentional destruction of aircraft due to own
onboard explosives
E994.2 Injury due to war operations by destruction of aircraft due to collision with other
aircraft
E994.3 Injury due to war operations by destruction of aircraft due to onboard fire
E994.8 Injury due to war operations by other destruction of aircraft
E994.9 Injury due to war operations by unspecified destruction of aircraft
E995.0 Injury due to war operations by unarmed hand-to-hand combat
E995.1 Injury due to war operations, struck by blunt object
E995.2 Injury due to war operations by piercing object
E995.3 Injury due to war operations by intentional restriction of air and airway
E995.4 Injury due to war operations by unintentional drowning due to inability to surface
or obtain air
E995.8 Injury due to war operations by other forms of conventional warfare
E995.9 Injury due to war operations by unspecified form of conventional warfare
E996.0 Injury due to war operations by direct blast effect of nuclear weapon
E996.1 Injury due to war operations by indirect blast effect of nuclear weapon
E996.2 Injury due to war operations by thermal radiation effect of nuclear weapon
E996.3** Injury due to war operations by nuclear radiation effects
7
NEW DIAGNOSIS CODES
Code
E996.8 Injury due to war operations by other effects of nuclear weapons
E996.9 Injury due to war operations by unspecified effect of nuclear weapon
E997.3** Injury due to war operations by weapon of mass destruction [WMD], unspecified
E998.0 Injury due to war operations but occurring after cessation of hostilities by
explosion of mines
E998.1 Injury due to war operations but occurring after cessation of hostilities by
explosion of bombs
E998.8 Injury due to other war operations but occurring after cessation of hostilities
E998.9 Injury due to unspecified war operations but occurring after cessation of hostilities
V10.90* Personal history of unspecified malignant neoplasm
V10.91 Personal history of malignant neuroendocrine tumor
V15.52 Personal history of traumatic brain injury
V15.80 Personal history of failed moderate sedation
V15.83 Personal history of underimmunization status
V20.31** Health supervision for newborn under 8 days old
V20.32 Health supervision for newborn 8 to 28 days old
V26.42 Encounter for fertility preservation counseling
V26.82 Encounter for fertility preservation procedure
V53.50 Fitting and adjustment of intestinal appliance and device
V53.51 Fitting and adjustment of gastric lap band
V53.59 Fitting and adjustment of other gastrointestinal appliance and device
V60.81 Foster care (status)
V60.89 Other specified housing or economic circumstances
V61.07 Family disruption due to death of family member
V61.08 Family disruption due to other extended absence of family member
V61.23 Counseling for parent-biological child problem
V61.24 Counseling for parent-adopted child problem
V61.25 Counseling for parent (guardian)-foster child problem
V61.42 Substance abuse in family
V72.60 Laboratory examination, unspecified
V72.61 Antibody response examination
V72.62 Laboratory examination ordered as part of a routine general medical examination
V72.63 Pre-procedural laboratory examination
V72.69 Other laboratory examination
V80.01 Special screening for traumatic brain injury
V80.09 Special screening for other neurological conditions
V87.32 Contact with and (suspected) exposure to algae bloom
V87.43 Personal history of estrogen therapy
V87.44 Personal history of inhaled steroid therapy
V87.45 Personal history of systemic steroid therapy
V87.46 Personal history of immunosuppressive therapy
Notes:
8
NEW DIAGNOSIS CODES
*
These diagnosis codes were discussed at the March 11-12, 2009 ICD-9-CM Coordination and
Maintenance Committee meeting and were not finalized in time to include in the proposed rule.
They will be implemented on October 1, 2009. Please note that the code title for 209.75 has
changed from the proposed rule to the final rule.
** The code title has changed from the proposed rule.
*** CDC created new flu codes to better capture H1N1 flu cases in response to the recent flu
outbreak.
9
INVALID DIAGNOSIS CODES
Code
239.8 Neoplasm of unspecified nature of other specified sites
274.0 Gouty arthropathy
279.4 Autoimmune disease, not elsewhere classified
348.8 Other conditions of brain
453.8 Other venous embolism and thrombosis of other specified veins
488*** Influenza due to identified avian influenza virus
768.7 Hypoxic-ischemic encephalopathy (HIE)
784.5 Other speech disturbance
799.2 Nervousness
969.0 Poisoning by antidepressants
969.7 Poisoning by psychostimulants
E992 Injury due to war operations by explosion of marine weapons
E993 Injury due to war operations by other explosion
E994 Injury due to war operations by destruction of aircraft
E995 Injury due to war operations by other and unspecified forms of conventional
warfare
E996 Injury due to war operations by nuclear weapons
E998 Injury due to war operations but occurring after cessation of hostilities
V10.9 Unspecified personal history of malignant neoplasm
V53.5 Fitting and adjustment of other intestinal appliance
V60.8 Other specified housing or economic circumstances
V72.6 Laboratory examination
V80.0 Special screening for neurological conditions
*** CDC created new flu codes to better capture H1N1 flu cases in response to the recent flu
outbreak. As a result, code 488 was deleted.
1
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FY10 ICD-9-CM Diagnosis Code Updates

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FY10 ICD-9-CM

Diagnosis Code Updates

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The American Health Information Management Association makes no

As a provider of continuing education the American Health Information

AHIMA 2009 Audio Seminar Series • http://campus.ahima.org/audio i

Lizabeth Fisher, RHIA

AHIMA 2009 Audio Seminar Series ii

Audio Seminar Discussion ..............................................................................................24

AHIMA 2009 Audio Seminar Series

 Review ICD-9-CM maintenance process

ICD-9-CM Maintenance Cycle

 ICD-9-CM Coordination and Maintenance

AHIMA 2009 Audio Seminar Series 1

AHIMA 2009 Audio Seminar Series 2

Highlights of Diagnosis Changes

Effective October 1, 2009

 Index changes - ~ 1800

AHIMA 2009 Audio Seminar Series 3

Influenza Due to Certain

Influenza due to identified avian influenza

Influenza Due to Certain

AHIMA 2009 Audio Seminar Series 4

Merkel Cell Carcinoma

Secondary neuroendocrine tumors

AHIMA 2009 Audio Seminar Series 5

Chapter 3 – Endocrine, Nutritional and

Chapter 3 – Endocrine, Nutritional and

AHIMA 2009 Audio Seminar Series 6

Chapter 3 – Endocrine, Nutritional and

Chapter 4 – Diseases of the Blood

AHIMA 2009 Audio Seminar Series 7

Temporal Sclerosis 348.81

AHIMA 2009 Audio Seminar Series 8

Chapter 7 – Diseases of the

AHIMA 2009 Audio Seminar Series 9

Chapter 7 – Diseases of the

Chapter 7 – Diseases of the

AHIMA 2009 Audio Seminar Series 10

Q: A patient is admitted with deep vein thrombosis

Chapter 9 – Digestive System

AHIMA 2009 Audio Seminar Series 11

Chapter 10 – Diseases of the

Chapter 11 – Pregnancy, Childbirth,

AHIMA 2009 Audio Seminar Series 12

Chapter 11 – Pregnancy, Childbirth,

Chapter 14 – Certain Conditions

AHIMA 2009 Audio Seminar Series 13

Chapter 14 – Certain Conditions

Chapter 14 – Certain Conditions

AHIMA 2009 Audio Seminar Series 14

Chapter 14 – Certain Conditions

Chapter 16 – Signs and Symptoms

AHIMA 2009 Audio Seminar Series 15

Chapter 16 – Signs and Symptoms

Chapter 17 – Injury and Poisoning

AHIMA 2009 Audio Seminar Series 16

Chapter 17 – Injury and Poisoning

Chapter 17 – Injury and Poisoning

Traumatic Brain Injury (TBI) – index changes

AHIMA 2009 Audio Seminar Series 17

Chapter 17 – Injury and Poisoning

AHIMA 2009 Audio Seminar Series 18

Q: Patient is seen to be assessed for possible

Review ICD-9-CM maintenance process

ICD-9-CM Coordination and Maintenance

Index changes - ~ 1800