Health Information Management

Understand ICD-9-CM coding for descriptive terms and nonspecific findings

JustCoding News: Inpatient, February 3, 2010

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by Joel Moorhead, MD, PhD

Sometimes it’s not easy to find a code for a condition that appears to be significant. Codes can be especially difficult to find for conditions that are not names, or that physicians describe in rather general terms.

Paging through the ICD-9-CM Manual’s Alphabetic Index, coders will find a bounty of descriptive terms that are eligible for code selection. Five columns of conditions are indexed under the term “Abnormal …” and another five columns under “Findings, abnormal.” The listings under “Deficiencies,” “Degenerations,” and “Disorders” occupy a total of 23 columns. There are 27 columns that follow “Diseases.” The ICD-9-CM Manual also indexes many more conditions under nonspecific terms, including the following:

  • Displacement
  • Deformity
  • Episode 
  • Impaired/Impairment
  • Increased
  • Injury
  • Lesion
  • Retention
  • Symptoms
  • Trouble

The output of your encoder search depends on the first term that you enter. Consider entering one of these headings as the first term in your encoder search string if your search strategy isn’t leading you to a reasonable code.

Some of the conditions that the ICD-9-CM Manual lists under these headings are CCs or MCCs, and will result in an appropriately higher severity of illness and case weight for the admission. Other conditions may be most useful as principal diagnoses, depending on the circumstances of admission. In either case, the first step to sequencing the condition is to find the listing in the ICD-9-CM Manual.

Understand how the conditions are indexed
Most conditions in the Alphabetic Index reside exactly where coders might expect to find them. However, let’s consider two exceptions.

Example 1
For a patient who has sustained major trauma, the attending physician may document “retroperitoneal bleeding” or “retroperitoneal hemorrhage.” This is a serious condition. The Alphabetic Index lists a number of conditions under “bleeding,” but retroperitoneal bleeding is not one of them. The Alphabetic Index directs “Hemorrhage, retroperitoneal” to “Hemorrhage, unspecified (code 459.0).” It may take awhile to find in the medical record, but you will almost always find that a radiologist or other physician has described such as a “hematoma.” ICD-9 classifies a traumatic retroperitoneal hematoma under “Injury, internal, retroperitoneum (code 868.04),” which is a more specific and more accurate code for the patient’s condition than “Hemorrhage, unspecified (code 459.0).”

Example 2
Patients commonly present to the hospital after an unresponsive episode. Physicians typically assign a diagnosis of “syncope” to patients who faint and “altered mental status” to patients who become confused or disoriented.

Sometimes physicians will document the unresponsive episode as the principal diagnosis, when they don’t find any underlying cause. The fact that the patient became unresponsive is often significant, but the Alphabetic Index doesn’t list an appropriate code under “Unresponsive.” Look for a code specific to this situation in the Alphabetic Index under “Episode, hyporesponsive (code 780.09).”

Descriptive terms may indicate greater severity of illness
Sometimes descriptive terms can indicate significant secondary diagnoses, even when the patient’s underlying conditions are well-documented.

Physicians may document that a patient following a significant weight loss has cachexia (code 799.4) or emaciation (code 261). In the Alphabetic Index, “Emaciation (due to malnutrition)” includes a note that directs coders to “Nutritional marasmus” (code 261). “Due to malnutrition” is in parentheses and is a nonessential modifier by ICD-9-CM coding conventions. Documentation of malnutrition is not required to assign code 261 under these circumstances.

Patients with chronic obstructive pulmonary disease often have high partial pressure of carbon dioxide levels documented on arterial blood gas testing. Physicians may document this finding as carbon dioxide retention. The Alphabetic Index lists an appropriate code for this condition under “Retention, carbon dioxide” (code 276.2).

Sometimes the underlying cause can inform the selection of secondary diagnosis codes.

Classifying physical signs according to underlying cause
ICD-9-CM presents opportunities to code some physical signs, such as edema, with a surprising degree of specificity.

The Tabular List entry “edema” (code 782.3) includes both “anasarca” and “localized edema, not otherwise specified (NOS).” The Alphabetic Index directs plain-vanilla “Edema” to listing 782.3, a chapter 16 code (Symptoms, signs, and ill-defined conditions 780–799). The Alphabetic Index lists almost two columns describing specific types of edema. When the physician documentation describes the patient’s edema more specifically, ICD-9 may list a code that expresses this higher degree of specificity.

The ICD-9 Alphabetic Index entry for “edema, nutritional (newborn)” and “anasarca, nutritional” directs coders to “other severe protein-calorie malnutrition” (code 262). Likewise, the Alphabetic Index entry for “renal edema” directs coders to code 581.9, which includes “Renal disease with edema NOS.” The Tabular Listing for code 459.3 (Chronic venous hypertension) includes the term “stasis edema,” which physicians apply occasionally to patients with peripheral vascular disease.

Rules for newborns differ slightly
The coding of descriptive terms is governed by slightly different rules when the patient is a newborn.

The ICD-9-CM Official Guidelines for Coding and Reporting (section I.C.15.a.4) state that a condition is clinically significant for a newborn when that condition “has implications for future healthcare needs.” Nonspecific findings documented during the perinatal period may have implications for future healthcare needs if the findings require monitoring during the birth admission or follow-up after the birth admission.

For example, a newborn who is Coombs-positive but who has no current signs of hemolytic disease may still require monitoring or follow-up because the blood test suggests ABO incompatibility. The addition of code 790.99 (Other nonspecific findings on examination of blood) may be appropriate to identify a Coombs-positive infant in such a case. This nonspecific finding during the perinatal period is a “single condition that requires more than one code,” according to multiple coding conventions (ICD-9-CM Official Guidelines for Coding and Reporting, section I.B.9). Because code 790.99 is a chapter 16 code and not specific to the perinatal period, the addition of chapter 15 (Other specified conditions originating in the perinatal period) code 779.89 would be necessary to identify all elements of this condition.

Physicians sometimes document in the newborn history and physical a “skin tag.” The Alphabetic Index entry “tag, skin” directs coders to “unspecified hypertrophic and atrophic conditions of skin (code 701.9)” and “tag, skin, congenital” to “other specified anomalies of skin (code 757.39).” Both codes 701.9 and 757.39 in the perinatal period require the addition of code 779.89 (other specified conditions originating in the perinatal period). The term “congenital” is not a nonessential modifier for code 757.39; physician documentation that the condition is “congenital” is required to list code 757.39 as an additional diagnosis. It may seem that a skin tag is an insignificant condition. However, a skin tag can indicate the presence of colon polyps or other congenital anomalies. Some physicians will monitor newborns with skin tags for the possible presence of other conditions.

Understand the rules to reap the rewards
Most of the cases that we see are straightforward. More complex cases take longer to code, but they are part of what makes coding such an interesting job. There is some satisfaction to be gained from chipping away at the more difficult cases until the coding of those cases meets our own standards of completeness and accuracy as well as the ICD-9 coding requirements. In-depth knowledge of descriptive terms and nonspecific findings indexed in the ICD-9-CM Manual can help coders reach a high level of accuracy for some of the most difficult cases.

Editor’s Note: Joel Moorhead MD, PhD is an adjunct Assistant Professor at the Rollins School of Public Health at Emory University in Atlanta. He is also a physician reviewer for FairCode Associates in Baltimore. E-mail him at jmoorhe@sph.emory.edu.



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