Health Information Management

Terminology used by physicians and ICD-9-CM doesn't always match up

JustCoding News: Inpatient, October 28, 2009

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by Joel Moorhead, MD, PhD

Editor’s note: This is the second article in a two-part series. Part two discusses coding challenges associated with documentation that does not match ICD-9-CM code descriptions. Part one addressed coding from insufficient documentation.

Physicians may document appropriate terminology to describe a patient’s condition(s), however this documentation may not correspond with the language that appears in the ICD-9-CM alphabetic and tabular indices.

Physicians and ICD-9-CM use different terminology

Consider the following examples:

Weakness, paresis, and paralysis: The ICD-9-CM Manual’s Alphabetic Index does not map to a hemiparesis code when physician documentation states ‘right-sided weakness’ for a patient who has had a stroke. Your encoder may not take you to ‘hemiparesis’ either.

ICD-9-CM code 438.2X (Hemiplegia/hemiparesis) indicates paralysis of one side of the body. The listing title ‘Hemiplegia/hemiparesis’ denotes that -plegia and -paresis are equivalent terms for ICD-9-CM coding purposes. It’s likely that nearly all physicians would document the term ‘hemiparesis’ when queried to provide a medical term corresponding to ‘right-sided weakness after stroke,’ which helps coders to assign the most specific code consistent with the documented clinical information.

The Alphabetic Index entry ‘paresis’ instructs the reader to ‘See also paralysis.’ The conditions indexed under the headings ‘paresis’ and ‘paralysis’ are notably different from the conditions indexed under the heading ‘weakness.’

The presence of a medical condition affecting the nervous system or muscle function may indicate that the patient’s condition is more consistent with the Dorland’s Medical Dictionary definition of ‘paresis’ (i.e., slight or incomplete paralysis) than with the less specific term ‘weakness.’ If so, query the physician to assign the most specific code.

Inflammatory bowel disease: Physicians commonly document ‘inflammatory bowel disease,’ but this often creates a coding dilemma.

When the condition is a non-specific, acute, or self-limited colitis, it’s reasonable to report a code from category 558, such as code 558.9 (Other and unspecified noninfectious gastroenteritis and colitis).

When the condition is a chronic intestinal inflammation requiring ongoing management, it may be more accurate to report a code from category 555 (Regional enteritis) or category 556 (Ulcerative colitis). In practice, physicians commonly use the term ‘inflammatory bowel disease’ to refer to Crohn’s disease, ulcerative colitis, and other serious chronic intestinal disorders—but not to refer to nonspecific colitis or gastroenteritis.

Documentation of the following medications, which physicians may prescribe for Crohn’s disease or ulcerative colitis, may indicate ongoing clinical management:

  • Mesalamine (Asacol®, Pentasa®)
  • Olsazine (Dipentum®)
  • Sulfasalazine (Azulfadine®)
  • Azathioprine (Imuran®)
  • 6-mercaptopurine (Purinethol®)
  • Cyclosporine A (Sandimmune®, Neoral®)
  • Methotrexate (Folex®, Rheumatrex®)
  • Corticosteroids, e.g. Prednisolone (Prednisone®)
  • Infliximab (Remicade®)
  • Budesonide (Entocort EC®)

These medications are not commonly prescribed for nonspecific gastroenteritis and colitis.
A query that notes documentation of inflammatory bowel disease and medications such as Asacol or other medication above might ask the physician to clarify whether Asacol is being prescribed for inflammatory bowel disease. The query might then ask for the specific type(s) of inflammatory bowel disease being treated, if known.

A query worded in this way is consistent with the American Health Information Management Association (AHIMA) practice brief titled, “Managing an Effective Query Process,” which states that coders may initiate queries “when there is clinical evidence for a higher degree of specificity or severity.”

Note: To view the AHIMA practice brief, click here. Then click on “All current practice briefs in chronological order by publication date” and scroll down to the brief.

Physicians may not document association between multiple conditions

Conditions present during the admission may be well-documented, but the physician may fail to document the significant connection between them. Consider the following examples.

Example one: An 85-year-old man with osteoporosis and a history of vertebral compression fractures falls off the commode and breaks his humerus. Was the fracture purely traumatic or due to a combination of minor trauma to bone weakened by osteoporosis?

A principal diagnosis of code 733.11 (Pathologic fracture of humerus) may be the most accurate code, and may result in a different DRG assignment than that which would result from reporting code 812.20 (Closed fracture of unspecified part of humerus) as the principal diagnosis.

Example two: A patient with a neurogenic bladder is admitted from a nursing home with a urinary tract infection (UTI). The pre-admission records and the emergency department records include documentation of a chronic indwelling Foley catheter.

A query to the physician may establish a causal relationship between the chronic indwelling Foley catheter and the patient’s UTI, resulting in principal diagnosis code 996.64 (Infection and inflammatory reaction due to indwelling urinary catheter).

A patient’s height and weight may be significant factors

Sometimes a patent’s height and/or weight can affect code assignment, and subsequently the DRG assignment. Note the following tips:

  • Check the height and weight to determine whether the patient’s body mass index (BMI) is greater than 40 (code V85.4) or less than 19 (code V85.0), both of which could affect the patient’s DRG assignment.
  • When the patient is underweight, look for documentation or clinical indicators of malnutrition (e.g., low albumin levels, cachexia, and emaciation).
  • Check newborns’ charts to determine whether the infants have a greater than 10% weight loss during the birth admission, which may have required monitoring, treatment, or follow-up after discharge.
  • Check the medical record for documentation of morbid obesity, risk factors, or other indications that the patient’s body habitus was clinically significant or affected patient care.

Remember that dieticians may document the BMI, but the physician must be the one to document the clinical significance of the patient’s height and weight.

Also, consider the following potential factors that could affect code assignment:

  • Post-operative complications: Could a medical condition such as pneumonia or congestive heart failure be considered a postoperative complication for a patient who has recently undergone surgery?
  • Conditions that are treated but not documented: The physician’s orders document an order for Nystatin® swish and swallow. Does the patient have undocumented oral thrush? 

Appropriate queries to obtain documentation of conditions for which clinical indicators are present can help coders to identify all significant conditions for the admission. Consistent querying can also gently remind physicians that coders need complete and accurate medical record documentation so they can continue to do the excellent work for which they are recognized throughout the hospital.

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, MD. E-mail him at

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