2008/7/1 1

:

:970624

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ICD-9-CM

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ICD-9-CM

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-1

(International Classification of Disease , Ninth Revision , Clinical Modification , ICD-9-CM).

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-2

ICD-9-CMTabular List of Diseases and Injuries

()Alphabetic Index of Diseases

()Tabular List of Procedure &Alphabetic

Index of Procedures()

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-3

:(tabular list of disease)

1.17(001-999)

2.10,0003.

(1).V code(V01-V82):

(2). E800-E999:

(a)

(b)

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-4

4.:

A:

B:

C:ICD-9-CM

D:

E:

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-5

:

(Alphabetic index to diseases)

1.:

(1)delivery ,pregnancy,puerperal

(2)complication

(3)late effect

(4)(V code)admission ,examination

history ,observation ,problem (of)

status ,vaccination

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-6

2.:

(1).

(2).

(3).

(4).

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-7

:

1.

:bone graft

(1)

2.16

(1).1-15

(2).16

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-8

.:( ):,

;

:gastroenteritis (acute)(chronic)(hemorrhagic) 558.9

:

:36.1 Bypass anastomosis for heart revascularization

code also cardiopulmomnary bypass extracorporeal circulationheart-lung machine

39.61

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-9

:,,

:diabetes,diabetic

with nephropathy 250.4 583.81

::,,

:487.0 with pneumonia

influenzal :

bronchopneumonia

pneumonia

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-10

}:,()

:529.0 glossitis

abscess

ulceration(traumatic) of tongue

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-11

.

1.NEC(Not Elsewhere Classifable):,,

: diseaselung NEC 518.89

2.NOS(Not Otherwise Specified)=unspecified:,

,

:511.9 unspecified pleural effusion(pleural effusion NOS)

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-12

.

1.include()::555 regional enteritis

include : Crohns diseasegranulomatous enteritis

2.exclude()::555 regional enteritis

include : Crohns diseasegranulomatous enteritis

exclude :ulcerative colitis(556)

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-13

3.use additional code():,

:599.0 urinary tract infection,sit not specified

use additional code,if desired ,to identify organism ,such as Escherichia coli

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-14

4.code also underlying disease():,,

:590.81 pyelitis or pyelonephritisin disease classified elsewhere

code also underlying disease ,as:

tuberculosis (016.0)

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-15

5.code also():,

(1)

45.6 Other excision of small intestine Code also any synchronous (anastomosis other than end -to -end (45.90-45.93 45.95)colostomy(46.10-46.13)enterostomy(46.10-46.39)

(2)

:39.27 anastomosis for renal dialysis

code also any renal dialysis(39.95)

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-16

6.omit code ():,,,.

:01.2 craniotomy and craniectomyexcludes :decompression of skull fracture (02.2)

exploration of orbit (01.61-01.69)that as operative approach omit code

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-17

7.if desired ():

: duodenal ulcer (532.90)use additional E code ,if desired ,to identify drug if drug induced

8.see ():

: hemarthrosistraumatic see sprain ,by site

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-18

9.see also() :

: laceration of hand laceration see also wound ,open ,by site

10.see category ():excision

bone for graft see category 77.7

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-19

And :or :38.5xligation and /or stripping of varicose vein

Due to():,

: lumber spinal stenosis(724.02) due to HIVD (722.10)HIVD 722.10,Due to(724.02+722.10)

(Q&A00031)

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-20

With():with ,with mentionof ,associated of ,in ,,,

:DM with nephropathy in CRF250.40+585

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-1

.:,:

531.90

(001-999) (.0 .9)

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-2

:

.8,,,0-7

.9,

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-3

.:,:

51.23

(01-99) (.0 .9)

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-1

.

1.:2.:

3.:,,

4.:biopsy or lysis

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-2

5.:

6.:,

7.,:,,

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-3

8.:,

9.:

10.:,,

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-4

.:

:

1.acute myocardial infarction,anterior wall(2) (1) (3)

2.Parkinsonism disease(1)(2) (1)

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-5

: Asthma ()Pneumonia ()Cataract ()Appendicitis (

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-6

Diseases ()Injury ()Infection ()Carcinoma ()Fracture ()

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-7DiseaseSyndromeOperation: Coopers Diseases

Reyes SyndromeHartmann Operation

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-8

(site) (stage) (etiology)(type)

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-9

a.

: Pneumonia 486Aspiration pneumonia 507.0Pneumococcal pneumonia 481gouty eczema 274.89

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-10

b.

: eczema (acute)(allergic) 692.9

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-11

.,

:

face lipomyxoma(1)--- see lipoma by site

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-12

.,,

:

left upper quadrant abdominal pain(2) (1)-----789.0(x)

789.02(o)

.,

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-1

sputum culture

Tuberculosis,.4

sputum culture

Tuberculosis,.4

011.94011.94

011.9pulmonary tuberculosis

Use additional digits

011.9pulmonary tuberculosis

Use additional digits

Tuberculosislung see Tuberculosis,Pulmonary 011.9x

Tuberculosislung see Tuberculosis,Pulmonary 011.9x

Tuberculosis of lung (by sputum

culture)

Tuberculosis of lung (by sputum

culture)

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-2

Acute and chronic condiction,

Acute and chronic pancreatitis577.0 + 577.1

:Acute and chronic cervicitis:616.0

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Combination code()a single code use to classify two diagnoses or a diagnosis with an associated secondary process(manifestation) or an associated complication is called a combination code:403.91 hypertension with renal failurediabetic nephrothy 250.4x+518.81

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-4

(Multiple codes)

Due toWithIncidental toSecondary to

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-51:

:

Diabetes with foot gangrene () 250.7x785.4

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2. Use additional code :

693.0 Dermatitis due to drug and medicines use additional E code to identify drug

(E-code)

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uncertain diagnosis :If the diagnosis documented at the time of discharge is qualified as probable, suspected, likely,

questionable,possible,or still to be ruled out, code the condition as if it existed or was stablished .()

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-8

Rule out Ruled outRule out ,,Ruled out

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-9

::Rule out angiodysplasia of the colon : 569.84

::Chest pain,acute myocardial infarction

Ruled out:786.50

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-10

Impending or threatened conditionif the subterms are list ,assign the given code .if the subterms ate not listed,code the existing forerunner conditons and not condition described as impending or threatened Impending Threatened, Impending Threatened

:pneumonia with impending respiratory failurepneumonia 486

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-11

(Late effect )

1.(residual condition )(nature of the late effect )

2. ( The cause of the late effect )

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-12

:

:Traumatic arthritis right ankle following fracture right ankle

716.17 + 905.4+E-codearthritistraumatic716.17

Late effectfractureextremitylower905.4

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-13

: Cerebrovascular accident two years ago with residual hemiplegia of the dominant side()

: 438.21hemiplegiadue to cerebrovascularlesion later effect affectingdominant side438.21

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,-1

.

.:

:

partial small intestine resection (3) (2) (1)-----45.62

with transverse colostomy

(1)-----46.10

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,-2

.

:

exploratory laparotomy with cholecystectomy(1) (1)

54.11(x) 51.22(o)

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,-3

:includes ,excludes, code also

: partial small intestine resection

(3) (2) (1)-----45.62with small to large intestine anastomosis

(3) (2) (1)----45.93

45.62

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,-4

65.6X(Bilateral salpingo-oophorectomy )

81.5x(joint replacement of lower extremity )

:left and right total hip replacement()

: 81.5181.51

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,-5

:: Esophagogastroduodenoscopy: 45.13(other endoscopy of small

intestine)

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,-6(operative approach )

Exploratory laparotomy ()(Omit code)

:Exploratory laparotomy with Splenectomy ,

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,-7(biopsy)

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,-8(incision) open procedure)V64.4 Laparoscopic surgical procedure converted to open procedure (

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,-9

Cholecystectomyopen following attempt by laparoscopy failure 51.22 + V64.4conversion()laparoscopic surgery procedure to open procedureV64.4

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,-10(biopsy)

(close biopsy)(needle) (brush) (aspiration)endoscopy)

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,-11

open biopsy)a. (incision)

b. need biopsy

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,-12

::Total cholecystectomy with needle

biopsy of pancreas : 51.22+52.11

: : Exploratory laparotomy with needle

biopsy of liver:54.11+50.11

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,-13

a.

b.

c.

d. V64.3

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,-14

Carcinoma in situ of breast Surgery canceled / other reason233.0 + V64.3Procedure (surgical) not done because of specified reasonV64.3

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-1

:,()

:,GU(), pneumonia()

:GU

:pneumonia

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-2,,

:

suspect acute choledocholithiasis (acute alcoholic hepatitis ,

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-3

1.,

: acute and chronic pancreatitis,acute pancreatitis

2.,

:appendicitisOP,OPwound infection , wound infection

: appendicitis

: wound infection

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-4

3.,,

:renal stone(),ureterstone(),ESWL()

: renal stone()

4.,

,

:diabetes with nephropathy

250.4x[583.81]:diabetes 250.4x

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-5

5.,()

::

(1)liver rupture

(2)laceration of hand

: liver rupture

:3rd degree burn of foot 2nd degree

burn of low leg

: :3rd degree burn of foot

6.,

:gastritis due to aspirin

:gastritis 535.4x

2008/7/1 73

-6

7.,

:coma due to accidental ingestion of four valium tablets

:valium poisoning 969.4

8.late effect residual

(1)residual condition late effect

(2)late effect E code

:complete quadriplegia due to C4-spine Fr 2yr ago

:quadriplegia 344.01

2008/7/1 74

-7

9.V30-V39:term birth ,living female right facial

nerve palsy due to difficult delivery withuse of high forceps :V30.00

10.,,

:fever R/O pul tuberculosis: pul tuberculosis

2008/7/1 75

-8

11.,

: inguinal hernia s/p wound infection: wound infection

12.,.

:fatigue(780.09) ,depressive reaction(300.4) orhypothyroidism(244.9)

:780.09+300.4+244.9:780.09

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-9

13.,,

:inguinal hernia ,OPWBC ,with fever,hold OP

inguinal hernia

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-10

14.,V code: admission for sterilization:schizophrenia :V25.2

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-11

15.,,640-648(),,

:DM,

:DM with pregnancy 32weeks

:648.03

:250.00

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-12

16.

:gastric ca,subtotal gastrectomy

: gastric ca(151.9)

17.,,

:gastric ca,subtotal gastrectomy

chemotherapy

: gastric ca(151.9)

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-13

18.,,,

:gastric ca s/p wound dehiscence

: wound dehiscence(998.3)

19.,V58.1()or

V58.0()

:lung ca ,admission for chemotherapy

: admission for chemotherapy (V58.1)

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-14

20.,,,,V58.1 or V58.0

:lung ca ,admission for chemotherapy

:(1)lung ca

(2)nausea & vomiting

: admission for chemotherapy (V58.1)

:lung ca(162.9)

: nausea & vomiting (787.01)

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-15

21.,,

:cons disturbance,lung ca , cons disturbance brain meta .

:lung ca with brain meta

: brain meta (198.3)

: lung ca (162.9)

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-16

22.E code():

,,(800-999)

23.M code():

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-17

24:(780-799)R/OR/O

:Anemia R/O UGI BLEEDING R/O Epistaxis?

:Anemia

: UGI BLEEDING , Epistaxis

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-1

():

,,,

1.

2.,

(1)hypertension

(2)DM

(3)COPD

(4)SLE

(5)parkinsons disease

.

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-2

Conditions that are an integral part of a disease process:SARS fever,fever

Abnormal findingsAbnormal findings(laboratory,x-ray,pathologic,and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance

2008/7/1 87

-3

,

:

CVA(cerebrovascular accident),coma ,hemiparesis(),,hemiparesis,comahemiparesisCVACVA

2008/7/1 88

:

(1)

(2)

(3),

,

(4),

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-1

,

::gastric cancer

: panendoscopy stomach with biopsyradical gastrectomy

radical gastrectomy

2008/7/1 90

-2

,

::femoral neck fracture

:leiomyoma , uteri

: open reduction with internal fixation of femoral

total abdominal hysterectomy

:open reduction with internal fixation of femoral

2008/7/1 91

-3

,,

::sigmoid cancer

:(1)sigmoid biopsy

(2)sigmoid excision

: sigmoid excision

2008/7/1 92

-4

,,

::renal stone

:femoral hernia

(1)IVP(intravenous pyelogram)

(2)repair of femoral hernia

: repair of femoral hernia

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-5

,,

::pneumonia

:acute appendicitis

:appendectomy

:appendectomy

2008/7/1 94

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-1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-18-19-20-1-2-3-1-2-3-4-5-6-7-8-9-10-11-12-1-2-3-4-5-6-7-8-9-10-11-12-13,-1,-2,-3,-4,-5,-6,-7,-8,-9,-10,-11,-12,-13,-14-1-2-3-4-5-6-7-8-9-10-11-12-13-14-15-16-17-1-2-3-1-2-3-4-5