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General Coding Guidelines

S#

Diagnosis

ICD 9 CM Codes

Bilateral Pneumonia

J18.8

Tubercular pleurisy

A15.6

Tubercular pleurisy confirmed by microscopy

A15.6

Tubercular pleurisy confirmed by Histological


examination

A15.6

Abdominal pain

R10.9

Abdominal pain right upper quadrant

R10.11

Upper Abdominal pain

R10.10

Kidney stone

N20.0

Gallbladder stone

K80.20

10

Screening for cancer

Z12.9

11

Screening for lung cancer

Z12.2

12

History of cancer

Z85.9

13

History of lung cancer

Z85.118

14

Observation of a MVC patient

Z04.1, V89.9XXA

15

Brain Neoplasm

D49.6

16

Acute bronchitis

J20.9

17

COPD

J44.9

18

COPD with acute exacerbation

J44.1

19

Female patient with infertility of anterior pituitary origin

E23.0

20

Anemia of prematurity

P61.2

21

Left upper limb monoplegia due to old stroke

I69.334

22

Aphasia due to previous CVA

I69.320

23

Knee pain due to healed distal femur fracture

M25.569,S72.409S

24

Dermatitis due to healed third degree burnof


abdomen

L30.9,T21.32XS

25

Stroke(CVA)

I63.9

26

History of stroke

Z86.73

27

Impending stroke (headache)

R51

28

Impending labor 40 weeks(Pelvic pain)

O47.1

29

Threatened MI (Chest pain)

I20.0

30

Impending gastritis ( Epigastric pain)

R10.13

31

Pressure ulcer of upper back(Stage 3 as per nurse


note)

L89.103

32

BMI 70 (obesity as per nurse note)

33

ARF in a patient with Chronic Renal Failure

34

Bleeding esophageal varices in liver cirhossis

35

Cholilithiasis with choledocholithiasis with acute


cholecystitis and obstruction.

36

Hip joint pain and swelling

37

Arm pain

38

Upper arm pain and Swelling

Z68.45
N17.9, N18.9
K74.60, I85.11
K80.63
M25.559,M25.459
M79.603
M79.629,M79.89

39

Hand pain

40

Hand joint pain

41

Wrist pain

42

Knee pain

43

Foot pain

44

Ankle pain

45

Back pain

46

Mid-back pain

47

Low-back pain

48

Cervical pain radiating to right upper extremity

49

Low-back pain radiating to right lower extremity

50

Sciatica

51

Substernal chest pain

52

Female pelvic pain

53

Male pelvic pain

54

Pelvic joint pain due to osteoarthritis

M79.643
M79.643
M25.539
M25.569
M79.673
M25.579
M54.9
M54.6
M54.5
M54.12
M54.16
M54.30
R07.2
R10.2
R10.2
M16.10, M25.559

Infection Coding ICD 9 CM


S#

Diagnosis

ICD 9 CM Code

Meningitis

G03.9

Meningitis due to echo virus

A87.0

Meningitus due to Hanta virus

Meningitis due to actinomycosis

A42.81

Urinary Tract Infection (UTI)

N39.0

UTI due to GONOCCOCAL infection ()

UTI due to hanta virus

Viral arthritis.

Shoulder joint arthritis due to viral infection

GO3.9, A98.5

N39.0, A54.00
N39.0,A98.5
B34.9,M01.X0

B34.9,M01.X19

10

Pulmonary tuberculosis confirmed histologically

A15.0

11

Nodular pulmonary tuberculosis confirmed by


bacteriological culture.

A15.0

12

Malarial fever with hepatitis

13

HIV infection

Z21

14

HIV positive with symptoms

B20

15

Screening for HIV infection

Z11.4

16

Inconclusive HIV serology

R75

17

HIV test negative

B15.9, B54

Z71.7

18

HIV patient with HIV related illness six months


back and currently the patient has no
symptoms.

B20

HIV patient encountered for abdominal pain and


ultrasound images confirmed appendicitis.
Appendectomy will be performed next week.
Currently patient is discharged with medications.

B20,K37

20

A patient admitted for appendectomy today for


the treatment of her appendicitis. Patient is HIV
positive

K37,B20

21

AIDS patient admitted today for the treatment of


radial shaft fracture by closed reduction method.

22

AIDS

23

AIDS patient admitted for the treatment of


atypical chest pain and abdominal swelling.

B20, R07.89, R19.00

24

HIV positive patient admitted today for the


treatment of radial shaft fracture by closed
reduction method.

S52.309A,Z21

25

HIV patient 12 weeks pregnant

O98.711, Z21

26

AIDS patient is now 22 weeks pregnant

O98.712,B20

27

Septicemia

A41.9

28

Sepsis

A41.9

29

Severe sepsis

A41.9,R65.20

30

Septic shock

A41.9,R65.21

31

SIRS due to anthrax induced septicemia

A22.7

32

Actinomycotic sepsis

A42.7

33

Sepsis due to MRSA with ARF

19

S52.309A,B20
B20

A41.02,R65.20,N17.9

34

Anerobic gram negative sepsis with SIRS

A41.4

35

Severe sepsis due to MSSA with acute


respiratory failure

36

Septic shock due to Pneumococcal septicemia


with ARF

A40.3,R65.21,N17.9

37

Septic shock with ARF

A41.9,R65.21,N17.9

38

SIRS due toActinomycoticsepticemia with ARF

39

Systemic Inflammatory Response Syndrome

40

Open femoral fracture with SIRS

41

Open femoral fracture

42

SIRS due to pancreatitis

43

SIRS due to severe third degree burn of chest


wall. ARF due to the SIRS.

44

Pneumococcal septicemia in a 20 weeks


pregnant patient

O98.812,A40.3

45

Pneumococcal Sepsis in a 20 weeks pregnant


patient

O98.812, A40.3

46

Pneumococcal sepsis with ARF in a 20 weeks


pregnant patient.

O98.812, A40.3,R65.20, N17.9

47

Pneumococcal induced septic shock in a 20


weeks pregnant patient with ARF

O98.812, A40.3,R65.21, N17.9

48

Endometritis and cervicitis due to gonococcal


infection.

A54.24,A54.03

49

Acute endomyometritis

N71.0

50

Chagas disease.

B57.2

A41.01,R65.20,N17.9

A42.7, R65.20, N17.9


R65.10
S72.90XB,R65.10
S72.90XB
K85.9,R65.10

Trauma Coding

T21.31XA,R65.11,N17.9

(Poisoning, Fracture, Lacerations, Injury and Observation Coding)


S#

Diagnosis

ICD 9 CM Codes

Weakness due to prescribed valium.

R53.1,T42.4X5A

GI hemorrhage due to accidental consumption


of lead paint by a 2 years old child.

T56.0X1A, K92.2

Severe nausea and vomiting due to intoxication


of prescribed antibiotics taken improperly

T36.94XA, R11.2
T58.02XA, R06.02, R07.9

Shortness of breath and chest pain due to CO


gas from exhaust gas of motor pump (suicidal
act)

Altered mental status due to drug interaction


between prescribed diazepam and 6 packs of
grain alcohol beverage (beer) which was
consumed by the patient on his birthday party.

Headache due to hypersensitivity of prescribed


barbiturate.

G44.40,T42.3X5A

Urticaria due to application of lubricating oil

T52.0X4A, L50.6

Unconcious patients blood test report


confirmed overdose of heroin.

T40.1X4A,R40.20

Open femoral fracture

S72.90XB

10

Compound fracture of distal end of radius and


ulna.

S52.509B,S52.609B

11

Compound fracture of distal end of radius and


shaft ulna

S52.509B,S52.209B

12

2-6 right ribs fracture

S22.41XA

13

Open fracture of 6th left rib

14

C1-C2 fracture (C1 Atlas, C2 Axis)

S12.000A,S12.100A

15

L1- L2 Fracture

S32.019A,S32.029A

T42.4X4A,T51.0X2A,R41.82

S22.32XB

16

Pathological fracture of L2 L3

M84.48XA

17

Pathological fracture of femoral shaft

M84.453A

18

Nontraumatic fracture of humeral neck

M84.429A

19

Infected fracture of proximal end of tibia and


fibula.

S82.109B,S82.839B

20

Open fracture of distal phalanx of right hand.

S62.669A

21

Ethmoid bone fracture with immediate loss of


consciousness.

SO2.19XA, S06.9X9A

22

Compound temporal bone fracture with


subdural hemorrhage and concussion

S02.19XB,S06.5X9A

23

Infected frontal bone fracture without loss of


consciousness

S02.0XXB, S06.9X0A

24

Parietal bone fracture with subarachnoid


hemorrhage

S02.0XXA,S06.6X9A

25

Nasal sinus fracture with 40 minutes loss of


consciousness.

S02.19XA, S06.9X2A

26

C3 fracture with complete transection of spinal


cord.

S12.200A,S14.113A

27

Open trimalleolar fracture

S82.853B

28

Colles fracture

S52.539A

29

Infected wound of right upperarm

S41.101A

30

Stab wound (LACERATION)of abdominal wall

S31.119A

31

Complicated wound of nasal septum

S01.20XA

32

Laceration of foot with tendon involvement

S96.929A

33

Delayed healing of index finger nail laceration

S61.318D

34

Laceration of chest wall withf glass pieces.

S21.92XA

35

Brain laceration with loss of consciousness for


30 hours.

S06.2X5A

36

Brain stem injury with LOC

S06.389A

37

Nontraumaticmetrorhexis

N85.8

38

Traumatic rupture of gallbladder

S36.128A

39

Anterior dislocation of shoulder (humerus)

S43,016A

40

Open inferior dislocation of shoulder


(humerus)

S43.036A

41

Congenital dislocation of spine

Q76.49

42

Head injury of a car driver due to MVC collision


with pedal cycle

S09.90XA, V41.5XXA

43

Passenger of a car injured in MVC with car

T14.90, V43.62XA

44

Left arm pain and swelling without any


apparent injury or fracture in a patient involved
in MVC on highway

M79.602, M79.89, V89.9XXA,


Y92.411

45

A victim of MVA observed and physician found


no injury or symptoms.

Z04.1, V89.2XXA

46

Knee pain and swelling due to fall from bed in


home.

M25.569, M25.469, W06.XXXA,


Y92.009

47

Hand pain due to injury

S69.90XA, M79.643

48

Lowerarm pain and injury

S59.91XA, M79.639

49

Middle Back pain

M54.6

50

Upper back pain (neck) radiating to right upper


extremity.

M54.12

Burns Coding

S#

Diagnosis

ICD 9 CM Codes
T30.0

Burns

10% of 2nd degree burn, 20% of 3rd


degree burn, 10% of 1st degree.

T31.42

20% of 2nd degree burn, 20% of 1st


degree burn.

T31.40

Third degree burn of abdomen

10% of Third degree burn of chest wall,


7% of 2nd degree burn of face

T21.31XA,T20.20XA,T31.10
T22.311A,T21.22XA,T31.21

7% of 2nd degree burn of abdominal


wall, 11 % of 3rd degree burn of right
forearm.8 % of 1st degree burn of right
lower arm.

T21.32XA,T20.36XA,T24.211A,T23.112A
, T31.31

11% of 2nd degree burn in right anterior


thigh, 3% of erythema in left hand
thumb, 7% of full thickness burn in
cheek and 11% of 3rd degree burn in
groin area.

T23.242A, T22.132A, T31.0

4% of blisters in left index finger and


thumb, 7% of first degree burn in left
upperarm.

T23.331A, T31.0

2% of 2nd degree burn and 3% of 3rd


degree burn in right hand index and
middle finger

10

Esophagus burn

T28.1XXA

11

11% of third degree burn in abdominal


wall.

T21.32XA,T31.0

12

Esophagus burn due accidental ingestion


of cleaning fluid

T65.891A ,T28.1XXA

13

Non- Healing 3rd degree burn of left


lowerarm

T22.312D

T21.32XA

14

Multiple site burn of upper extremity

T22.099A

15

2nd degree burn of chest wall due to


restaurant building fire

T21.21XA,X00.0XXA, Y92.511

Pregnancy and Delivery Coding ICD 9 CM


S#

Diagnosis

ICD 9 CM Code

A 22 weeks pregnant patient encountered


for general check up.

A 22 weeks primigravida pregnant patient


encountered for general check up.

A 36 year old with 22 weeks pregnant


patient encountered for general check up.

O09.522

A 22 weeks pregnant patient encountered


for general check up. She had an
spontaneous abortion last year

O09.892

A 22 weeks twin pregnancy patient


encountered for general check up.

O30.002

Hyperemesis gravidrum in a 12 weeks


pregnant patient.

O21.0

Hyperemesis gravidrum in a 28 weeks


pregnant patient.

O21.2

Single intra-uterine pregnancy with breech


presentation with 36 weeks gestation.

O32.1XX0

Placenta previa in a patient with 32 weeks


gestation with single intra-uterine
pregnancy.

O44.03

Z3A.22
Z3A
.22

10

A 22 weeks pregnant patient with preeclampsia

O14.92FFF

11

A single intrauterine gestation of 34 weeks


diagnosed with small for dates fetus.

O36.5930

12

A 28 weeks pregnant patient diagnosed with


Kidney stones.

O26.833,N20.0

13

Pancreatitis in a patient with 30 weeks


pregnancy.

O99.613, K85.9

14

Pregnancy induced weight gain

15

Abdominal pain induced by pregnancy in a


20 week pregnant patient.

16

A single liveborn by vaginal delivery with


cephalic presentation in 40 weeks with
episiotomy.

17

A single liveborn by vaginal delivery with


cephalic presentation in 40 weeks with
episiotomy

O26.00
O26.892,R10.9

O80,Z37.0

O66.5,Z37.0

(Forcep Delivery)
18

A single liveborn by vaginal delivery with


cephalic presentation in 40 weeks with stage
2 perineal laceration.

19

A single liveborn by vaginal delivery with


breech presentation in 40 weeks

O32.1XX0,Z37.0

20

A single liveborn by vaginal delivery with


breech presentation converted to cephalic
presentation in 40 weeks

O32.1XX0,Z37.0

21

A single live born by vaginal delivery with


cephalic presentation in 36 weeks.

O60.14X0, Z37.0

22

A single liveborn by vaginal delivery with


cephalic presentation in 41 weeks

O48.0,Z37.0

23

A single liveborn by vaginal delivery with


cephalic presentation in 43 weeks

O48.1,Z37.0

24

Dehiscence of cesarean section wound


requiring readmission a week after delivery
of a single liveborn.

25

Maternal hypotension syndrome, onset 10


mins after delivery of a single live born

O70.1,Z37.0

O90.0
O26.53,Z37.0

(39WEEKS)

26

The patient delivered a single liveborn


outside the hospital and was brought to
hospital for immediate postpartum care

Z39.0

27

6 weeks postpartum check up

Z39.2

Swordfish123
Neoplasm Coding
S#

Diagnosis

ICD 9 CM Codes

Neoplasm.

D49.9

Benign Neoplasm.

D36.9

Carcinoma in situ of vocal cord.

D02.0

Benign Neoplasm of adrenal gland.

D35.00

Lung neoplasm.

D49.1

Adrenal adenoma.

D35.00

Pituitary adenoma.

D35.2

Brain Tumor.

D49.6

Lung cancer.

C34.90

Adenocarcinoma of prostate.

C61

9
10

11

Chondroblastoma of fibula.

D16.20

12

Malignant chondroblastoma of tibia.

C40.20

13

Chordoma of vertebra

C41.2

14

Chondroma of ribs.

D16.7

15

Chondroma of nose.

D14.0

16

Liver carcinoma.

C22.7

17

Adenocarcinoma in situ of cervix.

D06.9

18

Erythroplasia of buttock.

D04.5

19

Adenocarcinoma of prostate metastasis to testis.

C61,C79.82

Duodenal cancer metastasis from gallbladder.

C78.4, Z85.09

20

Cholecystectomy performed last year without any


recurrence at the primary site

21

Secondary lung cancer.

C78.00

22

Metastatic duodenal cancer.

C78.4, C80.1

23

Cancer.

C80.1

24

Adenocarcinoma of prostate metastasis to testis,


Patient encounter for treatment of testicular cancer.

C79.82, C61

25

Anemia due lung cancer.

C34.90, D63.0

26

Anemia due lung cancer. Patient encountered today


for IV blood transfusion as per the schedule.

C34.90 ,D63.0

27

Dehydration due to lung cancer.

C34.90,E86.0

28

Dehydration due to lung cancer. Patient admitted for


IV rehydration.

E86.0, C34.90

Anemia due to chemotherapy given two days ago as


a treatment for breast cancer. Today patient admitted

D64.81,C50.919

29

for IV blood transfusion.


D64.81, C50.919, D63.0

30

A breast cancer patient developed anemia due to


cancer. Anemia further got worsened by the
chemotherapy given last week. Today both the
anemias were treated by IV blood transfusion.

Z51.11,C79.82, C61

31

Adenocarcinoma of prostate metastasis to testis,


Patients todays encounter is for treatment of
testicular cancer by chemotherapy.

32

Patient admitted today for radiation therapy of lung


cancer.

Z51.0,C34.90

33

Patient admitted today for radiation therapy and


chemotherapy of breast cancer

Z51.0,Z51.11,C50.919
C34.90, Z90.2

34

Lung cancer patient admitted today for


pneumonectomy. Operation successful and patient is
stable.

C34.90, Z90.2, Z51.11

35

Lung cancer patient admitted today for


pneumonectomy. Operation successful and patient is
stable.Chemotherapy was administered two hours
after the surgery.

L76.22, C34.90, Z90.2

36

Lung cancer patient admitted today for


pneumonectomy. Patient developed postoperative
bleedingat the surgery site(SKIN).
Patient admitted today for chemotherapy of lung
cancer. Patient developed uncontrolled nausea and
vomiting post chemotherapy.

Z51.11,R11.2,C34.90

37

38

Lung cancer patient admitted today for


pneumonectomy. Operation successful and patient is
stable.Chemotherapy was administered two hours
after the surgery. Patient developed uncontrolled
nausea and vomiting post chemotherapy.

39

Transplanted kidney cancer

40

Carcinoma in situ of Transplanted kidney

R11.2,C34.90 ,Z51.11

T86.19,C80.2,C64.9
T86.19,C80.2,D09.19

41

Patient admitted for treatment of gastritis due to lung


cancer.

K29.70, C34.90

Diabetes Coding
1

Diabetes mellitus

E11.9

Uncontrolled Diabetes

E11.65

NIDDM under control

E11.9

Uncontrolled type 2 diabetes

E11.65

Type 1 (Juvenile type) diabetes mellitus

E10.9

Out of control IDDM

E10.65

Diabetic ketoacidosis due to type 1 diabetes mellitus

E10.10

Diabetic mild non proliferative retinopathy

E11.329

Diabetic mild non proliferative retinopathy with


Diabetic macular edema.

E11.321

10

Diabetic macular edema due to type 1 DM

E10.311

11

Diabetic polyneuropathy and diabetic peripheral


angiopathy.

E11.42,E11.51

12

Diabetic skin ulcer in foot.

E11.621

13.

Diabetic mild non proliferative retinopathy. Patient is


on insulin for past 4 months

E11.329,Z79.4

14

Type 1 (Juvenile type) diabetic nephropathy patient


on insulin for past 4 months

E10.21

15

Type 1 (Juvenile type) diabetic CKD 3.

E10.22,N18.3

16

Diabetic skin ulcer in foot. Patients insulin level


dropped due to insulin pump malfunction.

T85.694A,E11.621, T38.3X6A

17

Diabetic ketoacidosis due to type 1 diabetes mellitus.


Overdose of insulin due to insulin pump malfunction

T85.694A,E10.10, T38.3X1A

18

Type 1 (Juvenile type) diabetic is on insulin pump


currently.

E10.9,Z96.41

19

Hypoinsulinemia post pancreatectomy performed 2


days ago.

E89.1,E13.9,Z90.410

20

Nephropathy due to secondary diabetes.

E13.21

21

Gestational Diabetes in a 30 week pregnant patient

O24.419

22

Type 1 (Juvenile type) diabetic patient is now 30


weeks pregnant

O24.013,E10.9

Hypertension Coding ICD 9 CM

S#

Diagnosis

ICD 9 CM Code

Hypertension

I10

Benign Hypertension

I10

Malignant Hypertension

I10

Accelerated Hypertension

I10

Hypertensive cardiomegaly

CHF due to benign hypertension

CHF and systolic heart failure due to accelerated


hypertension.

Hypertension and CHF

Hypertensive CKD

I12.9,N18.9

CKD 2 due to hypertension

I12.9,N18.2

10

I11.9
I11.0,I50.9
I11.0,I50.20
I50.9,I10

11

Hypertensive CKD-5

I12.0,N18.5

12

Hypertension, CKD

I12.9,N18.9

13

Hypertensive cardiomegaly and hypertensive


CKD

14

CHF and CKD-4 both due to hypertension

15

CKD-5 and cardiomegaly both due to


hypertension

16

CHF and ESRD both due to hypertension

I13.2,I50.9,N18.6

17

CHF, Hypertensive CKD

I50.9,I12.9,N18.9

18

CKD, Hypertensive CHF

19

CKD, CHF, HTN

20

Hypertensive retinopathy

H35.039,I10

21

Retinopathy due to benign hypertension

H35.039, I10

22

Hypertensive CVA

23

Hypertensive CVA and CKD

24

Hypertension due to brain tumor

D49.6,115.8

25

Hypertension due to kidney stone

N20.0,115.1

26

Hypertension due to renal artery stenosis

I70.1,115.0

27

Venous Hypertension due to DVT

28

Transcient hypertension

R03.0

29

Gestational Hypertension in a 20 weeks

O13.2

I13.10,N18.9
I13.0,I50.9,N18.4
I13.11,N18.5

I13.0, I50.9, N18.9


I50.9,I12.9,N18.9

I63.9,I10
I63.9,I12.9,N18.9

I87.009

pregnant.
30

Hypertension patient is now 30 weeks pregnant.

O10.913

31

Elevated BP

R03.0

32

Myocardial infarction

I21.3

33

ST Myocardial infarction of inferolateral wall


confirmed today

I21.19

34

STEMI Myocardial infarction of inferolateral wall


confirmed today

121.19

35

Myocardial infarction of inferolateral wall patient


readmitted 3 weeks after the initial treatment.

I21.19

36

NSTEMI of lateral wall confirmed today

I21.4

37

Subendocardial MI

I21.4

38

Subendocardial MI of inferolateral wall confirmed


three weeks back.

I21.4

39

Nontransmural MI of inferolateral wall confirmed


three weeks back.

I21.4

40

STEMI of inferolateral wall was converted to


NSTEMI by thrombolytic therapy.

41

A Patient who had MI of inferolateral wall


returned after 10 weeks for routine checkup

42

Stroke

43

Vertebral artery stenosis with cerebral infarction

I63.219

44

Bilateral Vertebral artery stenosis with cerebral


infarction

I63.211, I63.212

45

Carotid and Vertebral artery stenosis with


cerebral infarction

I63.239, I63.219

121.19

I25.2

I63.9

46

Carotid and Vertebral artery stenosis

I65.29, I65.09

47

Postoperative stroke

I97.811

48

History of stroke

Z86.73

49

Aphasia due to old stroke

I69.320

50

Impending stroke(HEADACHE)

R51

Z Codes

476.

Encounter for ear piercing -

Z41.3

477.

Hepatitis B carrier -

Z22.51

478.

History of carcinoma of the breast -

479.

History of colonic polyps - Z86.010

480.

Family history of ovarian cancer - Z80.41

481.

Well-baby visit 2 month child -

482.

Incidental pregnancy -

483.

Liveborn male twins, delivered by cesarean section and both the babies are fine

Z85.3

Z00.129

Z33.1

Z38.31
484.

Encounter for amniocentesis for screening for chromosomal anomalies Z13.79

485.

Visit to lactation Clinic -

486.

Kidney transplant status without complications - Z94.0

487.

Cardiac pacemaker is functioning well without any complications -

488.

Encounter for reprogramming of AICD - Z45.02

Z39.1

Z95.0

489.

Aftercare for pathological fracture of L4 vertebra -

490.

Admission for change of tracheostomy tube and stoma revision -

491.

Admission for planned colostomy closure -

492.

Admission for chemotherapy -

Z51.11

493.

Admission to donate kidney -

Z52.4

494.

Observation of child post MVA with no apparent injury and


no complaints -

M84.48XD

Z43.3

Z04.1, V89.2XXA

495.

Encounter for screening Mammogram -

Z12.31

496.

Rubella screening

497.

Six week postpartum check up

498.

Patient is HIV positive with no symptoms

499.

Screening for osteoporosis

Z13.820

500.

Vaccination for MMR

Z23

Z11.59
Z39.2
Z21

Z43.0