Note: ICD has transitioned to ICD-10-CM. However, the ICD-9-CM coding principles addressed in this module also generally apply to ICD-10-CM coding.
This module is the second in a series of reimbursement-related topics.
In Module One we introduced the concept of the two major recognized health care code sets—the Current Procedural Terminology (or CPT) codes and the International Classification of Diseases, 9th Revision, Clinical Modification (or ICD-9-CM). CPT codes are created and maintained by the American Medical Association and comprise Level I of the Healthcare Common Procedural Coding System (or HCPCS). Diagnostic codes are found in ICD-9-CM. They are coordinated and maintained by the National Center for Health Statistics of the Centers for Disease Control and Prevention. This module will focus on the ICD-9-CM.
The ICD-9-CM is a recognized code set under the Health Insurance Portability and Accountability Act (HIPAA). It assigns diagnostic codes to diseases and disorders. The current ICD used in the United States, the ICD-9, is based on a version that was first discussed in 1975. The United States adapted the ICD-9 as the ICD-9-Clinical Modification or ICD-9-CM. The ICD-9-CM contains more than 15,000 codes for diseases and disorders.
The ICD-9-CM is used by government agencies. The Centers for Medicare and Medicaid Services (or CMS) use ICD-9-CM codes as the centerpiece of the diagnosis-related groups (or DRG) system for the hospital inpatient prospective payment system.
Not only does CMS use the ICD-9-CM codes for its DRG system but it also coordinates and maintains the procedures section, or Volume 3, of the ICD-9-CM, which is used only for inpatient hospital procedures. The diagnoses, or Volumes 1 and 2, are coordinated and maintained by the NCHS. Both of these HHS agencies are responsible for overseeing the revisions and maintenance of the U.S. version of the international classification.
The ICD-9-CM manual is comprised of Volume 1, a list of diseases and injuries, and Volume 2, an alphabetic index of the diseases, conditions, and diagnostic terms. The manual also includes V-codes and E-codes. The use of these alpha-numeric codes will depend on your work setting.
ICD-9-CM provides codes to deal with encounters for circumstances other than a disease or injury. The Supplementary Classification of factors Influencing Health Status and Contact with Health Services (V01.0- V89) is provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.
Audiologists and speech-language pathologists may encounter patients with ICD-9-CM V- or E-codes when a specific factor causes or may be the cause of the speech, language, swallowing, hearing or balance disorder.
Diagnosis and procedure codes are to be used at their highest number of digits available. ICD-9-CM diagnosis codes are composed of codes with 3, 4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail. A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth-digit sub-classifications are provided, they must be assigned. A code is invalid if it has not been coded to the full number of digits required for that code. In other words, use the most specific code possible and carry the code to the 5th digit when possible. Codes have subclassifications. For example, 787.20 is dysphagia, not otherwise specified; however, dysphagia codes 787.21 thru 787.24 are subclassifications of dysphagia and are more specific.
In this example of coding specificity, you can see that the three digit code is for the general 389 hearing loss. A fourth digit brings specificity to the site of hearing loss whether it be conductive, sensorineural, mixed, and so on.
This level of specificity was added in 2008, so the site of hearing loss can be indicated regarding its laterality. This level of specificity is required for reporting a hearing loss diagnosis by audiologists.
Avoid NOS and NEC classifications when possible. NOS, or Not Otherwise Specified, is the equivalent of unspecified. Codes titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code. NEC, or Not Elsewhere Classifiable, represents "other specified". When a specific code is not available for a condition, the tabular list includes an NEC entry under a code to identify the code as the "other specified" code. Codes titled "other" or "other specified" are for use when the information in the medical record provides detail for which a specific code does not exist. Index entries with NEC in the line designate "other" codes in the tabular. These index entries represent specific disease entities for which no specific code exists so the term is included within an "other" code.
When billing, first list the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.
Here is an example of primary and secondary ICD-9-CM codes with a patient who has hoarseness due to a benign vocal cord lesion. The primary ICD-9-CM code is 784.42 to denote dysphonia, hoarseness and the secondary code is 212.1 denoting the cause of the hoarseness as a benign neoplasm of the larynx.
There are situations when a patient is referred to you and the results of your testing are normal. You should code the signs or symptoms that led to the referral and explain your normal findings in the report. Here are two examples of conditions that could prompt a referral to you for further assessment—dysphonia and hoarseness and a unilateral conductive hearing loss.
Patients will sometimes ask you to use a specific code that is covered by their insurance company instead of the most appropriate ICD-9-CM code. This is unacceptable and constitutes fraud, which is punishable by law. This is an example of something that can occur on first review by the health plan or when the clinician's records are audited by the third party payer. You should ensure that the disease or disorder code is consistent with the treatment code. For example, you would use 784.42 for hoarseness and the CPT code 92507.
These examples of inaccurate coding and billing occurred because the wrong primary ICD-9-CM code was used. Perhaps a patient was admitted for incontinence and at the same time also had a co-existing speech or language problem. Remember, if your procedure code (CPT) does not coordinate with your diagnostic code (ICD-9), your claim will likely be denied. If the claim is accepted, it can be uncovered as not medically necessary during an audit.
You must always use the most accurate ICD-9-CM code or codes. Do not misrepresent the service that was provided in order to receive reimbursement or for your patient's convenience! This may be considered fraud.
You should know the basic differences between the diagnostic coding system and the procedural coding systems. The ICD-9-CM codes are for the disorder or disorders you are treating while the CPT codes are for reporting the procedure or procedures you performed. The ICD-9-CM is coordinated and maintained by the federal government while the AMA maintains and updates the CPT codes. Both code sets are required by the Health Insurance Portability and Accountability Act known as HIPAA.
The rest of the world except for Italy and the U.S. have used ICD-10 for more than 10 years. The U.S. Department of Health and Human Services has set a deadline of October 1, 2015, as the compliance date for implementation of the ICD-10-CM. Remember that the ICD-9-CM has approximately 14,000 codes while the ICD-10-CM has approximately 68,000 codes.
The ICD-10-CM will allow for considerably more specificity with more characters for each diagnosis or disorder, thus eliminating considerable error in coding. For example, improvements in the ICD-10-CM will allow for coding laterality of hearing disorders.
The ICD-10-CM will also assist in the prevention and detection of health care fraud and abuse, allow for the measurement of quality and effectiveness, monitor resource use, improve systems for payment and claims processing and accommodate current, complex, and future health care needs.
Here is an example of speech-language pathology ICD coding differences in dysphagia. In this case, the descriptors are the same but the codes themselves are quite different with the ICD-10-CM having alphanumeric coding. Coding for oral phase dysphagia will go to R1311 from 787.21.
This slide illustrates the increased complexity and specificity of codes in the ICD-10-CM manual. For example in the current ICD-9-CM manual, there is only one benign vocal pathology listed under "Other diseases of vocal cords" and it is listed as "nodules." In ICD-10-CM, nodules of the vocal cords has its own individual code and 5 other possible benign vocal lesions are listed under "other diseases of vocal cords."
Here is an audiology example that illustrates the specificity of sensorineural hearing loss in the ICD-10-CM compared to the ICD-9-CM. Laterality was recently introduced in the ICD-9-CM for hearing loss but is inherent in the ICD-10-CM.
You can find more information on ICD-9-CM and ICD-10-CM at the websites listed here:
At this time please proceed to Module Three, which covers documentation of speech-language pathology services, or Module Four, which covers documentation of audiology services.