ICD CODES 1)Medical clearance (psychiatric cases) V70.

.2 2)Major depressive disorder (this code includes both acute psychosis and depress ion. When both psychosis and depression is mentioned, go for this code) 296.20 3)Cigarette smoking (non-dependent tobacco use disorder) 305.1 4)Post traumatic headache 339.20 5)Non-compliance to medication V15.81 6)Asymptomatic HIV V08 7)Seizure disorder (unspecified epilepsy without mention of intractable epilepsy ) 345.90 8)Observation for other specified conditions V71.89 9)Foley catheter complication 996.31 10)G-tube malfunctioning 536.40 11)Fluid overload (fluid retention) 276.69 12)Abnormal coagulation profile (sub-therapeutic) [SUBTHERAPEUTIC INR] (Related to blood) 790.92 13)Sub-therapeutic dilantin SUB-THERAPEUTIC LEVELS (nonspecific abnormal toxicol ogical findings; sub-therapeutic dilantin level) [SUBTHERAPEUTIC DEPAKOTE] 796.0 (QUESTIONABLE????) (Not related to blood) 14)Benign positional vertigo 386.11 15)Mechanical complication of gastrotomy tube 536.42 16)Cranial nerve palsy (unspecific paralytic strabismus) 378.50 17)Streptococcus pharyngitis 034.0 18)Angina decubitus code from 413 series 19)Myocardial infarction 410.0-410.9. The 5th digit in MI codes should always be 1 20)Pregnancy test (+ve test) V72.42 21)Right lobe infiltrate 511.9 22)Gangrene 785.4 23)When no specific complaints are there V71.89 24)NSTEMI 410.71 25)STEMI - 410.81 26)Necrosis (unspecified) - 709.8 27)Hypoxia (Hypoxemia) 799.02 28)Cardiac dysrrhythmia 427 series 29)Other specified complication, antepartam 646.83 30)Upper GI bleeding (vomiting of blood) 578.0 31)Lower GI bleeding (blood in stool) 578.1 32)Tetanus-diptheria vaccine administered V06.5 33)Tetanus-diptheria-"pertusis" vaccine administered - V06.1 34)Bloody discharge from penis (observation for other specified suspected condit ions) V71.89 35)Dysthymic disorder (use this code for depression and psychosis together and a lso for depression with anxiety together) 300.4 36)Other diseases of nasal cavity and sinuses (code for rhinorrhea, runny nose, nasal congestion, etc.) 478.19 37)Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified 403.90 38)Acute exacerbation of COPD 491.21 39)Only COPD - 496 40)Smoke inhalation / exposure 508.2 41)Cardiac valve dysfunction (mechanical complication due to heart valve prosthe sis) 996.02 42)Sneezing 784.99 43)Acute nasopharyngitis {(Common cold). When the impression is cough and cold, this code alone will not suffice. The code for cough 786.2 is also required alon g with this} - 460 44)Other acute pain 338.19

45)Other chronic pain 338.29 46)Alcoholic gastritis, without mention of hemorrhage 535.30 47)Vaginal abscess 616.10 48)Psychiatric features (psychotic disorder) 298.9 49)Screening for STD (venereal disease) V74.5 50)Need for prophylactic vaccination and inoculation against bacterial diseases - V03 series 51)Skin infection 686.9 52)Contact with or exposure to venereal disease V01.6 53)MVA follow up V71.4 54)Passed out, unconscious, etc. 780.09 55)Back spasm (other specified disorders relating to back) 724.8 56)Clostridium difficile colitis 008.45 57)Elevated CPK 790.5 58)Elevated blood pressure - 796.2 59)Confusion 293.0 60)Infected wound (other postoperative infection) 998.59 61)Other postoperative complication 998.89 62)Other syndromes affecting cervical region - 723.8 63)Premature ventricular contraction 427.69 64)Muscle spasm, muscle weakness (generalized) [use this code, when leg pain, le g swelling conditions are there] 728.87 65)Chronic obstructive asthma with acute exacerbation 493.22 66)Post LP intractable headache 349.0 67)Sinusitis (chronic or unspecified) 473.9 68)Sinusitis (acute) 461.9 69)Acute psychosis 298.1 70)Lumbar radiculopathy 724.4 71)Cervix lesion 616.89 72)Electrolyte imbalance - 276.9 73)Healing laceration V58.43 74)Anemia in neoplastic disease 285.22 75)Leg cramp 729.82 76)Pregnancy condition (the patient is pregnant) 648.93 77)Unspecified papilledema 377.00 78)Cervical radiculopathy - 723.4 79)Periorbital contusion 921.9 80)Hypertrophy of tonsils 474.11 81)Hypertrophy of adenoids 474.12 82)BPH (Benign Prostatic Hypertrophy) 600.00 83)ESRD (End Stage Renal Disease) 585.6 84)Combination code for ESRD with hypertension (this code is also used with chro nic renal failure, check this chart - M742063, A/C # 716233, David Carpenter) 40 3.91 (USE THIS CODE FIRST AND THEN THE ESRD CODE) 85)Tenysynovitis, synovitis of shoulder 726.10 86)Other drug allergy 995.27 87)Acute renal insufficiency 593.9 88)Acute renal failure 584. series 89)Chronic renal failure 585 series 90)Unspecified renal failure 586 series 91)Itching (pruritis) 698.9 92)Pedal edema 782.3 93)Cardiac edema - 782.3 94)Alcohol intoxication (heavy mentioned in Social History) 303.90 95)"Acute" alcohol intoxication - 303.00 96)Alcohol intoxication - 305.00 97)Pelvic inflammatory disease (PID) 614.9 98)Marijuana abuse 305.20 99)Burning sensation in urine, dysuria, painful urination and strangury (DO NOT CONFUSE WITH URINARY FREQUENCY, IT HAS A DIFFERENT CODE) 788.1

100)Abnormal laboratory values 796.4 101)Tonsillar exudate, tonsillar swelling 474.8 102)Lymphadenopathy (eg. Salivary gland swelling) 785.6 103)Subdural hematoma (non-traumatic) 432.1 104)Skin lesion (dermatosis) 709.9 105)Penis swelling or edema of penis 607.83 106)Facial or lip swelling 784.2 107)Superficial thrombophlebitis of upper extremity 451.82 108)Post-tussive vomiting 786.2 (1st code), 787.03 (2nd code) 109)Persistent vomiting 536.2 110)Otitis externa 380.10 111)Other specified disorders of ear 388.8 112)Pathological fracture 733.19 113)Substernal or sternal chest pain 786.51 114)Atypical chest pain 786.59 115)Abdominal pain (diffuse) is abdominal pain (generalized) 789.07 116)Unspecified wound 879.9 117)Aggressive behavior 312.00 118)Disturbance of conduct (unspecified) {bizarre behavior} 312.89 119)Postoperative pain 338.18 120)Postoperative bleeding 998.11 121)Paranoid schizophrenia (unspecified) 295.30 122)Schizoaffective disorder - 295.70 123)Superficial injury range starts from (all abrasions, foreign body and insect bite falls under this range) 910.. 124)Late effects range starts from 905... 125)Bipolar disorder 296.80 126)Upper back pain (pain in thoracic spine) 724.1 127)Well baby exam (when patient's age is above 28 days, for below 28 days codes are different) V20.2 128)Foley catheter change (without any complications) V56.1 129)STD 099.9 130)Elevated troponin 790.5 131)Elevated WBC - 288.60 132)Heme positive stool 792.1 133)Code for pain in the site where the indwelling catheter was inserted is (pos toperative pain) - 338.18 134)Removal of wound dressing (no mention of previous I + D or any other surgica l procedure) V58.30 135)Removal of wound dressing (I + D or any other surgical procedure done previo usly is mentioned) V58.31 136)Low back sprain - 846.9 137)Post-traumatic stress syndrome - 309.81 138)Follow up after any surgery or fracture care follow up - V67.59 139)Poisoning by other specified drug or medicinal substances 977.8 140)Poisoning by anti-depressants - 969.00 141)Poisoning by heroin - 965.01, 142)Poisoning by opium - 965.00 143)Heroin abuse - 304.00 144)Toxic effect of other substance, chiefly non-medical as to source 989.89 145)Toxic effects of other specified gases, fumes or vapors 987.8 146)Dilantin toxicity - 796.0 147)Complete abortion - 634.92 148)Incomplete abortion - 637.91 149)Inevitable abortion - 634.90 150)Flank pain - 789.09 151)Ganglion cyst - 727.41 152)Non toxic drug allergy - 995.27 153)Hyperglycemia (diabetes in past history) - 250.00, hypoglycemia ( diabetes i n past history) - 250.80

154)IBS (Irritable Bowel Syndrome) - 564.1 155)Sickle cell crisis (sickle cell pain) - 282.62 156)Urinary frequency (DO NOT CONFUSE WITH PAINFUL URINATION) - 788.41 157)Speech disturbance - 784.59 158)Seasonal allergy (allergic rhinitis) - 477.9 159)Allergic reaction due to food / food allergy (dermatitis due to food taken i nternally) 693.1 160)Dermatitis due to cosmetics (itching, rash or redness due to hair dye) - 692 .81 161)Urinary incontinence - 788.30 162)Depressive disorder - 311 163)DJD (knee) - 715.96 164)Elevated alkaline and phosphate - 790.5 165)Arthritis (back) - 721.90 166)Rib pain (illness) - 786.50 167)Rib pain (due to injury) - 786.52 168)Adrenal mass - 593.9 169)Dysfunctional uterine bleeding - 626.8 170)For critical care cases, review this chart - Perkins, Eddie, M984476, A/C 71 3069 171)Abnormal ECG / EKG - 794.31 172)Hyperventilation syndrome - 306.1 173)Tylenol ingestion - 965.4 174)Opium withdrawal - 292.0 175)Wound check-up status post sutures - V58.31 176)Cardiac defibrillator firing - 996.04 177)Deformity of finger - 736.20 178)PEG TUBE replacement - 536.42 179)Local reaction to suspected insect sting - 692.9 180)Acute blood loss anemia - 285.1 181)Plantar fasciitis - 728.71 182)Periorbital cellulitis - 373.13 183)Extrapyramidal reaction - 333.99 184)DKA - 250.10 185)Allergic conjunctivitis - 372.14 186)Rhonchi / rales - 786.7 187)Decrease in urine output - 788.5 188)Dislodged trachea tube - 519.02 189)Muscle stiffness - 728.89 190)Itching eyes - 379.99 191)If written CPR "resumed" in the HPI do not consider it as CPR done in ED 192)LBBB (Left Bundle Branch Block) - 426.3 193)Post-tonsillectomy bleeding from throat - 786.39 194)Follow up following tonsillectomy - V58.49 195)Hand, foot and mouth disease - 074.3 196)Bee sting - 989.5, 197)Viral illness 078.89 198)Bleeding from fistula port (due to HD done) site - 996.62 199)Saturday night palsy - 354.3 200)Uterine fibroids (leiomyoma) - 218.9 201)General medical examination (follow up or check up) - V70.8 202)Omental ventral hernia - 553.8 203)Infected dialysis port - 996.62 204)Wasp, Bees sting (toxic effect of venom) - 989.5, 205)Personal history of fall (at risk for falling) - V15.88 206)Chemical reaction - 692.4 207)Heme positive stool - 578.1 208)Adult sexual abuse - 995.83 209)Observation following rape or seduction - V71.5 210)Neck stiffness (torticollis) - 723.5

211)Heat exposure - 992.9 212)Insulin pump failure - 996.57 213)Blood clots - 286.9 214)Malignant neoplasm of pharynx, unspecified - 149.0 215)Shot administration (Haloparidol Deconate injection given in ED) - V03.89 Pregnancy complication codes (1)Pregnancy with genitourinary infection {(Eg. UTI, cervicitis, etc.) (Urinary Tract Infection, cervicitis or other conditions related to GU tract needs to be coded separately along with this code)} - 646.63 (2)Pregnancy with mental disorders 648.43 + 300.00 + 300.04 (3)Pregnancy with vomiting 643.93 (stand alone code) (4)Pregnancy with hyperemesis 643.03 (stand alone code) (5)Pregnancy with hyperemesis with metabolic disturbance 643.13 (stand alone cod e) (6)Pregnancy with any GI related conditions 646.83 (other codes are required wit h this code) (7)Pregnancy with anemia 648.23 (stand alone code) (8)Pregnancy with vaginal bleeding 640.93 (stand alone code) (9)Threatened abortion (miscarriage) 640.03 (10)Fetal demise < 22 weeks 632 (missed abortion) (11)Fetal demise > 22 weeks 646.43 (missed abortion) (12)Vaginal spotting, subchorionic bleeding, fever with pregnancy, weakness with pregnancy 646.83 or 648.93 (any other complications with pregnancy, always use the 646.83 / 648.93 first then other codes. For example if the impression is pre gnancy and abdominal pain the code will be 646.83 the first code and then 789.00 or 625.9 the second code) (13)Wound check up - V58.77 (14)Spotting during pregnancy - 649.53 (15)Pregnancy with hypertension - 642.93 (16)Neonatal fever 778.4 (17)Newborn Urticaria 778.8 (18)Newborn Cyanosis 770.83 (19)Other vomitin in newborn 779.33 (20)Chills without fever 780.64 (21)Hemoccult stool - 792.1 (22)Do not give 623.5 (vaginal discharge) code in pregnant patients when vaginal bleeding or spotting is there otherwise we can (23)Right / left side weakness - 729.89 (24)Discharge from wound - 998.9 (25)Buttock pain - 729.5 (26)Wound check, but not for suture removal - V58.31 (27)Fetal demise - 632 Notes: (a)Do not code palpitation with cardiac dysrrhythmia code (427............ range ) (b)Do not code asthma and wheezing together (c)When wheezing and SOB both are mentioned, only wheezing needs to be coded (d)When asthma, SOB and wheezing are mentioned, code for asthma and SOB only (e)When croup and cough is mentioned, only croup needs to be coded (f)Do not code asthma and bronchitis together, code only for asthma (g)GI bleeding (unspecified) is 578.9. Do not code rectal bleeding (569.3) and G I bleeding together. (h)When both COPD and/or asthma along with hypoxemia is there, 1st sequence COPD and/or asthma and then hypoxemia and when dysnea and hypoxia / hypoxemia is the re code 1st hypoxia / hypoxemia and then dysnea. (i)Always assign neoplasm codes last. For example if impression is headache, nau sea/vomiting and cancer of brain. First code headache, then nausea/vomiting and

then cancer after that (j)Always sequence Urinary Tract Infection and pneumonia codes first and then ot her diagnosis codes (Not always, sometimes more severe codes needs to be coded f irst) (k)Bipolar disorder will always come first, then other psychiatric codes. With b ipolar disorder "anxiety, depression" and / or "acute psychosis" code is not req uired. But you can give the code for "major depression" (l)Never code the blood in stool code when GI related symptoms (m)Dehydration comes before Acute Renal Insufficiency in sequencing (n)When back pain is given with lumbosacral pain, always give (724.2) code for b ack pain (o)When melena and abdominal pain is there, first give the code for melena and t hen abdominal pain (p)Bruises is contusion (q)THC / TCH abuse is Cannabis Abuse - 305.20 (r)Any head injury with LOC is CONCUSSION. Do not code closed head injury (959.01) with the code for concussion (s)Do not code RADIATING PAIN (t)Do not code 300.00 when you are already coding 300.01 (u)ICD-9 codes of laceration starts from 870.0 (laceration of skin of eyelid and periocular area) (v)Neoplasm table is between 140-239 range (malignant neoplasm 140-209 range, be nign neoplasm 210-229 range, carcinoma-in-situ 230-234, neoplasm of uncertain be havior 235-238 and neoplasm of unspecified nature 239 series (w)Code for erythema when "redness" is mentioned (x)Basic Metabolic Panel and Hepatic Panels are different so consider it as 2 po ints (y)With sore throat (462) and cold (460), give the code for sore throat only. Th e code for cold is not required (z)When dehydration and nausea + vomiting is mentioned. Sequence 1st the dehydra tion and then the N/V code (aa)Just Phenytoin, Tegretol or Valporic written in orders - consider them as in dividual laboratory tests i.e. 2 or 3 points whatever they might be (in case of admission only, when the patient is not admitted consider it as 1 point) (bb)GC Amplified DNA Probe and Chlamydia Amplified DNA Probe are 'not' two diffe rent laboratory tests, consider them 1 point only. {Weight preparation is differ ent} (cc)Vaginitis Panel and Basic Metabolic Panel are different, so consider it as t wo points (dd)In case of injury cases always give the injury codes first and then other co des even if injury is not mentioned in clinical impression and consider the char t as an injury. Exception to this rule is pregnancy cases (ee)In psychiatric cases when in doctor's documentation it is written as discha rged but in order sheet it is written as transferred consider them as transferre d (ff)"Superficial partial thickness burn" is second degree burn (gg)Do not use the vaginal bleeding in pregnancy code (640.93) with threatened a bortion code (hh)When using the pregnancy complication code, do not use any V codes (ii)With gestational diabetes 250.... series range code is not required (jj)A pregnant patient with diabetes code from the 250.... range is required (kk)When both foot and ankle sprain is mentioned give ankle sprain code only (ll)Do not consider alcohol intoxication and drug overdose from HPI (mm)In abdominal pain when in the PE tender (epigastric, LUQ, etc.) is mentioned under abdominal exam consider the abdominal pain as 789.06, 789.02, etc. instea d of 789.00 (nn)Strep screen and throat culture are two different labs (oo)Consider PTT/INR is one treatment option (pp)Consider CBC & PTT/INR as two treatment options (qq)In dementia, altered mental status, uncooperative and / or "medical emergenc

y" cases we can code the EMs without down coding even the full HPI, ROS or PFSH points are not there (rr)When intermediate laceration repair is done assign the ICD code "with mentio n of infection" (ss)"Chest compression done" or "ACLS protocol initiated" is mentioned then it m eans CPR is done for the patient (tt)For self pay "bill type" will always be "1" (uu)Reactive airway disease is asthma (vv)Thoracolumbar sprain?? CPT Codes Ancilliaries (A)Pulse oximetry 94760. For billing pulse ox percentage, on room air and interp retation needs to be mentioned. (B)Monitor 93042. Beats/minute and rhythm needs to be mentioned (C)EKG 93010. Beats/minute and rhythm needs to be mentioned (D)After hours - 99053 Other procedures A)CPR (ACLS) 92950 B)ET Tube 31500 C)Lumbar Puncture 62270 I+D A)Simple I+D 10060 B)I+D with gauze packing 10061 C)Pilonidal cyst (simple) 10080 D)Pilonidal cyst (with packing) 10081 E)Puncture aspiration of abscess 10160 F)Removal of FB from subcutaneous tissue, simple (incision must be made) 10120 G)Dental abscess I+D 41800 H)Bartholins gland cyst I+D 56420 I)Vaginal abscess - 56405 J)I + D of hematoma, seroma or fluid collection - 10140 "Tongue" laceration repair code 41250 "Mouth" Laceration repair code - 40830 Nasal packing A)Nasal packing B)Nasal packing C)Nasal packing D)Nasal packing anterior (simple) 30901 anterior (complex, rhinorocket is placed) 30903 posterior (initial) 30905 posterior (subsequent within 24 hrs) 30906

Burn care A)Treat 1st degree (erythema) burn (Silvadine cream + dressing is done) - 16000 B)Treat 2nd degree (blister) burn - 16020 **** Check the % of body surface area burned and then code, codes will change pe r the body surface area Foreign body removal (1)FB removal from nose 30300 (2)FB removal from ear 69200 (3)Removal of ear wax 69210 Note: Partial removal is not billed Arthrocentesis a)Arthrocentesis, small joint (finger, toes) 20600

b)Arthrocentesis, medium joints (wrist, elbow) 20605 c)Arthrocentesis, large joint (shoulder, hip, knee) 20610 LP / Spinal tap (LP for diagnostic purpose) 62270 LP for therapeutic purpose is not used 62272 Digital block 64450 Dental block 64400 Splinting (Upper Extremity) Long arm splint 29105 Short arm splint 29125 Finger splint 29130 Ace wrap shoulder 29240 Splinting (Lower Extremity) 29505 Long leg splint 29515 Short leg splint 29530 Ace wrap knee 29105, 29125, 29130, 29505, 29515 These codes are coded only when its done by th e physician for Medicare and Medicaid charts 29240, 29530 These codes can be coded from both nurses note and physician note Check for neurovascular status if splint has been done by some one else other th an physician (a)Removal of ingrown toe-nail 11750 (b)NG tube 43752 (c)NG tube with diagnosis of GI bleeding 43753 43760 - G-Tube replacement, change of gastrotomy tube Insertion of non-indwelling bladder catheter (e.g.-straight catheterizat ion for residual urine) - 51701 Insertion of temporary indwelling bladder catheter; simple (e.g. - Fole y) - 51702 Nebulization Less than 60 minutes 60 90 minutes 91 150 minutes 151 210 minutes 94640 94644 94644, 94645 94644, 94645 x 2

Notes: (a)Aspiration and arthrocentesis have the same CPT codes (b)When puncture wound is mentioned go for open wound . complicated" criteria (c)Avulsed fracture is open fracture (d)When infected wound is mentioned go for complicated laceration code (e)Tongue abrasion is face abrasion (f)When length of laceration is not mentioned bill with the shortest size and ma rk it to PBC audit (g)Ankle and foot x-rays are together 1 point, but knee x-ray is different (h)Laceration matrix is in 12001 range (i)Use modifier 59 with the other CPT procedure. Use the 59 modifier with the lowe st procedure (j)When Tegretol and Phenytoin tests are there consider as one treatment option (1 point), but when admission is mentioned consider as two treatment options (2 points) (k)In case of Medicaid charts, always mark 'E' in case of abscess cases

(l)Do not give code for cigarette smoking and diabetes in pregnancy cases (m)When the doctor's documentation is not there go to missing chart and then pre ss 'N' No Chart (n)"Type and Cross" or "Type and Screen" is a laboratory test, consider it as 1 point (o)Pelvic exam is 1 treatment option (so consider it as 1 point) E-Codes 1) Police custody, legal intervention and manhandling E975 2) Hit and fall (Fall resulting in striking against other object) E888.1 3) Assault by golf club E968.2 4) Assault by cutting and piercing instrument E966 5) Poisoning by heroin - 965.01, E980.0Accidental 6) poisoning by other specified drugs E858.8 7) Other drug or medicinal substances causing adverse effect in therapeutic use (do not use this code until and unless adverse effect is mentioned) E947.8 8) Accidental poisoning by unspecified carbon monoxide E868.9 9) Accidental poisoning by unspecified solid or liquid substance E866.8 10) Gunshot wound E922.9 11) Smashed by auto - E821.9 12) Bee sting - 989.5, E905.3 13) Place of occurrence E codes starts from E849.0.... range. 14) Cut with knife E920.3 15) Tackled in sports E886.0 16) Fall from skateboard E885.2 17) Fall from snowboard E885.4 18) Fall from non-motorized scooter E885.0 Activity Codes a) Food prep E015.0 b) Football E007.0 c) Relocation E013.5 d) Involving Golf E006.2 e) Horsback riding E006.1 f) Roller skating E006.0 g) Bike riding E006.4 h) Bowling E006.3 19) Football field E849.4 20) Church E849.6 21) Unspecified E849.9 22)Industrial place E849.3 23)Place of recreation/sport E849.4 24) Street / Highway E849.5 25) Public building E849.6 26) For allergic reaction(995.3) unspecified cause E946.9 27) Accidental poisioning by Heroine E850.0 28) Accidental poisioning by Methadone E850.1 29) Accidental poisioning by other opiates & related narcotics (i.e. Codein e, meperidine, morphine, opium etc.) E850.2 30) Accidental poisioning by unspecified gases & vapour E869.9 31) Accidental fall on or from escalator E880.0 32) Accidental fall on or sidewalk curb E880.1 33) Accidental fall from moving sidewalk E885.9 34) Accidental fall on other stairs or steps E880.9 35) For Popped E927.8 36) Sting of Wasp, Bees, Hornets E905.3