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Appendix N-Coding Conditions and Exceptions

ICD-9-CM Coding Conditions

  1. Prior to October 1, 1995 edits pertaining to ICD-9-CM codes are validated on the basis of the Discharge Date and the Expected Principal Reimbursement. The edit application reflects the yearly updating of the ICD-9-CM codes. ICD-9-CM updates become effective on October 1 for Medicare, CHAMPUS, and Medicare HMO discharges and on January 1 of the following year for all other payer discharges.

    After October 1, 1995, based on the Department of Health Memorandum (Health Facilities Series: H4 95-7) issued on May 1, 1995, all edits pertaining to ICD-9-CM codes are validated on the basis of the Discharge Date. The edit application reflects the yearly updating of the ICD-9-CM codes. ICD-9-CM updates become effective on October 1 for all payers.

  2. Sex-specific diagnosis or procedure codes as defined in the ICD-9-CM reference file with a Sex-Specific Indicator must be compatible with reported Patient Sex.

  3. Age-specific diagnosis codes as defined in the ICD-9-CM reference file with an Age-Specific Indicator must be compatible with Age (calculated from the Patient Birth Date at the time of admission) unless listed as an exception in the Age-Specific Diagnosis Code Exceptions section below.

ICD-9-CM External Cause-of-Injury Exceptions

  1. When the following diagnosis codes are reported as either an Other or Principal/Primary Diagnosis Code, an External Cause-of-Injury Code is not required.

    909.0, 909.1, 909.3, 909.4, 909.5, 909.9, 990, 995.0, 995.1, 995.2, 995.20, 995.21, 995.22, 995.23, 995.27, 995.29, 995.3, 995.4, 995.60-995.69, 995.7, 995.86, 995.89, 995.90-995.94, 999.80, 999.81, 999.82, 999.83, 999.84, 999.85, 999.88, 999.89

  2. When the following diagnosis codes are reported an appropriate E-code must be reported in either an Other Diagnosis Code field or in the External Cause-of-Injury Code field. If the E-code was as a result of a correct medicinal substance properly administered, the E-code should be reported in an Other Diagnosis Code field. If the E-code was a result of an incorrect medicinal substance and/or substance incorrectly administered, the E-code should be reported in the External Cause-of-Injury Code field.

    999.0-999.7, 999.9, 999.31, 999.39

Age-Specific ICD-9-CM Diagnosis Code Exceptions

  1. An age warning will be generated when the following diagnoses are reported for patients outside the age parameters on the Medicare code editor. It should be noted that this warning "DOES NOT" cause records to reject from the SPARCS system, but does flag possible coding problems.
   331.81 434.91 574.00 574.30 575.0 602.8 768.4
340 435.9 574.01 574.31 575.1@ 722.10 768.5
411.89 436 574.10 574.40 575.2 722.52 768.6
414.0* 440.9 574.11 574.41 575.3 724.02 768.9
433.x1 441.01 574.20 574.50 577.0 766.1 770.7
434.11 454.9 574.21 574.51 577.1 767.6 777.1
434.90 496 574.81 577.2 768.3 775.5

*NOTE:  Effective in 1995 additional levels of specificity were defined for diagnosis code 414.0. The valid codes are now 414.00, 414.01, 414.02, and 414.03.

@NOTE:  Effective in 1997 additional levels of specificity were defined for diagnosis code 575.1. The valid codes are now 575.10, 575.11, and 575.12.

ICD-9 Procedure Code Date Exception

  1. A procedure date exception warning will be generated when the principal or other procedure code dates are one to three days prior to the Admission Date for inpatient submissions. It should be noted that this warning "DOES NOT" cause records to reject from the SPARCS system, but does flag possible reporting problems.

  2. Any procedure date reported that is more than three (3) days prior to the Admission date or after the Statement-Covers-Thru Date will fail SPARCS edits.

Value Code Exceptions

  1. Listed below are the value codes that may be reported with an associated zero amount.
  45 A1 A2 X1 Y1 Z1
81 B1 B2 X2 Y2 Z2
86 C1 C2 X3 Y3 Z3
D1 D2 X4 Y4 Z4
E1 E2 X5 Y5 Z5
F1 F2 X6 Y6 Z6
G1 G2

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