Main description:

In the United States, the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is a standard national coding system used to report diagnoses. ICD-9-CM diagnostic codes are used to identify the patient's condition, illness, disease, symptom, or other reasons for seeking medical care. These codes are used in two ways: to report services to insurance carriers for reimbursement, and to track disease trends and incidence. Most complete editions of "The ICD-9-CM" book include "The Official Guidelines for Coding and Reporting". These are summarized in the introductions to volume 1 and volume 2 of this book. Adherence to the guidelines is required under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Because these codes are required for physician reimbursement, it is important that both the physician and his or her staff understand how the ICD-9-CM coding system works. The physician needs to document his or her services using the same terms used in the ICD-9-CM. The staff person needs to be able to interpret the physician's documentation in order to select the appropriate ICD-9-C diagnostic code or codes.
If the documentation is unclear or not specific enough, the staff person should seek additional information from the physician. "The ICD-9-CM" consists of 3 volumes: "Volume 1: Diseases: Tabular List"; "Volume 2: Diseases: Alphabetic Index"; and, "Volume 3: Procedures: Tabular List and Alphabetic Index". This booklet includes excerpts from volume 1 and volume 2, including those codes most often reported by obstetrician-gynecologists. Volume 3, used almost exclusively by hospital medical records departments, is not included.