General Surgery Coding Alert

Question: Does ICD-9 have a default way to code acute versus chronic if the medical record does not specifically document the distinction? For instance, if the doctor just writes “Cholecystitis,” what is the best way to determine acute versus chronic?

California Subscriber

Answer: If the medical record doesn’t document a condition as “acute” or “chronic” but the codes have those options, you’ll typically see that one of the codes states, “unspecified” or “NOS,” which means “not otherwise specified.” If the physician’s documentation doesn’t state “acute” or “chronic” or provide other information indicating that the condition is one or the other, you should report the condition to the unspecified or NOS code.

To use your example of cholecystitis, ICD-9 lists the following codes:

• 575.0 — Acute cholecystitis
• 575.10 — Cholecystitis unspecified
• 575.11 — Chronic cholecystitis
• 575.12 — Acute and chronic cholecystitis.

In this case, if the physician simply documents “cholecystits,” you should code 575.10.

Same goes for ICD-10: Once ICD-10 goes into effect, you’ll follow the same rules regarding acute/chronic/unspecified. Taking the cholecystitis example again, here are your ICD-10 code choices:

• K81.0 — Acute cholecystitis
• K81.1 — Chronic cholecystitis
• K81.2 — Acute cholecystitis with chronic cholecystitis
• K81.9 — Cholecystitis, unspecified.

Caution: The word “acute” isn’t the only way that the medical record might document that the condition is acute. You need to look at the full description in the tabular list to see if other parts of the physician’s documentation direct you to one code or another. For instance, 575.0 (Acute cholecystitis) lists several terms such as “abscess,” “gangrenous,” and “suppurative.” If the physician documents one of those conditions, you should choose 575.0 instead of 575.10 even if the documentation doesn’t use the word, “acute.”

If you encounter a condition that has codes for acute and chronic but does not provide an “unspecified” code choice, your default assumption should be acute or subacute.

Both: If the medical record specifies that the condition is both acute and chronic, you should use the combination code if one is available, such as 575.12 or K81.2 for cholecystits. If a combination code isn’t available but separate acute and chronic codes are available for the condition, you should “code both and sequence the acute (subacute) code first,” according to coding guidelines for ICD-9 and ICD-10.