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ICD9 history

  1. Question ICD9 history
    Medical Coding Books
    Can someone tell me what ICD9 to use for history of indwelling catheter?

  2. #2
    Not sure if I understand. Is there a complication with the catheter? Has it been left in place? Does the patient have a history of urinary problems?

    2009 ICD-9-CM Diagnosis Code 996.31
    Mechanical complication due to urethral (indwelling) catheter

    Would this one work?
    The Oracle

  3. Default
    thanks you that will work. My doctor does not give me alot of information to go by I have to research alot.

  4. #4
    Stuart, Florida
    A complication code is NOT acceptable to use for documentation written as "history of indwelling catheter", especially if the doctor does not give you a lot of info to go by. The documentation must support the code. "History of indwelling cath" says to me that the patient had indwelling cath, no longer does, end of story. No code needed. Only you are the one that has the true documentation so, if there is more to it explaining that there was a mechanical complication with a patient's current indwelling cath, by all means code it. Just be aware that the use of the word "history" denotes something that is no longer occuring/there and you cannot have a mechanical complication with something that is no longer there.

    If your doctor does not give you a lot of info to go by, rather than reaching for a DX code barely supported if supported at all, you may want to have a sit down with the doctor. Explain that you need the most specific documentation possible with any current DXs addressed to be able to do your job. An auditor is not going to research the patient's life history to try to decipher what the doctor is trying to get across. Please remember that you, as the coder, will be the person they come to if there is a problem with what is coded not being supported by the documentation. Protect yourself. DO NOT code something if it is iffy.
    Vanessa Mier, CPC

  5. #5
    Thumbs up
    Thanks for the long drawn out explanation of what I meant Vanessa.

    That is why I asked all those questions. We have providers that write 'history of' for every condition the patient currently is even being treated for. Got to be careful, because the providers thoughts are not always on the same level as ours.

    So, yes, please, mamacase1, verify with your provider what s/he meant by it before you give the patient a complication code.

    I apologize for my previously posted short reply that may have been too misinforming.
    The Oracle

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