Table A1.
ICD-9 Diagnosis and CPT Billing Codes for Indicator Specifications
| Quality Measure | ICD-9 Code (and CPT code) Indicators of a Patient Case | CPT Code or ICD-9 Procedure Code for Meeting the Criterion |
|---|---|---|
| Chronic condition management | ||
| Visit every 6 months for patients with chronic stable angina | Chronic stable angina: 413.0-413.9 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058; preventive visit: 99381, 99387, 99391, 99397 |
| Visit every 6 months for patients with congestive heart failure | CHF: 428.0-428.9, 402.01, 402.11, 402.91 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058; preventive visit: 99381, 99387, 99391, 99397 |
| Visit every 6 months for patients with COPD | COPD: 491.0-491.9, 492.0-492.8, 496 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058; preventive visit: 99381, 99387, 99391, 99397 |
| Visit every year for patients with diagnosis of transient ischemic attack | TIA: 435.0-435.9 | Office visit 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058; preventive visit: 99381, 99387, 99391, 99397 |
| Cholesterol test every 6 months for patients hospitalized for acute myocardial infarction and who have hypercholesterolemia | Acute MI: 410.0-410.9; anterior MI: 410.0-410.1; hypercholesterolemia: 270.0-272.2, 272.4 | Cholesterol test: 82465; multichannel tests: 80012-80019; general health panel: 80050; lipid panel: 80061; lipoprotein, HDL, VLDL, LDL cholesterol: 83715-83721 |
| Lipid profile ≤ 1 year after initial diagnosis of angina | Chronic stable angina: 413.0-413.9 | Cholesterol test: 82465; multichannel tests: 80012-80019; general health panel: 80050; lipid panel: 80061; lipoprotein, HDL, VLDL, LDL cholesterol: 83715-83721 |
| Visit every 6 months for patients with diabetes | Diabetes: 250.00-250.93 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058; preventive visit: 99381, 99387, 99391, 99397 |
| Eye examination every year for patients with diabetes | Diabetes: 250.00-250.93 | Ophthalmologic visit: 92002-92014, ICD-9 V72.0 V80.2, 95.02, 95.03, 95.05, 95.11; ophthalmoscopy: 92225-92250 |
| Glycosylated hemoglobin or fructosamine every 6 months for patients with diabetes | Diabetes: 250.00-250.93 | Hemoglobin, glycated: 83036; fructosamine: 82985 |
| Avoidable events | ||
| Among patients with known angina, ≥ three emergency department visits for cardiovascular-related diagnoses in 1 year | Chronic stable angina: 413.0-413.9 | ER visit: 99281-99285; diseases of circulatory system: ICD-9 390-459; diseases of respiratory system: ICD-9 460-519; respiratory and chest symptoms: ICD-9 786.0-786.9; vascular insufficiency, intestine: ICD-9 557.1-557.9 |
| Among patients with known cholelithiasis, diagnosis of perforated gallbladder | Cholelithiasis: 574.0-574.5 | Perforated gallbladder: ICD-9 575.4 |
| Among patients with known diabetes, admission for hyperosmolar or ketotic coma | Diabetes: 250.00-250.93 | Hyperosmolar coma: ICD-9 250.2; ketotic coma: ICD-9 250.3 |
| Among patients with known chronic obstructive pulmonary disease, subsequent admission for a respiratory diagnosis | COPD: 491.0-491.9, 492.0-492.8, 496 | Upper respiratory infection: ICD-9 465; bronchitis, acute: ICD-9 466; pneumonia: ICD-9 480-486; influenza: ICD-9 487; chronic bronchitis: ICD-9 491; emphysema: ICD-9 492; asthma: ICD-9 493; chronic airway obstruction: ICD-9 496; pulmonary congestion: ICD-9 514; dyspnea: ICD-9 786.00-786.09 |
| Among patients with known emphysema, subsequent admission for a respiratory diagnosis | Emphysema: 492.0-492.8 | Upper respiratory infection: ICD-9 465; bronchitis, acute: ICD-9 466; pneumonia: ICD-9 480-486; influenza: ICD-9 487; chronic bronchitis: ICD-9 491; emphysema: ICD-9 492; asthma: ICD-9 493; chronic airway obstruction: ICD-9 496; pulmonary congestion: ICD-9 514; dyspnea: ICD-9 786.00-786.09 |
| Among patients with pneumonia, diagnosis of lung abscess or emphysema | Pneumonia (viral: 480.0-480.9; pneumococcal: 481; other bacterial: 482.0-482.9; other specified organism: 483.0-483.8); bronchopneumonia, organism unspecified: 485; pneumonia, organism unspecified: 486; influenza with pneumonia: 487.0 | Lung abscess: ICD-9 513.0; emphysema: ICD-9 510.1, 510.9 |
| Nonelective admission for congestive heart failure | CHF: 428.0-428.9, 402.01, 402.11, 402.91 | Check IP file for any admission with first listed diagnosis of CHF |
| Acute care quality indicators | ||
| Visit ≤ 4 weeks after discharge for patients hospitalized with acute myocardial infarction | Acute MI: 410.0-410.9; anterior MI: 410.0-410.1 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Electrocardiogram during emergency department visit for unstable angina | Unstable angina: 411.1 | ECG, evaluation: 93000-93014, ICD 89.52, 89.53; ER visit: 99281-99285 |
| Follow-up visit or hospitalization ≤ 1 week after initial diagnosis of unstable angina | Unstable angina: 411.1 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with unstable angina | Unstable angina: 411.1 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with congestive heart failure | CHF: 428.0-428.9, 402.01, 402.11, 402.91 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Electrocardiogram ≤ 3 months after initial diagnosis of congestive heart failure | CHF: 428.0-428.9, 402.01, 402.11, 402.91 | ECG, evaluation: 93000-93014, ICD 89.52, 89.53 |
| Chest radiograph ≤ 3 months after initial diagnosis of congestive heart failure | CHF: 428.0-428.9, 402.01, 402.11, 402.91 | Chest x-ray: 71010-71035, ICD 87.44, 87.49 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with cerebrovascular accident | CVA: 430-434.9, 436-437.9 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| For patients hospitalized with carotid artery stroke, carotid imaging ≤ 2 weeks of initial diagnosis | Carotid territory stroke: 433.1, 433.10, 433.11 | Angiogram, carotid artery: 75650-75685, ICD 88.41; noninvasive carotid imaging: 93880-93882, 70544-70549, ICD 88.71 |
| For cerebrovascular accident patients with eventual carotid endarterectomy, interval between carotid imaging and carotid endarterectomy < 2 months | CVA: 430-434.9, 436-437.9 34001, 35301; carotid endarterectomy: ICD 38.12 | Angiogram, carotid artery: 75650-75685, ICD 88.41; noninvasive carotid imaging: 93880-93882, 70544-70549, ICD 88.71 |
| Electrocardiogram within 2 days of initial diagnosis of transient ischemic attack | TIA: 435.0-435.9 | ECG, evaluation: 93000-93014, ICD-9 89.51-89.54; ECG, rhythm: 93040-93042; ECG, monitoring: 93224-93237 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with transient ischemic attack | TIA: 435.0-435.9 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| For transient ischemic attack patients with eventual carotid endarterectomy, interval between carotid imaging and carotid endarterectomy < 2 months | TIA: 435.0-435.9; carotid endarterectomy: 34001, 35301 | MRI: 70544-70549; angiogram, carotid artery: 75650-75685; noninvasive carotid imaging: 93880-93882; other: ICD-9 88.41, 88.71 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with diabetes | Diabetes: 250.00-250.93 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Visit ≤ 2 weeks after discharge for patients hospitalized with depression | Depression: 296.2, 296.3, 296.90, 311 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058; psychiatric visit: 90841-90844, 90862; individual medical psychotherapy: 90855; individual psychoanalysis: 90845 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with malignant or otherwise severe hypertension | Hypertension urgency or hypertension emergency: 401.0, 402.0, 403.0, 404.0, 405.0, 405.1, 405.9, 437.2 | Office visit: 99201-99215; office consultation: 99241-99245; home visit 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Visit ≤ 4 weeks after discharge for patients hospitalized with GI bleeding | GI hemorrhage: 578.0-578.9; gastroesophageal laceration hemorrhage syndrome: 530.7; esophageal hemorrhage: 530.82; gastric ulcer with hemorrhage: 531.0, .2, .4, .6; duodenal ulcer with hemorrhage: 532.0, .2, .4, .6; peptic ulcer NEC with hemorrhage: 533.0, .2, .4, .6; gastrojejunal ulcer with hemorrhage: 534.0, .2, .4, .6 | Office visit: 99201-99215; office consultation: 99241-99245; home visit: 99341-99353; ER visit: 99281-99285; nursing home visit: 99301-99337; emergency office visit: 99058 |
| Cholecystectomy (open or laparoscopic) for patients with cholelithiasis and ≥ one of the following: cholecystitis, cholangitis, gallstone pancreatitis | Cholelithiasis: 574.0-574.5 | Cholecystectomy: 47601-47619, 47620, 56340, 56341, 56342, ICD 51.22, 51.23; cholecystitis: 575.0, 575.1; cholangitis: 576.1; gallstone pancreatitis: 574.0, 574.1, 574.2, 577.0 |
| Arthroplasty or internal fixation of hip during hospital stay for hip fracture | Transcervical closed: 820.00-820.09; transcervical open: 820.10-820.19; pertrochanteric closed: 820.20-820.22; pertrochanteric open: 820.30-820.32; hip, NOS closed: 820.8; hip NOS open: 820.9 | Partial or total hip replacement: 27125, 27130, 27132, 27134, 27137, 27138; hip replacement: ICD 81.51-81.53; open treatment femoral, proximal, end, neck: 27236; open treatment intertrochanteric, subtrochanteric, pertrochanteric, femoral: 27244-27245; open treatment greater trochanteric: 27248; arthroplasty: ICD 78.55 |
Abbreviations: CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPT, Current Procedural Terminology; CVA, cerebrovascular accident; ER, emergency room; HDL, high density lipoprotein; ICD-9, International Classification of Diseases, Ninth Revision; IP, inpatient; LDL, low density lipoprotein; MI, myocardial infarction; MRI, magnetic resonance imaging; NEC, not elsewhere classifiable; NOS, not otherwise specified; TIA, transient ischemic attack; VLDL, very low density lipoprotein.