| Ambulatory care sensitive conditions such as asthma, diabetes, or dehydration are potential conditions for hospitalization for which timely and effective ambulatory care can decrease hospitalizations by preventing the onset of an illness or condition, controlling an acute episode of an illness, or managing a chronic disease or condition. | |
| Ambulatory Care Sensitive Conditions [and ICD-9-CM Codes] (by primary diagnosis unless otherwise noted) | Comments |
| Avoidable Conditions | |
| Congenital syphilis [090] | Secondary diagnosis for newborns only |
| Failure to thrive [783.41] | Age <1 y |
| Dental conditions [521–523, 525, 528] | |
| Vaccine preventable conditions [032, 033, 037, 041.5, 045, 052.1, 052.9, 055–056, 070.0–070.3, 072, 320.3, 390, 391, 771.0] | Hemophilus meningitis [320.0] for ages 1–5 y only |
| Iron deficiency anemia [280.1, 280.8, 280.9] | Primary and secondary diagnoses |
| Nutritional deficiencies [260–262, 268.0, 268.1] | Primary and secondary diagnoses |
| Acute Conditions | |
| Bacterial pneumonia [481,482.2,482.3,482.41,482.42,482.9, 483,485,486]* | Excludes cases with secondary diagnosis of sickle cell anemia [282.6] and patients <2 mo of age |
| Cellulitis [681,682,683,686] | Excludes cases with a surgical procedure (01–86.99), except incision of skin and subcutaneous tissue (86.0) for which it is the only listed surgical procedure |
| Convulsions [780.3] | |
| Dehydration—volume depletion [276.5] | Principal and secondary diagnoses examined separately |
| Gastroenteritis [558.9] | |
| Hypoglycemia [251.2] | |
| Kidney/urinary infection [590.0, 599.0, 599.9, 595.0, 595.9]† | |
| Pelvic inflammatory disease [614] | |
| Severe ear, nose, and throat infections [382, 462, 463, 465, 472.1] | Excludes otitis media [382] cases with myringotomy with insertion of tube [20.01] |
| Skin grafts with cellulitis (DRGs 263 and 264) | Excludes admissions from SNF/ICF |
| Chronic Conditions | |
| Angina [411.1, 411.8, 413] | Excludes cases with a surgical procedure (01-86.99) |
| Asthma [493] | |
| Chronic obstructive pulmonary disease [466.0, 491, 492, 494, 496] | Includes acute bronchitis (466.0) only with secondary diagnosis of 491, 492, 494, 496 |
| Congestive heart failure [402.01, 402.11, 402.91, 428, 518.4] | Excludes cases with the following surgical procedures: 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 |
| Diabetes [250.0–250.3, 250.8–250.9] | Excludes diabetes with renal manifestations [250.4], diabetes with ophthalmic manifestations [250.5], diabetes with neurological manifestations [250.6], and diabetes with peripheral circulatory disorders [250.7] |
| Grand mal and other epileptic conditions [345] | |
| Hypertension [401.0, 401.9, 402.00, 402.10, 402.90] | Excludes cases with the following procedures: 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 |
| Tuberculosis (nonpulmonary) [012–018] | |
| Tuberculosis (pulmonary) [011] | |
SNF/ICF = skilled nursing facility/intermediate care facility; DRG = diagnosis related group; AHRQ = Agency for Healthcare Research and Quality.
In addition to the above, we added bacterial pneumonia due to methicillin-resistant Staphyloccocus aureus (MRSA) bacteremia compared with methicillin-sensitive Staphyloccocus aureus (MSSA) bacteremia as included in AHRQ Prevention Quality Indicators #11 Technical Specifications Bacterial Pneumonia Numerator definition and acute cystitis and cystitis as included in AHRQ Prevention Quality Indicators # 12 Technical Specifications Urinary Tract Infection Numerator definition.
In addition to this list, we added acute cystitis and cystitis as included in AHRQ Prevention Quality Indicators #12 Technical Specifications Urinary Tract Infection Numerator definition.
Source: Institute of Medicine, Millman M, ed. Access to Health Care in America. Washington, DC: National Academy Press; 1993.