Table 6.
ICD codes used to define ambulatory care sensitive conditions
| Category | Condition | ICD-9-Codes |
|---|---|---|
| Chronic conditions | Asthma | ICD-9-CM 493; ICD-10-CA J45 |
| Angina | ICD-9-CM 411, 413; ICD-10-CA 120, 123.82, 124.0, 124.8,124.9 Excluding cases with the following surgical procedures**: ICD-9 01.01 – 86.99; CCI 1.^,2.^,5.^ (i.e., any procedure from CCI section 1, 2, 5) | |
| Heart failure and pulmonary edema | ICD-9-CM 428, 518.4; ICD-10-CA 150, J81, I11.0Excluding cases with the following surgical procedures**: ICD-9 36.01, 36.02, 36.05, 36.1, 37.5, 37.7; CCI 1.IJ.50, 1.IJ.57.GQ, 1.HZ.85, 1.IJ.76, 1.HB.53; 1.HD.53, 1.HZ.53, 1.HB.55, 1.HD.55, 1.HZ.55, 1.HB.54, 1.HD.54 | |
| Diabetes with complications | ICD-9-CM 250; ICD-10-CA E10, E11, E13, E14 | |
| Hypertension | ICD-9-CM 401, 402; ICD-10-CA I10.0, I10.1, I11 Excluding cases with the following surgical procedures**: ICD-9 36.01, 36.02, 36.05, 36.1, 37.5, 37.7; CCI 1.IJ.50, 1.IJ.57.GQ, 1.HZ.85, 1.IJ.76, 1HB.53; 1.HD.53, 1.HZ.53, 1.HB.55, 1.HD.55, 1.HZ.55, 1.HB.54, 1.HD.54 | |
| COPD | ICD-9-CM 491, 492, 494, 496; ICD-10-CA J41, J42, J43, J44, J47 | |
| Pneumonia | Pneumonia (only when a secondary diagnosis of COPD is present): ICD-9-CM 480, 481, 482, 483, 484, 485, 486; ICD-10-CA J12, J13, J14, J15, J16, J18*Exclude if secondary diagnosis of sickle cell anemia is present | |
| Bronchitis | Acute bronchitis (only when a secondary diagnosis of COPD is present): ICD-9-CM 466.0 ICD-10-CA J20 | |
| Vaccine-preventable conditions | Diphtheria | ICD-9-CM 032; ICD-10-CA A36 |
| Hemophilus influenza type B | ICD-9-CM 320.0; ICD-10-CA G00.0 | |
| Hepatitis A | ICD-9-CM 070.0, 070.1; ICD-10-CA B15 | |
| Hepatitis B | ICD-9-CM 070.2, 070.3; ICD-10-CA B16 | |
| Influenza | ICD-9-CM 487; ICD-10-CA J10, J11 | |
| Measles | ICD-9-CM 055; ICD-10-CA B05 | |
| Meningococcal disease (meningitis) | ICD-9-CM 036; ICD-10-CA A39 | |
| Mumps | ICD-9-CM 072; ICD-10-CA B26 | |
| Pertussis | ICD-9-CM 033; ICD-10-CA A37 | |
| Pneumococcal | ICD-9-CM 038.2, 041.2, 320.1, 567.1, 711.0, 481; ICD-10-CA G00.1, A40.3, J13 Note: “Chronic conditions” are given the priority in the hierarchy for code 481 or J13 (see Pneumonia, only when a secondary diagnosis of COPD is present). | |
| Poliomyelitis | ICD-9-CM 045; ICD-10-CA A80 | |
| Tuberculosis | ICD-9-CM 011 – 018; ICD-10-CA A15 – A19 | |
| Rubella | ICD-9-CM 056; ICD-10-CA B06 | |
| Tetanus | ICD-9-CM 037; ICD-10-CA A34, A35 | |
| Acute Conditions | Dental Conditions | ICD-9-CM 521, 522, 523, 525, 528; ICD-10-CA K02.0, K02.1, K02.2, K02.3, K02.4, K02.8, K02.9, K03.0, K03.1, K03.2, K03.3, K03.4, K03.5, K03.6, K03.7, K03.8, K03.9, K04.0, K04.1, K04.2, K04.3, K04.4, K04.5, K04.6, K04.7, K04.8, K04.9, K05.0, K05.1, K05.2, K05.3, K05.4, K05.5, K05.6, K06.0, K06.1, K06.2, K06.8, K06.9, K08.0, K08.1, K08.2, K08.3, K08.80, K08.81, K08.82, K08.83, K08.87, K08.88, K08.9, K09.8, K09.9, K12.0, K12.1, K12.2, K13.0, K13.1, K13.2, K13.3, K13.4, K13.5, K13.6, K13.7 |
| Cellulitis | ICD-9-CM 681, 682, 683, 686; ICD-10-CA, L03, L04, L08, L44.4, L88, L92.2, L98.0, L98.3 Excluding cases with the following surgical procedures except incision of skin and subcutaneous tissue where it is the only listed: ICD-9 01.01 – 86.99 (except 86.0 – 86.09) CCI 1.^,2.^,5.^ (i.e. any procedure from CCI section 1, 2, 5) (except 1.AX.53.LA-QK, 1.IS.53.HN-LF, 1.IS.53.LA-LF, 1.JU.53.GP-LG, 1.KR.53.LA-LF, 1.OA.53.LA-QK, 1.SY.53.LA-QK, 1.YA.35.HA-W1, 1.YA.35.HA-X4, 1.YA.52.HA, 1.YA.52.LA, 1.YA.55.DA-TP, 1.YA.55.LA-TP, 1.YA.56.LA, 1.YB.52.HA, 1.YB.52.LA, 1.YB.55.DA-TP, 1.YB.55.LA-TP, 1.YB.56.LA, 1.YF.35.HA-W1, 1.YF.35.HA-X4, 1.YF.52.HA, 1.YF.55.DA-TP, 1.YF.55.LA-TP, 1.YF.56.LA, 1.YG.52.HA, 1.YG.52.LA, 1.YG.55.DA-TP, 1.YG.55.LA-TP, 1.YG.56.LA, 1.YR.52.HA, 1.YR.52.LA, 1.YR.56.LA, 1.YS.35.HA-W1, 1.YS.35.HA-X4, 1.YS.52.HA, 1.YS.52.LA, 1.YS.55.DA-TP, 1.YS.55.LA-TP, 1.YS.56.LA, 1.YT.35.HA-W1, 1.YT.35.HA-X4, 1.YT.52.HA, 1.YT.52.LA, 1.YT.55.DA-TP, 1.YT.55.LA-TP, 1.YT.56.LA, 1.YU.52.HA, 1.YU.52.LA, 1.YU.55.DA-TP, 1.YU.55.LA-TP, 1.YU.56.LA, 1.YV.35.HA-W1, 1.YV.35.HA-X4, 1.YV.52.HA, 1.YV.52.LA, 1.YV.55.DA-TP, 1.YV.55.LA-TP, 1.YV.56.LA, 1.YW.52.HA, 1.YW.52.LA, 1.YW.55.DA-TP, 1.YW.55.LA-TP, 1.YW.56.LA, 1.YX.52.HA, 1.YX.52.HA-AV 1.YX.52.LA, 1.YX.56.LA, 1.YZ.35.HA-W1, 1.YZ.35.HA-X4, 1.YZ.52.HA, 1.YZ.52.LA, 1.YZ.55.DA-TP, 1.YZ.55.LA-TP, 1.YZ.56.LA | |
| Pelvic Inflammatory Disease | ICD-9-CM 614, ICD-10-CA, N70, N73, N99.4 Exclude males or cases with a hysterectomy procedures: ICD-9 68.3 – 68.89, CCI 1.RM.87, 1.RM.89, 1.RM.91, 5.CA.89.CK, 5.CA.89.DA, 5.CA.89.GB, 5.CA.89.WJ, 5.CA.89.WK | |
| Gastroenteritis & Dehydration | ICD-9-CM 558, 276.5; ICD-10-CA K52.2, K52.8, K52.9, E86 | |
| Severe Ear, Nose and Thoat (ENT) infections | ICD-9-CM 382, 462, 463, 465, 472.1; ICD-10-CA H66, J02, J03, J06, J31.2, H67 Exclude otitis media cases with a myringotomy procedure: ICD-9 20.01; CCI 1.DF.53.JA-TS | |
| Mental health | Mood disorders | ICD-9-CM 296.1-296.8, 300, 309 or 311; ICD-10-CA F31, F32, F33, F34.1, F38.0, F38.1, F41.2, F43.1, F43.2, F43.8, F53.0, F93.0 or with a diagnosis for an anxiety state, phobic disorders or obsessive-compulsive disorders: ICD-9-CM 300.0, 300.2, 300.3, 300.7; ICD-10-CA F40, F : ICD-9-CM 300; ICD-10-CA F32, F34.1, F40, F41, F42, F44, F45.0, F45.1, F45.2, F48, F68.0, or F99, F41.0, F41.1, F41.3, F41.8, F41.9, F42, F45.2 |
| Schizophrenia | ICD-9-CM 295 ICD-10-CA F20, F21, F23.2, F25 |
* “Secondary diagnosis” refers to a diagnosis other than most responsible; ** Code may be recorded in any position. Procedures coded as cancelled, previous and “abandoned after onset” are excluded