| Ambulatory Care Sensitive Condition and ICD-9-CM Code(s) |
Comments |
|---|---|
| Congenital syphilis [090] | Secondary diagnosis for newborns only |
| Immunization-related and preventable conditions [033, 037, 045, 320.0, 390, 391] | Hemophilus meningitis [320.2] age 1-5 only |
| Grand mal status and other epileptic convulsions [345] | |
| Convulsions "A" [780.3] | Age 0-5 |
| Convulsions "B" [780.3] | Age >5 |
| Severe ear, nose, and throat infections [382, 462, 463, 465, 472.1] | Exclude otitis media cases [382] with myringotomy with insertion of tube [20.01] |
| Pulmonary tuberculosis [011] | |
| Other tuberculosis [012-018] | |
| Chronic obstructive pulmonary disease [491, 492, 494, 496, 466.0] | Acute bronchitis [466.0] only with secondary diagnosis of 491, 492, 494, 496 |
| Bacterial pneumonia [481, 482.2, 482.3, 482.9, 483, 485, 486] | Exclude case with secondary diagnosis of sickle cell [282.6] and patients <2 months |
| Asthma [493] | |
| Congestive heart failure [428, 402.01, 402.11, 402.91, 518.4] | Exclude cases with the following surgical procedures: 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 |
| Hypertension [401.0, 401.9, 402.00, 402.10, 402.90] | Exclude cases with the following procedures: 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7 |
| Angina [411.1, 411.8, 413] | Exclude cases with a surgical procedure [01-86.99] |
| Cellulitis [681, 682, 683, 686] | Exclude cases with a surgical procedure [01-86.99], except incision of skin and subcutaneous tissue [86.0] where it is the only listed surgical procedure |
| Skin grafts with cellulitis [DRG 263, DRG 264] | Exclude admissions from skilled nursing facility/intermediate care facility |
| Diabetes "A" [250.1, 250.2, 250.3] | |
| Diabetes "B" [250.8, 250.9] | |
| Diabetes "C" [250.0] | |
| Hypoglycemia [251.2] | |
| Gastroenteritis [558.9] | |
| Kidney/urinary infection [590, 599.0, 599.9] | |
| Dehydration - volume depletion [276.5] | Examine principal and secondary diagnoses separately |
| Iron deficiency anemia [280.1, 280.8, 280.9] | Age 0-5 only, and examine principal and secondary diagnoses separately |
| Failure to thrive [783.4] | Age <1 only |
| Pelvic inflammatory disease [614] | Women only denominator - exclude cases with a surgical procedure of hysterectomy [68.3-68.8] |
| Dental Conditions [521, 522, 523, 525, 528] |
"Marker" or "Reference" Conditions
| Conditions and ICD-9-CM Code(s) | Comments |
|---|---|
| Appendicitis with appendectomy [540, 541, 542] | With principal procedure of 47.0 or 47.1 |
| Acute myocardial infarction [410] | Only cases with LOS >5 days or disposition of death |
| Gastrointestinal Obstruction [560] | |
| Fracture hip/femur [820] | Age 45+ only |
"Referral Sensitive" Surgeries
| Conditions and ICD-9-CM Code(s) | Comments |
|---|---|
| Hip/joint replacement [81.41, 81.48, 81.5, 81.6] | |
| Breast reconstruction after mastectomy [85.7, 85.95] | Women only |
| Pacemaker insertion [37.7] | |
| Organ and bone marrow transplant surgeries [37.5, 50.5, 55.6, 41.0] | |
| Coronary artery bypass surgery [36.1] | |
| Coronary angioplasty [36.01, 36.02, 36.05] |
Where only three digits are listed, all diagnoses at the 4th and 5th digit should be included (e.g., asthma is listed as 493, but you should include 493.0, 493.00, 493.01, 493.1, 493.10, 493.11, etc.). Where only four digits are listed, all diagnoses at the 5th digit should also be included.
All diagnoses refer to principal diagnosis, unless otherwise specified (e.g., dehydration, iron deficiency, nutritional deficiency, etc.). Where exclusions of surgical patients are specified (e.g., hypertension), search all procedure fields for excluded procedures.