. "Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Access to Health Care in America. Washington, DC: The National Academies Press, 1993.
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Access to Health Care in America
D "Ambulatory-Care-Sensitive" Conditions and "Referral-Sensitive" Surgeries
"AMBULATORY-CARE-SENSITIVE" CONDITIONS
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 ENT infections [382, 462, 463, 465, 472.1]
Exclude otitis media cases [382] with myringotomy with insertion of tube [20.01]
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D
"Ambulatory-Care-Sensitive" Conditions and "Referral-Sensitive" Surgeries
"AMBULATORY-CARE-SENSITIVE" CONDITIONS
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 ENT infections [382, 462, 463, 465, 472.1]
Exclude otitis media cases [382] with myringotomy with insertion of tube [20.01]
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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 SNF/ICF
Diabetes "A" [250.1, 250.2, 250.3]
Diabetes "B" [250.8, 250.9]
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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
Dental Conditions [521, 522, 523, 525, 528]
"REFERRAL-SENSITIVE" SURGERIES
Condition 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]
Womens only
Pacemaker insertion [37.7]
Coronary artery bypass surgery [36.1]
Coronary angioplasty [36.01, 36.02, 36.05]
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