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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OCR for page 219
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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Access to Health Care in America 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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Access to Health Care in America 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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