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ICD-9, CPT, E&M Coding Documentation and Compliance …or the in-service for the in-service!! ICD Codes ICD = International Statistical Classification of Diseases and Related Health Problems ICD = International Statistical Classification of Diseases and Related Health Problems Provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. CPT CPT = Current Procedural Terminology CPT = Current Procedural Terminology Code Set accurately describes medical, surgical, and diagnostic services Code Set accurately describes medical, surgical, and diagnostic services Designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. Relationship between CPT and ICD-9 The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure. Researchers have observed that when head-shaking nystagmus (HSN) is provoked in patients with peripheral vestibular disorders, usually (in more than 75% of cases) it beats toward the normal or unaffected ear. Head-shaking nystagmus (HSN) almost always is pathological when it is recognized under the Frenzel's glasses in darkness, and suggests a vestibular lesion of peripheral or central origin.
HSN beating toward the normal ear in patients with unilateral peripheral vestibular lesions is known as deficiency nystagmus. We retrospectively analyzed clinical records of eight patients who had unilateral Meniere's disease and came to Gunma University Hospital for consultation in the period from June 1984 through June 1989. These facts suggested that the occurrence of HSN directed to the morbid ear in the recuperation period in Meniere's disease might indicate the impending recurrence of a vertigo attack in a few days.
MS, a 28-year-old woman (patient 5; see Table 1), first consulted us on August 12, 1985 with a 2-year history of frequently occurring episodic vertigo associated with right hearing loss. Spontaneous nystagmus (SN) and HSN were not observed under the Frenzel's glasses on the day of the patient's first visit (August 12, 1985) nor on August 15. These facts suggested that the appearance of HSN directed toward the involved ear could be a warning signal for the imminent occurrence of vertigo attacks in this case.
The patient wanted to have a second child, so we avoided giving medicine and sectioned both the chorda tympani and the tympanic plexus of her right ear on January 7, 1986.
The occurrence of HSN beating toward the morbid ear in the recuperation period in Meniere's disease may indicate the impending recurrence of a vertigo attack in a few days. This work was presented at the Twenty-Fifth Ordinary Congress of the Neurootological and Equilibriometric Society, March 19-22, 1998. DSM codes are used for clinical billing by psych ) 290-319: Mental disorders (used by primary care and psych for research. Professional Coders in your office or from insurance companies have been trained to match documentation in charts to the billing information Professional Coders in your office or from insurance companies have been trained to match documentation in charts to the billing information It is the Content, not the volume, of documentation that determines your E&M code!


Researchers have observed that when HSN is provoked in patients with peripheral vestibular disorders, usually (in more than 75% of cases) it beats toward the normal or unaffected ear. In contrast, HSN beating toward the morbid ear in unilateral peripheral vestibular lesions may be a recovery nystagmus or an irritative nystagmus [2]. They were required to meet the following condition: In the period prior to the attacks of vertigo, for which a l0-day period preceding the attack was arbitrarily considered (the forerunning period), HSN observed using the Frenzel's glasses in darkness reversed its direction, appeared, or disappeared. Numbers of male and female patients were equal within the age range of 27-58 years (average, 47).
In the present group of patients, vertigo attacks occurred from 6 hours to 8 days (average, 3.2 days) after the observation of HSN beating toward the morbid ear.
Usually the vertigo attacks lasted for some 3-4 hours, accompanied by nausea and, at times, vomiting, by a sensation of fullness or pressure of the right ear, and by increased tinnitus or other auditory symptoms. Cercine (a diazepam) and Merislon (betahistine mesylate) were prescribed for the patient, but she had an episode on August 17 at home. On October 30, HSN was provoked to the left but, on November 7, it appeared in the opposite direction. The immediate administration of a hyperosmotic diuretic in this stage of Meniere's disease successfully may suppress the recurrence of vertigo attacks. Every health condition can be assigned to a unique category and given a code, up to six characters long.
Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. This finding presumably reflects the changeable pathophysiological state of the labyrinth of Meniere's disease.
These facts have led us to consider that HSN beating toward the morbid ear may warn of impending vertigo recurrence in Meniere's disease and that the attack of vertigo may be avoided if the patient is treated properly during this pathological state of the inner ear. When the HSN showed a biphasic pattern [2,3] , only the first phase was considered in the present analysis.
The observation periods of each patient were from 2 months to 1 year and 10 months (average, 1 year and 3 weeks). In three of these patients, the immediate administration of isosorbide, a hyperosmotic diuretic [4], in this stage successfully suppressed the recurrence of vertigo attacks. We retrospectively analyzed clinical records of eight patients who had unilateral Meniere's disease and carne to Gunma University Hospital for consultation in the period from 1984 through 1989.


This finding presumably reflects the changeable pathophysiological state of the labyrinth, such as endolymphatic hydrops, of Meniere's disease.
Audiometric examination revealed a mild sensorineural low-tone loss in the right ear, with normal hearing in the opposite ear. Two digit modifiers may be added when appropriate to clarify or modify the description of the procedure. All patients satisfied the following condition: In the period prior to the attacks of vertigo, for which a l0-day period preceding the attack was arbitrarily considered (the forerunning period), HSN reversed its direction, appeared, or disappeared. The right-ear deafness remained in the 25-to 45-dB range, with normal hearing in the left ear. The place of service (inpatient or outpatient) The place of service (inpatient or outpatient) The type of service (new vs. When HSN showed a biphasic pattern, only the first phase was considered in this present analysis. Twenty days thereafter (October 9), the patient came to the hospital because she had an episode early that morning. In the period before the attack, HSN reversed its direction from the normal to the morbid ear five times in four patients, appeared toward the morbid ear in three patients, and disappeared from one beating toward the normal ear before the forerunning period of vertigo attacks in one patient. The use of “Follow-up” is insufficient documentation as it does not indicate medical necessity.
These findings suggest that the occurrence of HSN directed to the morbid ear in the recuperation period in Meniere's disease might indicate the impending recurrence of a vertigo attack in a few days. On October 17, SN could not be observed any longer, but HSN still appeared to the right, and the patient experienced vertigo attacks on October 20 and 22. In the present group of patients, vertigo attacks occurred from 6 hours to 8 days (average, 3.2 days) after the observation ofHSN beating toward the morbid ear.
In three of these patients, the immediate administration of isosorbide (a hyperosmotic diuretic) in this stage successfully suppressed the recurrence of vertigo attacks.
A clinical diagnosis was made of classic Meniere's disease involving the right ear (Table 2).



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