APPENDIX A - CODING PRINCIPLES
There are specific guidelines for coding diagnoses and surgical procedures. This
appendix contains excerpts of coding principles (modified for instructional purposes)
from the Individual Patient Data System (IPDS) User's Manual published by the U.S.
Army Patient Administration Systems and Biostatistics Activity (PAS&BA). These
excerpts provide coding principles for diagnostic and operative coding using the
ICD-9-CM. The IPDS User's Manual includes additional principles that are not provided
in this appendix. The numbers for each of the principles in this appendix are the same
as the corresponding principle in the IPDS User's Manual so you will be able to identify
the principles that are not covered in this subcourse.
In previous lessons, you have reviewed the preliminary coding guidelines that, for the
most part, are applicable generically; i.e., they apply to all coding processes. To
provide more specific guidance, this appendix includes 18 principles in short, narrative
form. However, each coder should have his/her own copy of the Triservice Disease and
Procedure Coding Guidelines ICD-9-CM , which became effective 1 January 1991.
Principle I. SUSPECTED CONDITIONS
1. Qualifying adjectives used in the final diagnostic statement imply that a final
judgment has not been made. When words such as "suspected," "probable,"
"questionable," "likely," etc., are used in the diagnosis, code the condition as if it were a
2. The code assigned to the questionable condition may be used as the principal
diagnosis if it was proven to be the condition, after study, that occasioned this
3. Qualifying adjectives such as "Rule Out," "R/O," and "Ruled Out" present special
problems for which the following coding rules have been developed.
a. Rule Out and R/O. When these words appear in the final diagnostic statement,
they have the same meaning as "suspected" and are to be coded as if the condition
b. When "Ruled Out," "Not Proven," "Not Confirmed," and "No Evidence Of" appear
as part of the diagnosis or the diagnosis is stated in terms which indicate the absence of
the condition under investigation, the appropriate code from the Supplementary
Classification (V71 category) will be used. The medical record documentation must
support the investigation of the suspected condition. Admissions following head trauma
where there is no visible evidence of injury and which after observation show no
evidence of after effects are coded to V71.4--, the code extender for Observation,
head injury, ruled out. (V713-V716 categories require STANAG Cause of Injury Code
and Trauma code.) Note that codes from the V71 category may only be used as a