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Appendix B. Ambulatory Care Sensitive Conditions

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.


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