Ambulatory Care Sensitive Conditions (ACSCs) are a set of health conditions where appropriate outpatient care can prevent or reduce the need for hospitalization. Understanding the diagnosis codes associated with these conditions is crucial for healthcare professionals, policymakers, and anyone interested in healthcare quality and efficiency. This article provides a detailed overview of ACSCs and their corresponding ICD-9-CM and ICD-10-CM diagnosis codes, offering a valuable reference for navigating this important aspect of healthcare.
Understanding Ambulatory Care Sensitive Conditions
ACSCs are essentially conditions for which timely and effective ambulatory care (outpatient care) can prevent acute episodes or effectively manage chronic diseases, thus avoiding unnecessary hospital admissions. Monitoring ACSC hospitalization rates is a key indicator of the effectiveness of primary care and the overall healthcare system’s accessibility and quality. Higher hospitalization rates for ACSCs may suggest issues with access to primary care, quality of outpatient management, or public health concerns within a community.
The concept of ACSCs helps in identifying areas where improvements in healthcare delivery can lead to better patient outcomes and reduced healthcare costs. By focusing on enhancing ambulatory care for these conditions, healthcare systems can strive to keep individuals healthier and out of the hospital.
ACSC Diagnosis Codes: ICD-9-CM and ICD-10-CM Groupings
The following tables categorize ACSCs into Avoidable, Acute, and Chronic conditions, providing the associated diagnosis codes under both the ICD-9-CM and ICD-10-CM coding systems. It’s important to note that ICD-9-CM codes were used for diagnoses reported before October 1, 2016, while ICD-10-CM has been used since.
Avoidable Conditions
These are conditions that, with effective preventative care and management in the ambulatory setting, should ideally not lead to hospitalization.
| Ambulatory Care Sensitive Conditions | ICD-9-CM | ICD-10-CM | Comments |
|---|---|---|---|
| Congenital Syphilis | 090 | A50 | Secondary diagnoses for newborn only |
| Failure to Thrive | 783.41 | R62.51, R62.52, R62.0, R62.50 | Age-related considerations |
| Dental Conditions | 521-523, 525, 528 | K02-K05, K060-K062, K08, K12-K13, M27.6, A69.0, K09.8 | Broad range of dental health issues |
| Vaccine Preventable Conditions | 033, 037, 045, 320.0, 390-391; and 320.2 for ages 1-5 only | A33-A35, A37, A80, G00.0, I01; and G00.2 for ages 1-5 only | Includes conditions preventable by vaccination; age-specific for some codes |
| Nutritional Deficiencies | 260-262, 268.0, 268.1 | E40-E41, E43, E55.0, E64.3 | Applicable as primary and secondary diagnoses |
Acute Conditions
These are acute illnesses that can often be effectively treated in an outpatient setting, and hospitalization might indicate a failure in timely or appropriate ambulatory care.
| Ambulatory Care Sensitive Conditions | ICD-9-CM | ICD-10-CM | Comments |
|---|---|---|---|
| Bacterial Pneumonia | 481, 482.2-482.3, 482.9, 483, 485-486 | J13-J14, J153-J154, J157, J159, J16, J18 | Excludes specific patient groups like those with sickle cell disease or infants under 2 months |
| Cancer of the Cervix | 180.0-180.1, 180.8-180.9 | C51.0, C53.1, C53.8-C53.9 | Focuses on cervical cancer diagnoses |
| Cellulitis | 681-683, 686 | L03-L04, L08, L88, L98.0 | Excludes cases involving major surgical procedures, with specific exceptions for minor procedures |
| Convulsion | 780.3 | R56 | General convulsions |
| Dehydration (Volume Depletion) | 276.5 | E86 | Can be primary or secondary diagnosis |
| Gastroenteritis | 558.9 | K52.9, K528.9 | General gastroenteritis cases |
| Hypoglycemia | 251.2 | E16.2 | Low blood sugar conditions |
| Kidney/Urinary Infection | 590.0, 599.0, 599.9 | N10-N12 | Covers kidney and urinary tract infections |
| Pelvic Inflammatory Disease | 614 | N70, N73 | Pelvic inflammatory conditions |
| Severe Ear, Nose & Throat Infections | 382, 462, 463, 465, 472.1 | H66, J02, J03, J06, J312 | Excludes specific otitis media cases with tube insertion |
| Skin Grafts with Cellulitis | MS-DRG = 573-575 | MS-DRG = 573-575 | Classified under specific MS-DRG codes |
Chronic Conditions
These are long-term conditions that require ongoing management. Hospitalization for these conditions might be avoidable with consistent and effective outpatient care to manage exacerbations and complications.
| Ambulatory Care Sensitive Conditions | ICD-9-CM | ICD-10-CM | Comments |
|---|---|---|---|
| Angina | 411.1, 411.8, 413 | I20, I24.0, I24.8-I24.9 | Excludes cases involving surgical procedures |
| Asthma | 493 | J45 | Excludes specific surgical procedures related to asthma management |
| Chronic Obstructive Pulmonary Disease | 466.0, 491, 492, 494, 496, 466.0 only with secondary diagnosis of 491, 492, 494, 496 | J20, J40-JJ44, J47, J20.9 only with secondary diagnosis of J41-J44, J47 | COPD and related conditions |
| Congestive Heart Failure | 402.01, 402.11, 402.91, 428, 518.4 | I50, I11.0, J81.0 | Excludes cases with surgical procedures |
| Diabetes | 250.0-250.3, 250.8-250.9 | E10.1, E13.1, E11.0, E13.0, E10.641, E11.641, E10.6, E11.6, E11.8, E10.9, E11.9 | Broad range of diabetes diagnoses |
| Grand Mal Status and Other, Epileptic Convulsions | 345 | G40 | Epilepsy and related convulsive disorders |
| Hypertension | 401.0, 401.9, 404.00, 402, 10 | I10, I11.0 | Excludes specific surgical procedures related to hypertension management |
| Tuberculosis (Non-Pulmonary) | 012-018 | A15.0, A15.5, A15.9 | Non-pulmonary tuberculosis conditions |
| Pulmonary Tuberculosis | 011 | A15.4, A15.6, A15.8, A17, A18, A19 | Pulmonary tuberculosis conditions |
Note:
(1) Diagnosis reported prior to 10/01/16 are coded using ICD-9-CM. The codes are selected by primary diagnosis, unless otherwise noted.
(2) Diagnosis reported after 10/01/16 are coded using ICD-10-CM. The codes are selected by primary diagnosis, unless otherwise noted.
(3) This website uses DRGs defined by an algorithm owned by the 3M Company.
Source:
ACS Listing (ICD-9-CM Groupings): Institute of Medicine, “Access to Health Care in America”, Michael Millman, Ph.D, Editor, National Academy Press, Washington, D.C., 1993.
ACS Listing and (ICD-10-CM Groupings): John Billings, Professor, Director, Health Policy and Management Program. Robert F. Wagner School of Public Service, New York University.
Conclusion
Understanding Ambulatory Care Sensitive Conditions and their diagnosis codes is essential for monitoring and improving healthcare delivery. By focusing on effective outpatient care and utilizing these diagnostic codes, healthcare systems can work towards reducing preventable hospitalizations and enhancing the overall health of communities. This guide serves as a starting point for professionals and anyone interested in delving deeper into the specifics of ACSCs and their coding within the ICD-9-CM and ICD-10-CM systems.
