ICD 9 - DX code Mandatory Fiftt digit

Mandatory Fifth Digit

A 3-digit code is the primary classification for an illness or injury, a 4-digit code is a secondary classification of the same illness or injury, and a 5-digit code is a classification of the same illness or injury.

Notes are also used to list the fifth-digit sub classifications for subcategories – such as entries “Tuberculosis” or Diabetes mellitus.” Only the four-digit code is given for the individual entry, and you must refer to the note following the main term to locate the appropriate fifth-digit sub classification.

Not all ICD codes are valid for use on insurance claim forms. Carriers require the greatest specificity possible when using the codes. The idea is never to use a 3-digit code that has been sub-classified into 4-digit codes, and never use a 4- digit code that has been sub-classified as a 5-digit code.


Not all codes have fourth and fifth digits, but when a fourth or fifth digit is available, it must be used. It is a good idea to highlight codes with which a fifth digit is listed. This will serve as a reminder to you to always use that fifth digit. The following is a list of fifth digits that are used to identify location.

0 site unspecified
1 shoulder region
2 upper arm
3 forearm
4 hand
5 pelvic region and thigh
6 lower leg
7 ankle and foot
8 other specified sites
9 multiple sites

HERNIA REPAIR Procedures and Related CPT and ICD-9 Procedure Codes

CPT Code	CPT Description	ICD -9 Procedure
49495	Repair initial inguinal hernia, under age 6 months, with or without hydrocelectomy; reducible	5300
49496	incarcerated or strangulated	5300
49500	Repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; reducible	5300
49501	incarcerated or strangulated	5300
49505	Repair initial inguinal hernia, age 5 years or over; reducible	5300
49507	incarcerated or strangulated	5300
49520	Repair recurrent inguinal hernia, any age; reducible	5300
49521	incarcerated or strangulated	5300
49525	Repair inguinal hernia; sliding, any age	5300
49540	Repair lumbar hernia	539
49550	Repair initial femoral hernia, any age; reducible	5329
49553	incarcerated or strangulated	5329
49555	Repair recurrent femoral hernia; reducible	5329
49557	incarcerated or strangulated	5329
49560	Repair initial incisional or ventral hernia; reducible	5351
49561	incarcerated or strangulated	5351
49565	Repair recurrent incisional or ventral hernia; reducible	5351
49566	incarcerated or strangulated	5351
49568	Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for the incisional or ventral hernia repair)	5351 (49565)
49570	Repair epigastric hernia (e.g. Preperitoneal fat); reducible (separate procedure)	5359
49572	incarcerated or strangulated	5359
49580	Repair umbilical hernia, under age 5 years; reducible	5359
49582	incarcerated or strangulated	5359
49585	Repair umbilical hernia, age 5 years or over; reducible	5349
49587	incarcerated or strangulated	5349
49590	Repair spigelian hernia	5359
49600	Repair of small omphalocele, with primary closure	5349
49605	Repair of large omphalocele or gastroschisis; with or without prosthesis	5341
49606	with removal of prosthesis, final reduction and closure, in operating room	5341
49610	Repair of omphalocele (Gross type operation); first stage	5349
49611	second stage	5349

ICD 9 - V76.2 - Pap smear

Screening Pap Smears

Effective, January 1, 1998, §4102 of the Balanced Budget Act (BBA) of 1997 (P.L. 105-33) amended §1861(nn) of the Act (42 USC 1395X(nn)) to include coverage every three years for a screening Pap smear or more frequent coverage for women:
1. At high risk for cervical or vaginal cancer; or
2. Of childbearing age who have had a Pap smear during any of the preceding three years indicating the presence of cervical or vaginal cancer or other abnormality.

Effective July 1, 2001, the Consolidated Appropriations Act of 2001 (P.L. 106-554) modifies §1861(nn) to provide Medicare coverage for biennial screening Pap smears. Specifications for frequency limitations are defined below.

For claims with dates of service from January 1, 1998, through June 30, 2001, screening Pap smears are covered when ordered and collected by a doctor of medicine or osteopathy (as defined in §1861(r)(1) of the Act), or other authorized practitioner (e.g., a certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist, who is authorized under State law to perform the examination) under one of the following conditions.

The beneficiary has not had a screening Pap smear test during the preceding three years (i.e., 35 months have passed following the month that the woman had the last covered Pap smear ICD-9-CM code V76.2 is used to indicate special screening for malignant neoplasm, cervix); or

There is evidence (on the basis of her medical history or other findings) that she is of childbearing age and has had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years; and at least 11 months have passed following the month that the last covered Pap smear was performed; or

She is at high risk of developing cervical or vaginal cancer ICD-9-CM code V15.89, other specified personal history presenting hazards to health) and at least 11 months have passed following the month that the last covered screening Pap smear was performed. The high risk factors for cervical and vaginal cancer are:

Cervical Cancer High Risk Factors

Early onset of sexual activity (under 16 years of age);
Multiple sexual partners (five or more in a lifetime);
History of a sexually transmitted disease (including HIV infection); and
Fewer than three negative or any Pap smears within the previous seven years.

Vaginal Cancer High Risk Factors

The DES (diethylstilbestrol) - exposed daughters of women who took DES during pregnancy

The term “woman of childbearing age” means a woman who is premenopausal, and has been determined by a physician, or qualified practitioner, to be of childbearing age, based on her medical history or other findings. Payment is not made for a screening Pap smear for women at high risk or who qualify for coverage under the childbearing provision more frequently than once every 11 months after the month that the last screening Pap smear covered by Medicare was performed.

For Claims with Dates of Service on or After July 1, 2001

When the beneficiary does not qualify for a more frequently performed screening Pap smear as noted in items 1 and 2 above, contractors pay for the screening Pap smear only after at least 23 months have passed following the month during which the beneficiary received her last covered screening Pap smear. All other coverage and payment requirements remain the same.

High Risk Medication DX Codes - V58.61

High Risk Medication Codes

V58.61 Long-term (current) use of anticoagulants
V58.62 Long-term (current) use of antibiotics
V58.64 Long-term (current) use of non-steroidal anti-inflammatories (NSAID)
V58.65 Long-term (current) use of steroids
V58.66 Long-term (current) use of aspirin
V58.67 Long-term (current) use of insulin
V58.69 Long-term (current) use of high risk medications