Access to Health Care in America (1993)
Chapter: Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries
D
"Ambulatory-Care-Sensitive" Conditions and "Referral-Sensitive" Surgeries
"AMBULATORY-CARE-SENSITIVE" CONDITIONS
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 ENT infections [382, 462, 463, 465, 472.1] | Exclude otitis media cases [382] with myringotomy with insertion of tube [20.01] |
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 SNF/ICF |
Diabetes "A" [250.1, 250.2, 250.3] |
|
Diabetes "B" [250.8, 250.9] |
|
Diabetes "C" [250.0] |
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Hypoglycemia [251.2] |
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Gastroenteritis [558.9] |
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Kidney/urinary infection [590, 599.0, 599.9] |
|
Dehydration—volume depletion [276.5] | Examine principal and secondary diagnoses separately |
Dental Conditions [521, 522, 523, 525, 528] |
|
"REFERRAL-SENSITIVE" SURGERIES
Condition 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] | Womens only |
Pacemaker insertion [37.7] |
|
Coronary artery bypass surgery [36.1] |
|
Coronary angioplasty [36.01, 36.02, 36.05] |
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