A patient is admitted for appendicitis and has an appendectomy. Which coding system would be used to report the diagnosis and procedure?

• A. ICD-9-CM
• B. HL7
• C. CDT
• D. CPT

Answer: (A)

The main idea is that hospital inpatient coding uses ICD-9-CM to capture both what the patient’s diagnosis is and what procedure was performed. ICD-9-CM includes separate sets for diagnoses and procedures, so coding the appendicitis diagnosis and the appendectomy procedure together in the patient’s hospital record is done within the same coding system. HL7 is just a data-exchange standard for how information moves between systems, not a coding scheme. CDT is dental terminology, not applicable to general medical conditions or procedures. CPT is typically used for reporting physician services, especially for outpatient or professional billing, whereas the inpatient hospital setting relies on ICD-9-CM Procedure codes for the surgery. So ICD-9-CM is the appropriate system to report both the diagnosis and the procedure in this situation.