National Academies Press: OpenBook

Access to Health Care in America (1993)

Chapter: Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries

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Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
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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]

Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
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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]

 

Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
×

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

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]

 

Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
×
This page in the original is blank.
Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
×
Page 219
Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
×
Page 220
Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
×
Page 221
Suggested Citation:"Appendix D: Ambulatory-Care Sensitive Conditions and Referral-Sensitive Surgeries." Institute of Medicine. 1993. Access to Health Care in America. Washington, DC: The National Academies Press. doi: 10.17226/2009.
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Page 222
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Americans are accustomed to anecdotal evidence of the health care crisis. Yet, personal or local stories do not provide a comprehensive nationwide picture of our access to health care. Now, this book offers the long-awaited health equivalent of national economic indicators.

This useful volume defines a set of national objectives and identifies indicators—measures of utilization and outcome—that can "sense" when and where problems occur in accessing specific health care services. Using the indicators, the committee presents significant conclusions about the situation today, examining the relationships between access to care and factors such as income, race, ethnic origin, and location.

The committee offers recommendations to federal, state, and local agencies for improving data collection and monitoring.

This highly readable and well-organized volume will be essential for policymakers, public health officials, insurance companies, hospitals, physicians and nurses, and interested individuals.

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