ICD-9-CM Request Form Proposed Coding Change to ICD-9
If you have any questions concerning the completion of this form, please consult with the AAP at 800/433-9016, ext. 4325 or send e-mail message to: bdolan@aap.org
Change request by:
Section Affiliation (if any):
Name:
Address:
City:
State:	Alaska Alabama Alberta Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico Newfoundland North Carolina North Dakota Ohio Oklahoma Ontario Oregon Pennsylvania Puerto Rico Quebec Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
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1. Please provide a complete description of the diagnosis, condition, or symptom for which you think a new ICD-9 code is required. Please provide an example to illustrate the need for a new code.
2. Indicate the specific reasons why this code is necessary.
3. Specify the recommended terminology (descriptor) for the proposed ICD-9 code.
4. Please explain how you are currently coding for this diagnosis/condition/symptom and why the existing ICD-9 codes do not meet your needs.
5. Indicate how often the code is used.
6. If you are recommending code deletions and revisions, please explain.
Other Comments: