Medical Assistance Chapter 15 Basics Of Diagnostic Coding

Front 1

History of the ICD9 Book

Back 1

*the first volume was identified as the International Classification System of the causes of Death
*in the near future the ICD10(International Classification of Diseases and Related Health problems will be adopted for use here in the US
*the ICD10 is currently being used overseas

Front 2

What is Diagnosis Coding?

Back 2

*it is a translation of written information into numeric codes
*covers diseases, illnesses, injuries, and symptoms of patients
*this information is used on the healthcare claim form to verify the necessities the medical necessity as to why a particular test was ordered

Front 3

Why use ICD.9 Codes?

Back 3

*To explain medical necessity of a procedure provided for reimbursement to the provider or facility
*Standardized system understood by all reimbursement parties
*Provide statistical information for research
*Appropriateness and timeliness of medical care

Front 4

Terms with Coding

Back 4

*Primary-diagnosis in an outpatient medical setting
-Reason for the encounter
*Secondary-listed after primary. Indicating possible cause of current condition or need for higher level of care
*Principal-diagnosis in a hospital setting
*Rule Out-suspected, proable, questionable, but has not been confirmed
-Never used as a primary diagnosis
*Professional-billing for physicians
*Facility-billingfor hospitals

Front 5

ICD.9 Volumes

Back 5

*Volume I-Tabular Index(Professional Billing)
*Volume II-Alphabetic Index(Professional Billing)
*Volume III-Procedures:Tabular Index and Alphabetic Index(Hospital Billing)

Front 6

Volume I

Back 6

*17 Chapters:
1. (001-139)Infectious and Parasitic Diseases
2. (140-239)Neoplasm's
3. (240-279)Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders
4. (280-089)Disease of the Blood and Blood-forming Organs
5. (290-319)Mental Disorders
6. (320-389)Diseases of the Nervous System and Sense Organs
7. (390-459)Diseases of the Circulatory System
8. (460-519)Diseases of the Respiratory System
9. (520-579)Diseases of the Digestive System
10. (580-629)Diseases of the Genitourinary System
11. (630-677)Complications of Pregnancy, Childbirth and Puerperium
12. (380-709)Diseases of the Skin and Subcutaneous Tissue
13. (710-739)Disease of the Musculoskeletal System and Connective Tissue
14. (740-759)Congential Anomalies
15. (760-779)Certain Conditions Originating in the Perinatal Period
16. (780-799)Symptoms, signs, and III defined Conditions
17. (800-999)Injury and Poisoning

*V-Codes
*E-Codes

Front 7

Volume II

Back 7

*Section 1-Alphabetic Index to Diseases
-Main terms-boldface
-Subterms-indented two spaces under main term
-Subterm of a subterm-indented two spaces under subterm
-Carry over line-indented more than two spaces from the preceded line
*Section 2-Table of Drugs and Chemicals
*Section 3-Index to External Causes of Injury
*Special tables:Hypertension and Neoplasm

Front 8

Volume III

Back 8

*is for hospital billing
*it is an alphabetical index to procedures and tabular procedures to volume 3 unlike the professional side of volume 1 & 2

Front 9

Structure of the ICD.9 Code

Back 9

*3rd digit category
*4th digit subcategory
*5th digit sub-classification

854.11
-854=Intracranial Injury
-854.1=with open intracranial wound
-854.11=with no loss of consciousness

*all ICD.9 codes with have a minimum of 3 digits and a maximum of 5-may have 4th or 5th digit

Front 10

Supplemental Classifications

Back 10

*V Codes-Supplementary Classification of Factors Influencing Health Status and Contact with Health Service
-Preventative, admission, history
-Can be used as primary diagnosis or alone

*E Codes-Supplemental Classification of External Causes of Injuries and Poisoning
-Injury, poisioning, adverse effects
-Cannot be used as primary diagnosis or alone

*gives insurance companies and third party pares additional information as to the specifics about the individual posioning

Front 11

Abbreviations

Back 11

*NOS-Not Otherwise Specified(Unspecified)
-statement does not provide more specificity or definition of the diagnosis

*NEC-Not Elsewhere Classified
-No specific classification exists to support specificity or defintion of the diagnosis

Front 12

Punctuation

Back 12

*[]Brackets-enclose synonyms, alternative wording and explanatory phrases
-Fracture of metacarpal bone(s) hand [except fingers]

*()Parentheses-supplemetal words to further describe a statement. Does not affect code selection. Referred to as nonessential modifiers
-Diabetes, diabetic(brittle) (congential) (familiar) (mellitus) (poorly controlled) (sever) (slight) (without complication)

*:Colon-used after an incomplete term which needs more information to assign a code.
-Aneurysm:
*Mural
*ventricular

Front 13

Symbols

Back 13

*dot-New Code
*triangle-Revision of text to an existing code
*4th-requires a subcategory code to be valid
*5th-requires a subclassification code to be valid
*+-female diagnosis only
*^-male diagnosis only

Front 14

Italicized Typeface

Back 14

*Used for all exclusion notes
-Excludes:arteriovenous aneurysm or fistula:
>Acquired(447.0)
>Congential(747.60-747.69)
>Traumatic(900.0-904.9)

*Used to identify categories not to be used as a primary diagnosis code
-Diabetic neuropathy 250.4[583.81]
583.81 Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere

*Used for additional notes or directions
-Code first additional notes or directions
-Code first underlying diseases, as:
-Diabetes mellitus (250.7)

Front 15

Includes

Back 15

*Notation under a category that can:
-further defines
-give examples
-provide modifying adjectives, sites or conditions

Front 16

Excludes

Back 16

*Exclusion terms are enclosed in a box
*Text is in italicized print
*Used to guide coder to proper code assignment

Pneumonitis due to solids and liquids
-fetal aspiration pneumonitis(770.18)

Front 17

Notes

Back 17

*used to define terms
*give coding instructions
*often used in 5th digit categories
*sometimes written in italics

Chronic airway obstruction, not elsewhere classified
Note:this note is not to be used with any code from categories 491-493

The following fifth-digit subclassification is for use with codes 493.0-493.2, 493.9:
0-unspecified
1-with status asthmaticus
2-with (acute) exacerbation

Front 18

"SEE"

Back 18

*See-indicates that a different term should be used
Breast- see condition
*See category-variation of the "see" instructions. Directs coder to a specific category code. This must be follwed

*See also-directs coder to another entry that may be useful
Ringing in the ear (see also Tinnitus) 388.30
Tinnitus (aurium) 388.30
audible 388.32
objective 388.32
subjective 388.31

Front 19

Code First

Back 19

*Indicates sequence of coding order

581.81 Nephrotic syndrome in disease classified elsewhere
8Code first underlying disease, as:
diabetes mellitus(250.4)
malaria(084.9)
system lupus erythematosus(710.0)

Front 20

Use Additional Code

Back 20

*A supplemental code should be used to provide a more complete description

429.Myocarditis, unspecified
Use additional code, if desired, to identify presence of arteriosclerosis.

429.7 Certain sequelae of myocardial infarction, NEC
Use additional code to identify the associated myocardial infarction:
with onset of 8 weeks or less(410.00-410.92)
with onset of more than 8 weeks(414.8)

Front 21

"And"

Back 21

*And-interpreted as "and" or "or"

478.1 Other disease of nasal cavity and sinuses
Excludes: varicose ulcer of nasal septum(456.8)

Front 22

"With"

Back 22

*With-is sequenced immediately following the term. Provides additional information or specificity to a code.

Cholelithiasis(impacted) (multiple) 574.2

Note:Use the 5th digit subclassification with category 574:
0 without mention of obstruction
1 with obstruction

with
cholecystitis 574.1
acute 574.6
chronic 574.1

Front 23

Nine Basic Steps

Back 23

1. Abstract the diagostic statement

2. Determine main terms in statement describing condition

3. Determine modifying words

4. Locate term in plphabetical index(volume 2)

5. Review notes and cross referencing(see also)

6. Choose a tentative code

7. Reference the code in the tabular listing(volume 1)

8. Verify the code's accuracy. Review:notes, exclusive, etc.

9. Assign and document the appropriate code in record

Front 24

Coding Example

Back 24

*Acute myocardial infarction of the lateral wall initial episode
1. Abstract diagnostic statement
2.Determine main terms in statement describing condition(infraction)
3. Determine modifying words(myocardial, lateral wall, acute)
4. Locate term in alphabetical index(Volume 2) (infarction, myocardial, lateral wall,)
Infarct, Infarction
myocardium, myocardial
lateral wall 410.5

5. Review notes and cross referencing (see also)

6.Choose a tentative code

7. Refernce the code in the tabular listing (volume 1)
5th 410.5 Of other lateral wall
ST elevation myocardial infarction(STEMI) of other lateral wall

8. Verify the code's accuracy. Review: notes, exclusions, etc.

9. Assign and document the approipriate code in record (410.51)

Front 25

Coding Rules

Back 25

*Code only what the provider has documented
*Never change or add a code
*Review the record for additional information
*Query provider for additional information
*Always use current ICD9 books
*Always use Volume 1 & 2
*Always code to highest level of specificity
*Always read and follow surrounding notes and guidelines of codes
*Never code "rule out", "questionable" or "suspected" in professional diagnosis coding

Front 26

Coding Tips

Back 26

*Look up words and abbreviation
*Add notes to your books
*Avoid non-specific code
*Be careful when coding pre-existing or late effect conditions
*Know that documentation supports the diagnosis code
*Inaccurate coding can lead to claim denial, fraud and abuse