Medical assisting Administrative and clinical procedures (5e) Chapter 18 Diagnostic coding

In this chapter students will be able to: Explain the purpose and format of the ICD9CM volumes that are used by medical offices, describe how to analyze diagnoses and locate correct codes using the ICD9CM, identify the purpose and format of the CPT, name three key factors that determine the level of Evaluation and Management codes that are selected,...

Diagnostic Coding

Learning Outcomes (cont.)

18.1 Recall the six ways that ICD codes are used

Learning Outcomes (cont.)

18.5 Name the appendixes found in ICD-9-CM.

18.6 Compare ICD-9-CM and the ICD-10-CM.

18.7 Summarize the ICD-10-CM general coding

guidelines.

18.8 Illustrate unique coding applications for

neoplasms, diabetes mellitus, fractures, R

codes, poisonings, and Z codes.

Introduction

• Diagnosis – translated into ICD codes

• Reimbursement is based on codes

entered so you must

– Understand what the codes mean

– Know how to chose correct codes

The Reasons for Diagnostic Codes

The Reasons for Diagnostic Codes

• International Classification of Diseases

– 9th edition ~ ICD-9-CM

– 10th edition ~ ICD-10-CM

• Original purpose of ICD-9-CM

– Classification of morbidity and mortality

statistics – Medical research, education, and

administration

The Reasons for Diagnostic Codes (cont.)

• Current uses

– Facilitation of payment

– Evaluation of utilization patterns

– Study healthcare costs

– Research

– Prediction of trends

– Planning for future

Apply Your Knowledge

How are ICD codes used?

ANSWER: ICD codes are used for:

•Facilitation of payment for medical services

•Evaluation of utilization patterns

•Study of healthcare costs

•Research regarding quality of healthcare

•Prediction of healthcare trends

•Planning for future healthcare needs

An Overview of the ICD-9-CM

• Diseases and Injuries Tabular List (Volume 1)

– 17 chapters of disease descriptions and codes

– V codes

– E codes

• Alphabetic Index (Volume 2)

• Volume 3 ~ edition for hospitals

• Appendices

NOS – not otherwise specified

NEC – not elsewhere classified

[ ] – brackets

[ ] – slanted bracket

Conventions (cont.)

• Code first underlying disease

• Code, if applicable, any causal condition

first

• Be aware of

– Boldface type

– Italicized typeface

The Alphabetic Index

• Contains terms needed to locate codes

The Tabular List

• Organized by source or body system

• Code structure - categories

– Rubrics ~ three digit

– Subcategories ~ four digit

– Subclassifications ~ five digit

• Code to highest level of specificity

The Tabular List (cont.)

– Encounters not related to illness or injury

– Primary or supplemental codes

– May not be covered by insurance carrier

The Tabular List (cont.)

– External causes of injuries and poisoning

– “How did that happen?”

– Only a supplemental code

Apply Your Knowledge

Matching

_ contains synonyms or alternative wordings A NOS

_ surround nonessential or supplementary terms B NEC

_ used after an incomplete term C [ ]

_ ICD-9 does not contain a code specific enough D [ ]

_ used if condition cannot be better descriped E ( )

_ a directive; refers you to a different term F :

_ indicates that 2 codes are needed G See Also

_ a suggestion; you might find a better code H See Condition

Locate the patient’s diagnosis

 Find the diagnosis in the Alphabetic Index



Locate the code from the Alphabetic

Index in the Tabular List

 Read to find the best code

 Record the code



Coding with ICD-9

Coding with ICD-9 (cont.)

• Acute vs chronic conditions – list acute

code first

• Combination codes – used in place of

single codes

• Multiple coding – more than one code

required to describe diagnosis

Coding with ICD-9 (cont.)

• Coding unclear diagnoses

• Principal vs primary diagnosis

– Principal diagnosis

– Primary diagnosis

– Secondary diagnosis

Apply Your Knowledge

What are the steps to code a diagnosis?

ANSWER:

1.Locate the diagnosis in the medical record

2.Find the diagnosis in the Alphabetic Index

3.Locate the correct code in Alphabetic Index and then

in the Tabular Index

4.Read all instructions to find the best code

5.Record the code

V Codes and E Codes

• V codes – Supplementary Classification of

Factors Influencing Health Status and

Contact with Health Services

• E codes – Supplementary Classification of

External Causes of Injury and Poisoning

E Codes

• General use

– Initial treatment only, except fractures

– Use as many codes as required

• Poisonings and Adverse Effects

– Refer to poisoning column then to

how it occurred– Must be documented in the medical

record to code

– How it occurred (E code)

E Codes are never the primary code

patient required stitches to close a wound from a knife patient was exposed to a chemical that caused a rash patient was seen for a shingles vaccination

patient had an annual physical patient presented with a fractured wrist child came to office for a sports exam patient is requesting birth control pills

Apply Your Knowledge

Determine whether a V code or E code should

Appendices of ICD-9

A Morphology of Neoplasms

B Deleted

C Classification of Drugs

D Classification of Industrial Accidents

E List of the Three Digit Categories

Apply Your Knowledge

List the appropriate Appendix:

• ICD-10-PCS – hospital codes

Characters and Specificity

• Codes begin with an Alpha character

• Possible characters ~ 3-7

• More precise clinical picture

• Enhances trending analysis

ICD-9 (limited specificity) ICD-10 (expanded specificity)

Code: 233.0 Carcinoma in situ

breast (vague as to cancer

type)

Code: D05.01 Lobular carcinoma in situ of right breast

OR Code: D05.11 Intraductal carcinoma in site

of right breast

910.0 Face, neck, and scalp;

abrasion or friction burn

without mention of infection

S00.01 Abrasion of scalp (code noted to √x7th)

910.1 Face, neck, and scalp;

abrasion or friction burn,

infected

S00.01xA Abrasion of scalp, initial encounter S00.01xD Abrasion of scalp, subsequent

encounter S00.01xS Abrasion of scalp, sequela

Combination Codes

• More combination codes available

• Decreased need for multiple codes

ICD-9-CM ICD-10-CM 995.92 Severe sepsis

and 785.52 Septic shock

R65.21 Severe sepsis with septic shock

Apply Your Knowledge

List at least two ways that the ICD-10 is an improvement

over the ICD-9

ANSWER:

The ICD-10 contains many more codes, allows for expansion;

has more combination codes, and incorporates placeholders

all of which enables more precise coding.

Basic Coding Guidelines for ICD-10

Refer to notes

Read and follow terms

in ( ) and [ ]

Read and follow terms

Follow instructional terms to appropriate code

Assign the appropriate

code with highest

degree of specificity

Assign the appropriate

code with highest

• Conventions are similar to ICD-9

• ICD-10

– More detailed documentation by physician

– Never code from the Alpha Index

– Verify codes in Tabular list

Apply Your Knowledge

What are the general coding guidelines for the

ICD-10?

ANSWER:

Locate the diagnosis in the Alphabetic Index

Read and follow all notes and conventions.

Locate in Tabular list.

Follow instructions to the appropriate code.

Assign the code with highest degree of specificity.

• Chapter 1 – HIV coding

– R75 ~ inconclusive laboratory evidence

– B20 ~ positive serology

– Z21 ~ HIV positive, asymptomatic

– Z71.7 ~ counseling provided

– Appropriate code from G89 category

Chapter (cont.)

• Chapter 6

– Eye and ear not

included– G89 ~ pain diagnoses

– If present, list

underlying cause first then the pain code

• Chapter 9 – Hypertension

– I10 ~ essential hypertension

– Code underlying

etiology then code hypertension

– R030.3 ~ transient hypertension

Chapter (cont.)

• Chapter 19

– Poisoning

• 5th digit – placeholder “x”

• 6th digit – how occurred

• 7th digit – type of encounter

– Burns and Corrosions

• Depth, extent, agent

• Corrosive material sequenced first

Chapter (cont.)

• Chapter 20

– Replaces E codes

– Accidents or injuries

– Research and prevention

– Abuse codes take priority

Chapter (cont.)

• Practice

• Read guidelines carefully

• Ask questions

Apply Your Knowledge

When a code requires a 7th code, what does it

indicate?

ANSWER: The 7 th character of a code indicates

the type of encounter: initial, subsequent, or

sequela.

In Summary

18.1 ICD codes are used to facilitate payment for medical

services; evaluate utilization patterns; study healthcare costs; research quality of healthcare;

predict healthcare trends; and plan for future healthcare

needs

18.2 There are conventions used in the ICD

Bold and italics are used in both the Alphabetic Index and Tabular List

Instructions to omit code, see condition, and see

also are found exclusively in the Alphabetic Index.

Document each code carefully using instructions as

to code sequencing on the CMS-1500 claim form

In Summary (cont.)

18.6 ICD-10-CM is intended to provide a more precise

clinical picture of the patient and enhanced trending analysis for data reporting

The number of codes increases in the ICD-10 and the characters change from 3–5 numerical to 3–7 alphanumeric

Both contain the Alphabetic Index of the diseases, conditions, and related terms

The I-10 Tabular List incorporates 21 chapters Many codes use an “x” as a placeholder for future expansion; which was not possible with ICD-9

In Summary (cont.)

18.7 The technique of coding with ICD-10 is very similar

to that of coding with ICD-9-CM

Locate the diagnosis or symptom in the Alphabetic Index and consider all notes

You then move to the Tabular List as instructed in the Alpha Index

After following terms, abbreviations and symbols, the appropriate code with the highest specificity supported by medical record documentation is selected

End of Chapter 18

Fraud and falsehood only dread

examination

Truth invites it.

~ Samuel Johnson