1 2 Learning Objectives Explain the reasons and importance of coding diagnoses. Describe the importance of matching the correct diagnostic code to the appropriate procedural code. Differentiate between primary (first listed), principal, and secondary diagnoses. Discuss the history of diagnostic coding. 3 Learning Objectives (cont d.) Demonstrate an understanding of diagnostic code conventions, symbols, and terminology. Apply coding guidelines to translate written descriptions of conditions into diagnostic codes. Demonstrate the ability to abstract medical conditions from the medical record and accurately assign diagnostic codes by completing the problems in the Workbook. 4 5 Importance of Correct Diagnostic Coding Diagnostic coding must be accurate because payment for inpatient services rendered to a patient may be based on the diagnosis. In the outpatient setting, the diagnosis code must correspond to the treatment or services rendered to the patient or payment may be denied. 6 The Diagnostic Coding System Guidelines for diagnostic coding must be followed when assigning codes Only diagnoses that currently relate to patient state should be coded Payment for services may be tied into diagnostic coding, due to medical necessity requirements 7 Sequencing of Diagnostic Codes Primary diagnosis (first-listed) Related to the chief complaint Main reason for the encounter Secondary diagnosis May contribute to the primary diagnosis Not the underlying cause (etiology) Principal diagnosis Only applicable to inpatient cases/claims Similar to primary diagnosis for outpatient 8 Reasons for the Development and Use of Diagnostic Codes Tracking of disease processes Classification of causes of mortality Medical research Evaluation of hospital service utilization 9 Use of Standard Transaction Code Sets Each transaction must include the use of medical and other code sets ICD-9-CM CM must be used for when assigning diagnostic codes Required, per HIPAA standards
Diagnostic codes should tie into the services rendered to the patient Indicated by procedure codes (in Ch. 6) Physician s s fee profile 10 History of Coding Diseases 1869: American Nomenclature of Diseases (AMA) 1903: Bellevue Hospital Nomenclature of Diseases Standard Nomenclature of Diseases and Operations 1960s-1991: 1991: Current Medical Information and Terminology (CMIT) (AMA) Current: Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT) 11 International Classification of Diseases 17 th century: ICD developed in England 18 th century: ICD use began in U.S. 1950s: ICD used in hospitals to classify and index disease Current: ICD-9 9 (9 th revision) in use 12 Organization and Format Three volumes Volume 1: Tabular List of Diseases Volume 2: Alphabetic Index of Diseases Volume 3: Tabular List and Alphabetic Index of Procedures Volumes 1 and 2 are used in physician offices and hospitals for diagnoses Volume 3 is used in hospitals for procedures 13 Outline of Volumes 1 and 2 of ICD-9-CM CM 14 ICD-9-CM CM Conventions 15 ICD-9-CM CM Conventions 16 ICD-9-CM CM Conventions 17 General Coding Guidelines Code only conditions or problems that are actively managed at the e visit First, look up condition in Volume 2 Main term is the condition Second, go to Volume 1 to assign the code Follow instructions from Volume 2 and conventions in Volume 1 18 Illustration of Main Terms, Subterms,, and Nonessential Modifiers 19 Code Digits ICD-9-CM CM contains at least three digits Fourth or fifth digits can also be appended Provides greater specificity Must be used if available Fifth digit codes can appear: At the beginning of the chapter At the beginning of a section At the beginning of a three-digit category In a fourth-digit subcategory
20 V Codes & E Codes V Codes are used when a person who is not currently sick encounters ers health services for some specific purpose. E Codes are used when some circumstance or problem is present that influences the person s s health status but is not in itself a current illness or injury. 21 V Code Use V codes are used in four circumstances When a person who is not currently sick encounters health services es for a specific purpose (vaccination, etc.) When a person with a resolving disease or injury seeks aftercare When a circumstance influences an individual s s health status but the illness is not current When it is necessary to indicate the birth status of a newborn 22 V Code Examples 23 V Code Examples (cont d.) 24 V Code Examples (cont d.) 25 E Codes Used to explain the mechanism for the injury Used to gather data about injury causes Should be reported in addition to the appropriate procedural/diagnostic codes E codes are NEVER the primary diagnosis 26 E Codes (cont d.) 27 Table of Drugs and Chemicals 28 E Coding Examples 29 E Coding Examples (cont d.) 30 31 Signs, Symptoms, and Ill-Defined Conditions Signs and symptoms codes can be used: No precise diagnosis can be made Signs and symptoms are transient, and a specific diagnosis was not n made Provisional diagnosis for a patient who does not return for further care A patient is referred for treatment before a definite diagnosis is made 32 Sterilization V25.2 should be used for sterilization for contraceptive purposes Elective sterilization: only V25.2 Elective sterilization after obstetric delivery: V25.2 as secondary Sterilization for other reasons does not require a V code 33 Neoplasm Terminology Benign tumor: one that does not have properties of invasion and metastasis and a is usually surrounded by a fibrous capsule Malignant tumor: has the properties of invasion and metastasis
Carcinoma: refers to a cancerous or malignant tumor Carcinoma in situ: cancer confined to the site of origin without invasion of neighboring tissues 34 Coding for Neoplasms 35 Neoplasm Coding Examples 36 Neoplasm Coding Examples (cont d.) 37 Cardiovascular System Conditions Hypertension Malignant vs. benign Cause should be coded when specified Myocardial infarctions Chronic rheumatic heart disease Conditions presumed to be caused by rheumatic fever Arteriosclerotic cardiovascular/heart disease Cardiovascular vs. heart 38 Classification of Diabetes Mellitus 39 Pregnancy, Delivery, and Abortion Many codes in this category require five-digit subclassifications Follow guidelines for coding deliveries and complications 40 Admitting Diagnosis 41 Burns Criteria for admitting inpatient diagnosis One or more significant findings representing patient distress or abnormal findings on examination A diagnosis established on an ambulatory care basis or previous hospital admission An injury or poisoning A reason or condition not classifiable as an illness or injury Percentage of body area for code assignment The Rule of Nines Severity of burn First degree Second degree Third degree 42 Injuries and Late Effects Multiple injuries List diagnosis in order of importance Most severe problem listed first Guidelines for coding injuries Decide whether a diagnosis represents a current injury or late effecte Fractures are coded as closed if there is no indication of open or closed The word with indicates involvement of both sites, and the word and indicates involvement of one or two sites when multiple injury sites are given 43 Common Injury Medical Terms
44 ICD-10 10-CM and ICD-10 10-PCS ICD-10 10-CM will replace ICD-9-CM CM Volumes 1 and 2 (diagnosis codes) ICD-10 10-PCS will replace ICD-9-CM CM Volume 3 (procedure codes) Reasons for development ICD-9-CM CM was not expandable, comprehensive, or multiaxial ICD-9-CM CM did not have standardized terminology and included diagnostic information 45 ICD-10 10-CM vs. ICD-9-CM CM Change in code book organization New categories and chapters New six- to seven-digit alphanumeric codes Old injuries are to use S and T codes, by site Expanded explanatory notes and instructions Expanded dual classification system E and V codes are now separate chapters New procedures get unique codes Combination diagnosis/symptom codes added Postoperative complication codes describe type and site or complication misadventure early complication late complication sequela transient postoperative condition New activity code category ICD-10 10-PCS is more specific than CPT 46 ICD-10 10-CM Coding Conventions Braces and brackets are not applicable Added conventions and Excludes 1 Excludes 2 Acute and chronic conditions can be assigned together Acute should be sequenced first Bilateral sites Right side is character 1; Left side is character 2 Bilateral is character 3 Unidentified side requires unspecified code 47 Transition to ICD-10 10-CM Implementation could be October 2010 Requires higher level of clinical knowledge Training is necessary Different ICD-10 10-CM books will be offered 48 Basic Steps in Coding Locate the main term in the Alphabetic Index in Volume 2. Refer to any notes under the main term. Read any terms enclosed in parentheses after the main term. Look for appropriate subterm. Look for appropriate sub-subterm subterm. Follow any cross-reference reference instructions. Write down the code. 49 Basic Steps in Coding (cont d.) Verify the code number in the Tabular List in Volume 1. Read and be guided by any instructional terms in the Tabular List.
Read complete description and assign the code to the highest specificity. 50 Coding Chronic Alcoholic Liver Disease 51 Tabular List Coding Examples 52 Tabular List Coding Examples (cont d.) 53 Coding by Etiology 54 Four-Digit Residual Subcategories 55 Combination Coding 56 Special Points to Remember in Volume 1 Use two or more codes if necessary to completely describe a diagnosis. Search for one code when two diagnoses or a diagnosis with an associated secondary process or complication is present. See Figure 5-8. 5 Use category codes only if there are no subcategory codes. 57 Special Points to Remember in Volume 2 Notice that appropriate sites or modifiers are listed in alphabetic order under the main terms, with further subterm listings as needed. Examine all modifiers that appear in parentheses next to the main n term. Check for nonessential modifiers that apply to any of the qualifying terms used in the statement of the diagnosis found in the patient s s medical record 58 Special Points to Remember in Volume 2 (cont d) Notice that eponyms appear as both main term entries and modifiers under main terms such as disease or syndrome and operation. operation. Look for sublisted terms in parentheses that are associated with the eponym. Locate closely related terms, code categories, and cross-referenced referenced synonyms indicated by see and see also. 59 Excerpt from Alphabetic Index of ICD-9-CM CM Volume 2 60 Excerpt from Tabular List of ICD-9-CM CM Volume 1