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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. secondary Discuss the history of diagnostic coding.

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Learning Objectives (cont'd.)

Demonstrate an understanding of diagnostic code conventions, symbols, and terminology. symbols, Apply coding guidelines to translate written descriptions of conditions into diagnostic codes. conditions Demonstrate the ability to abstract medical conditions from the medical record and accurately assign diagnostic codes by completing the problems in the Workbook. Workbook.

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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.

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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

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Sequencing of Diagnostic Codes

Primary diagnosis (first-listed) (firstRelated 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

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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

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Use of Standard Transaction Code Sets

Each transaction must include the use of medical and other code sets ICD-9-CM must be used for when assigning diagnostic codes ICDRequired, per HIPAA standards

Diagnostic codes should tie into the services rendered to the patient patient

Indicated by procedure codes (in Ch. 6)

Physician's fee profile Physician'

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History of Coding Diseases

1869: American Nomenclature of Diseases (AMA) 1903: Bellevue Hospital Nomenclature of Diseases Standard Nomenclature of Diseases and Operations 1960s-1991: Current Medical Information and Terminology (CMIT) (AMA) 1960sCurrent: Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT) (SNOMED-

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International Classification of Diseases

17th century: ICD developed in England 18th century: ICD use began in U.S. 1950s: ICD used in hospitals to classify and index disease Current: ICD-9 (9th revision) in use ICD-

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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

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Outline of Volumes 1 and 2 of ICD-9-CM ICD-9-CM Conventions ICD-9-CM Conventions ICD-9-CM Conventions General Coding Guidelines

Code only conditions or problems that are actively managed at the visit the First, look up condition in Volume 2

Main term is the condition

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Second, go to Volume 1 to assign the code

Follow instructions from Volume 2 and conventions in Volume 1

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Illustration of Main Terms, Subterms, and Nonessential Modifiers Code Digits

ICD-9-CM contains at least three digits ICDFourth 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 threeIn a fourth-digit subcategory fourth-

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V Codes & E Codes

V Codes are used when a person who is not currently sick encounters health services for encounters some specific purpose. E Codes are used when some circumstance or problem is present that influences the that person's health status but is not in itself a current illness or injury. person' injury.

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V Code Use

V codes are used in four circumstances

When a person who is not currently sick encounters health services for a specific purpose (vaccination, services etc.) When a person with a resolving disease or injury seeks aftercare When a circumstance influences an individual's health status but the illness is not current individual' When it is necessary to indicate the birth status of a newborn

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V Code Examples V Code Examples (cont'd.) V Code Examples (cont'd.) 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 procedural/diagnostic E codes are NEVER the primary diagnosis

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E Codes (cont'd.) Table of Drugs and Chemicals E Coding Examples E Coding Examples (cont'd.)

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 made not Provisional diagnosis for a patient who does not return for further care further A patient is referred for treatment before a definite diagnosis is made

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Sterilization

V25.2 should be used for sterilization for contraceptive purposes purposes

Elective sterilization: only V25.2 Elective sterilization after obstetric delivery: V25.2 as secondary secondary

Sterilization for other reasons does not require a V code

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Neoplasm Terminology

Benign tumor: one that does not have properties of invasion and metastasis and is usually and 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 neighboring tissues

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Coding for Neoplasms Neoplasm Coding Examples Neoplasm Coding Examples (cont'd.) 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

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Classification of Diabetes Mellitus Pregnancy, Delivery, and Abortion

Many codes in this category require five-digit subclassifications fiveFollow guidelines for coding deliveries and complications

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Admitting Diagnosis

Criteria for admitting inpatient diagnosis

One or more significant findings representing patient distress or abnormal findings on examination or 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

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Burns

Percentage of body area for code assignment

The Rule of Nines

Severity of burn

First degree Second degree Third degree

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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 effect effect Fractures are coded as closed if there is no indication of "open" or "closed" open" closed" The word "with" indicates involvement of both sites, and the word "and" indicates involvement of one or with" and" two sites when multiple injury sites are given

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Common Injury Medical Terms

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ICD-10-CM and ICD-10-PCS

ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 (diagnosis codes) ICD- 10ICDICD-10-PCS will replace ICD-9-CM Volume 3 (procedure codes) ICD- 10ICDReasons for development

ICD-9-CM was not expandable, comprehensive, or multiaxial ICDICD-9-CM did not have standardized terminology and included diagnostic information ICD-

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ICD-10-CM vs. ICD-9-CM

Change in code book organization New categories and chapters New six- to seven-digit alphanumeric codes six- sevenOld 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 complication misadventure early complication late complication sequela transient postoperative condition New activity code category ICD-10-PCS is more specific than CPT ICD- 10-

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ICD-10-CM Coding Conventions

Braces and brackets are not applicable Added conventions

"and" 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

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Transition to ICD-10-CM

Implementation could be October 2010 Requires higher level of clinical knowledge Training is necessary Different ICD-10-CM books will be offered ICD- 10-

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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. subterm. Look for appropriate sub-subterm. sub- subterm. Follow any cross-reference instructions. crossWrite down the code.

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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. List.

Read complete description and assign the code to the highest specificity. specificity.

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Coding Chronic Alcoholic Liver Disease Tabular List Coding Examples Tabular List Coding Examples (cont'd.) Coding by Etiology Four-Digit Residual Subcategories Combination Coding Special Points to Remember in Volume 1

Use two or more codes if necessary to completely describe a diagnosis. diagnosis. Search for one code when two diagnoses or a diagnosis with an associated secondary associated process or complication is present. See Figure 5-8. 5Use category codes only if there are no subcategory codes.

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Special Points to Remember in Volume 2

Notice that appropriate sites or modifiers are listed in alphabetic order under the main terms, alphabetic with further subterm listings as needed. Examine all modifiers that appear in parentheses next to the main term. main Check for nonessential modifiers that apply to any of the qualifying terms used in the qualifying statement of the diagnosis found in the patient's medical record patient'

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Special Points to Remember in Volume 2 (cont'd)

Notice that eponyms appear as both main term entries and modifiers under main terms such modifiers as "disease" or "syndrome" and "operation." disease" syndrome" operation." Look for sublisted terms in parentheses that are associated with the eponym. Locate closely related terms, code categories, and cross-referenced synonyms indicated by crosssee and see also. also.

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Excerpt from Alphabetic Index of ICD-9-CM Volume 2 Excerpt from Tabular List of ICD-9-CM Volume 1

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