CHAPTER 18 Diagnostic Coding 18-2 Learning Outcomes (cont.) 18.1Recall the six ways that ICD codes are used today. 18.2Describe the conventions used

CHAPTER

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18Diagnostic Coding

18-2


Learning Outcomes (cont.)

18.1 Recall the six ways that ICD codes are used today.

18.2 Describe the conventions used by ICD-9-CM.

18.3 Outline the steps to code a diagnosis using ICD-9-CM.

18.4 Explain the purpose and usage of V codes and E codes.

18-3


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.

18-4


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

18-5


The Reasons for Diagnostic Codes

• Chief complaint (CC)

– Diagnosis (DX)• Proves medical necessity of treatment• Diagnostic code

– Coexisting conditions

18-6


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

18-7


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

18-8


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

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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

18-10


Conventions

NOS – not otherwise specified

NEC – not elsewhere classified

[ ] – brackets

[ ] – slanted bracket

18-11


Conventions (cont.)

( ) Parentheses

: Colon

} Brace

Includes

Excludes

Use additional code

18-12


Conventions (cont.)

• Code first underlying disease

• Code, if applicable, any causal condition first.

• Be aware of– Boldface type– Italicized typeface

18-13


Conventions (cont.)

• Alphabetic Index– Omit Code– See Condition– See Also

• Read Coding Guidelines

18-14


The Alphabetic Index

• Contains terms needed to locate codes

• Organized by condition

• Main terms

• Subterms

• Nonessential terms

• Cross-references

18-15


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

18-16


The Tabular List (cont.)

• V codes– Encounters not related to illness or injury

– Primary or supplemental codes

– May not be covered by insurance carrier

18-17


The Tabular List (cont.)

• E codes– External causes of injuries and poisoning

– “How did that happen?”

– Only a supplemental code

18-18



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

ANSWER:

H

G

F

E

D

C

B

A

18-19


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

18-20


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

18-21


Coding with ICD-9 (cont.)

• Coding unclear diagnoses

• Principal vs. primary diagnosis– Principal diagnosis

– Primary diagnosis

– Secondary diagnosis

18-22



What are the steps to code a diagnosis?

ANSWER: 1.Locate the diagnosis in the medical record2.Find the diagnosis in the Alphabetic Index3.Locate the correct code in Alphabetic Index and then in the Tabular Index4.Read all instructions to find the best code5.Record the code

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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

18-24


V Codes

• Outpatient use

• Examples:– V04.81 Influenza vaccination – V58.11 (Encounter for) Chemotherapy

treatment– V14.0 History (personal) of allergy to penicillin

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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

18-26


E Codes (cont.)

• Poisoning – Accidental

– Therapeutic

– Suicide attempt

– Assault

• Burns– Degree of burn

– Extent (% of body burned)

– How it occurred (E code)

E Codes are never the primary codeE Codes are never the primary code

18-27


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


Determine whether a V code or E code should be used: ANSWER:

V code

V code

V code

V code

E code

E code

E code

18-28


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

18-29



List the appropriate Appendix:

deleted in 2004

Classification of Drugs

Three Digit Categories

Morphology of Neoplasms

Classification of Industrial Accidents

ANSWER:

A

D

E

C

B

18-30


Basic Comparison of ICD-9-CM and ICD-10-CM

• Internal List of Causes of Death – 1893

• ICD-9 ~ 1975

– 14,200 codes

– No expansion

– Volume 3 for hospital codes

• ICD-10-CM– Over 68,000

diagnostic codes– Greater specificity– Provides for expansion

• ICD-10-PCS – hospital codes

18-31


ICD-10 Information

• Alpha Index

• Tabular (numeric) List– 21 chapters

– Category ~ 3 characters

– Subcategory ~ 4-5 characters

– Final code ~ up to 7 characters

18-32


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

ORCode: D05.11 Intraductal carcinoma in site of right breast

18-33


Placeholders

• “x” – placeholder for future expansion of code’s specificity

• Do not drop placeholder when adding characters

ICD-9-CM ICD-10-CM

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

18-34


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

18-35



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.

18-36


Basic Coding Guidelines for ICD-10

Locate term in Alphabetic

Index

Locate term in Alphabetic

Index

Refer to notes

Refer to notes

Read and follow terms in ( ) and [ ]

Read and follow terms in ( ) and [ ]

Go to Tabular list

Go to Tabular list

Follow instructional

terms to appropriate code

Follow instructional

terms to appropriate code

Assign the appropriate code with highest

degree of specificity

Assign the appropriate code with highest

degree of specificity

Assign additional code for s/s not associated

with disease

Assign additional code for s/s not associated

with disease

18-37


Basic Coding Guidelines for ICD-10 (cont.)

• Conventions are similar to ICD-9

• ICD-10 – More detailed documentation by physician

– Never code from the Alpha Index

– Verify codes in Tabular list

18-38


3-38


What are the general coding guidelines for the ICD-10?

ANSWER: Locate the diagnosis in the Alphabetic IndexRead and follow all notes and conventions.Locate in Tabular list.Follow instructions to the appropriate code.Assign the code with highest degree of specificity.

18-39


Synopsis of ICD-10 Coding Guidelines by Chapter

• Chapter 1 – HIV coding– R75 ~ inconclusive laboratory evidence

– B20 ~ positive serology

– Z21 ~ HIV positive, asymptomatic

– Z71.7 ~ counseling provided

18-40


Synopsis of ICD-10 Coding Guidelines by Chapter

• Chapter 2 – Neoplasms – Type of neoplasm

– Location

– Additional codes

– Primary vs. secondary neoplasms

– Treatments

18-41


Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)

• Chapter 4 – Diabetes mellitus

– Type

– Body system affected

– Complications

– Use of insulin

• Chapter 5 – Pain

– Psychological

– F45.41

– Appropriate code from

G89 category

18-42



• 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

18-43



• Chapter 10– Avian or H1N1

influenza

– Other types of influenza

• Chapter 13 – Fractures– Laterality

• Unilateral – 4th digit “1”• Designated by 5th digit

– Required 7th character• Initial• Subsequent • Sequela

18-44



• Chapter 14– Four stages of chronic kidney disease– ESRD

• Chapter 15– 7th digit– Read instructions carefully

18-45



• Chapter 17– Congenital or chromosomal – Primary or secondary diagnosis

• Chapter 18 (NEC)– R codes – No definitive diagnosis– Multiple combination codes

18-46



• 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

18-47



• Chapter 20– Replaces E codes

– Accidents or injuries

– Research and prevention

– Abuse codes take priority

18-48



• Chapter 21– Z codes replace V codes

– Expanded to include• Chemo, radiation, and immunotherapy

• After care

• Administrative exams

• Family history

• Personal history

18-49



• Practice

• Read guidelines carefully

• Ask questions

18-50



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

ANSWER: The 7th character of a code indicates the type of encounter: initial, subsequent, or sequela.

18-51


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.

18-52


In Summary (cont.)

18.3 To choose an ICD code, locate all applicable diagnoses.

Find the key term in the Alphabetic Index and any applicable subterms.

Verify the code’s description in the Tabular List, reading all applicable notations for other coding options and instructions.

Document each code carefully using instructions as to code sequencing on the CMS-1500 claim form.

18-53


In Summary (cont.)

18.4 V codes are used for patients who, though not ill, are seeking healthcare.

E codes are used to explain how an illness or injury came about.

18.5 The following appendices are found in ICD-9-CM: • Appendix A • Appendix B • Appendix C • Appendix D • Appendix E

18-54


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.

18-55


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.

18-56


In Summary (cont.)

18.8 The majority of ICD-10 CM codes follow the general guidelines.

However, unique coding applications do exist and chapter guidelines must be followed.

These include but are not limited to the chapters on neoplasms, diabetes mellitus, fractures, R codes, poisonings, and the new Z codes.

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End of Chapter 18

Fraud and falsehood only dread examination. Truth invites it.

~ Samuel Johnson

Documents

CHAPTER 18 Diagnostic Coding 18-2 Learning Outcomes (cont.) 18.1Recall the six ways that ICD codes are used today. 18.2Describe the conventions used