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Presentation on theme: "Medical Coding Chapter 3. CHAPTER 3 ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES."— Presentation transcript:

1 Medical Coding Chapter 3


3 Section IV Diagnostic Coding Physicians office Hospital-based outpatient services Part of Official Guidelines for Coding and Reporting, Section IV

4 Section IV Diagnostic Coding Guidelines do not address specific sequencing or diseases as inpatient do Though not stated, if there is no outpatient guideline, follow inpatient guidelines

5 Diagnostic Coding Guideline A Term first-listed diagnosis, rather than principal diagnosis Outpatient Surgery: Reason for surgery –Even if surgery is cancelled due to contraindication

6 Diagnostic Coding Guideline A Observation Stay: Medical condition that occasioned admission –Assign a code from medical condition Observation Stay: Complications from outpatient surgery lead to observation report: Reason for surgery as first reported diagnosis Codes for complications necessitating observation

7 Selection of First-Listed Diagnosis Condition for encounter –Why patient presented, not necessarily most serious condition noted Documented Chiefly responsible for services provided Also list co-existing conditions

8 Diagnosis and Services Diagnosis and procedure MUST correlate Medical necessity must be established through documentation No correlation = No reimbursement

9 Symptoms, Signs, and Ill-Defined Conditions Can be the first-listed diagnosis if no more specific diagnosis available Diagnoses often are not established at the time of the initial encounter/visit

10 Diagnostic Coding Guideline B Use codes through V91.99 to code: –Diagnosis –Symptoms –Conditions –Problems –Complaints –Or other reason(s) for visit

11 Diagnostic Guideline C Documentation should describe patient's condition, using terminology that includes: –Specific diagnoses –Symptoms –Problems –Reasons for encounter

12 Diagnostic Guideline D Selection of codes through (Chapters 1- 17) frequently used to describe reason for encounter

13 Diagnostic Guideline E Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when –An established diagnosis has NOT been determined by physician

14 Diagnostic Guideline F V codes deal with encounters for circumstances other than disease or injury –Example: Well-baby checkup See Section I.C.18 for information on V codes

15 Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service V01-V91 –Assigned as first-listed diagnosis for: Admissions for evaluation Following an accident that would ordinarily result in health problem, BUT there is none –Car accident, driver hits head, no apparent injury, admit to R/O head trauma –Never a secondary diagnosis

16 V Codes Located after in Tabular Two digits before decimal (e.g., V10.1X) Index for V codes is Alphabetic Index to Diseases Main terms: –Contraception –Counseling –Dialysis –Status –Examination

17 Uses of V Codes Not sick BUT receives health care (e.g., vaccination) Services for known/resolving disease/injury (e.g., chemotherapy) Codes for aftercare (e.g., surgery or fracture) Indicate birth status/outcome of delivery

18 Uses of V Codes A circumstance/problem that influences patients health BUT NOT current illness/injury –Example: Organ transplant status –Example: Birth status and outcome of delivery (newborn) Section I.C.18.e. of Guidelines contains the V Code Table –Identifies if V code can be listed as first, first/additional, additional only

19 History V Code Categories in Tabular V10 Personal history of malignant neoplasm V11 Personal history of mental illness V12 Personal history of certain other diseases V13 Personal history of other diseases V14 Personal history of allergy to medicinal agents V15 Other personal history presenting hazards to health V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V18 Family history of certain other specific diseases V19 Family history of other conditions Condition no longer present or treated

20 Diagnostic Guideline G Codes have either 3, 4, or 5 digits 4 and/or 5 digit codes provide greater specificity (detail)

21 Diagnostic Guideline G 3-digit code used ONLY if no 4 or 5 digit Where 4 and/or 5 digits provided, must be assigned Diagnoses NOT coded to full digits available invalid Claims bounce!

22 Diagnostic Guideline H List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided List additional codes that describe any coexisting conditions Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis

23 Diagnostic Guideline I Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit

24 Diagnostic Guideline J Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)

25 Diagnostic Guideline K Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management Do NOT code conditions previously treated, no longer existing

26 Diagnostic Guideline K History of codes (V10-V19) may be used as secondary codes if: –Impacts current care or treatment

27 Special Note AboutHistory of Index to Disease, MAIN term History Entries between family and visual loss V19.0 = family history of (FHO) Entries before family and aftervisual loss = personal history of (PHO) Personal history = V10-V15 Family history = V16-V19

28 Diagnostic Guidelines L and M For patients receiving diagnostic services ONLY Sequence first –Diagnosis –Condition –Problem OR –Other reason shown in medical record to be chiefly responsible for encounter

29 Diagnostic Guidelines L and M Codes for other diagnoses (e.g., chronic conditions) –May be sequenced as secondary diagnoses Exception: Therapeutic Services –Patients receiving chemotherapy (V58.11), radiation therapy (V58.0), or rehabilitation (V57.0-V57.9) –V code first diagnosis and problem for which service being performed second

30 Diagnostic Guideline N For patients receiving preoperative evaluations ONLY –Code from category V72.8 (Other specified examinations) –Assign secondary code for reason for surgery –Code also any findings related to preoperative evaluation

31 Diagnostic Guideline O, Ambulatory Surgery Code diagnosis which required ambulatory surgery Pre- and post-op diagnosis different –Code the post-op diagnosis

32 Diagnostic Guideline P Code routine prenatal visits with no complications: –V22.0 (Supervision of normal first pregnancy) –V22.1 (Supervision of other normal pregnancy) –DO NOT use these codes with pregnancy complication codes (Chapter 11, ICD-9-CM)

33 V91 Multiple Gestation Placenta Status New in 2011 Identifies twins, triplets, quadruplets, other multiples



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