Presentation on theme: "Medical Coding Chapter 2. CHAPTER 2 AN OVERVIEW OF ICD-9-CM."— Presentation transcript:
Medical Coding Chapter 2
CHAPTER 2 AN OVERVIEW OF ICD-9-CM
An Overview of the ICD-9-CM Classification System –Morbidity (illness) –Mortality (death) ICD = International Classification of Diseases WHOs ICD-9 used globally –World Health Organization ICD-9-CM = 9th Revision; CM, Clinical Modification –Continuity of data
Overview 1977: US develops ICD-9-CM version More code subsets define medical care ICD-9-CM data comparable to global data in ICD-9 Updated October 1 of each year Must use new codes as of October 1 Also updates April 1 with no grace period
Medicare Medicare Catastrophic Act of 1988 –Required use of ICD-9-CM codes for diagnosis Act later repealed, but codes still used Effective 2003, all claims must have valid diagnosis –Excludes ambulance suppliers
Uses of ICD-9-CM Facilities track facility use through codes Fiscal entities track health care costs
Uses of ICD-9-CM Research –Health care quality –Future needs Newer cancer center built if patient use warrants
Uses of ICD-9-CM Use and results evident every day –Newscaster reference to number of AIDS cases –Newspaper article about measles epidemic
ICD-9-CM Principles/Practices Four groups function together to maintain ICD-9-CM Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA)
ICD-9-CM Principles/Practices National Center for Health Statistics (NCHS) American Health Information Management Association (AHIMA) American Hospital Association (AHA)
ICD-9-CM Documents Medical Necessity Diagnoses establish medical necessity Services and diagnoses must correlate Correct diagnosis codes allow: –Accurate reimbursement –Fewer rejected claims –Reduced risk of sanctions/fines from audit
CMS-1500 (08/05) in Blocks 21 and 24E (Outpatient ) Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.
UB04 in Blocks (Inpatient) Courtesy U.S. Department of Health and Human Services, Public Health Service, Centers for Medicare and Medicaid Services.
Ethics Documentation must support diagnosis Example: –Services provided –Diagnosis justifies services If in doubt, check it out; dont make assumptions
Your Job Translate documentation into ICD-9-CM codes –Legionnaires disease = Assign code to highest level specificity Medical record must substantiate diagnosis code assignment
Format of the ICD-9-CM Volume 1, Diseases, Tabular List (diagnosis) (17 chapters) Volume 2, Diseases, Alphabetic Index (diagnosis) (3 sections) Volume 3, Procedures, Tabular List and Alphabetic Index (inpatient)
Volume 1, Diseases, Tabular List Contains code numbers Diagnosis codes describe condition V and E codes = supplemental information
Volume 2, Diseases, Alphabetic Index Appears first in book (may vary with publishers) Terms and code numbers verified in Volume 1 Never code directly from Index! Read all notes and follow instructions (e.g., see also) Tables (e.g., Drugs/Chemicals, Hypertension, Neoplasm)
Volume 3, Procedures, Tabular List and Alphabetic Index Not used for physician services Index and Tabular List used for procedures and therapies Inpatient settings only Procedures and therapies Maximum 4 digits –20.41 Simple mastoidectomy
Volume 1, Tabular List Two major divisions –Classification of Diseases and Injuries (codes ) –Supplementary Classification (V codes and E codes)
V Codes (V01.0-______) Patient not ill but encounters health services –e.g., Vaccination Patient presents for treatment –e.g., Chemotherapy Some V codes are primary only (e.g., V58.11, encounter for chemotherapy) V89.09
V Codes (V01.0-V89.09) Factors that influence patients health status –e.g., Personal history of [PHO] malignant tumor, organ transplant –Birth status and outcome of delivery
Classification of Diseases and Injuries Main portion of ICD-9-CM Codes from Most chapters are organ systems –Digestive System –Respiratory System
Divisions of Classification of Diseases and Injuries Chapters: 1 through 17 Section: A group of related conditions
Volume 1, Diseases, Format Figure: 2.5 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Category Code Category: Represent single disease/condition (3 digits) Figure: 2.6 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Subcategory Code Subcategory: More specific (4th digit) Figure: 2.7 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Subclassification Code Subclassification: More specific (5th digit) Referenced from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Specificity in ICD-9-CM Codes Each digit adds to the specificity (detail) Figure: 2.9
Remember Assign to the highest level possible, based on documentation If 4-digit code exists, do not report 3-digit code If 5-digit code exists, do not report 4-digit code
Appendices in Volume 1 There are five appendices in official ICD-9-CM Private publishers may have more
Appendix A, Morphology of Neoplasms Used in conjunction with codes from Chapter 2, Neoplasm –Inpatient setting: Cancer registries and claim forms –Not placed on a billing claim form (M codes)
Appendix A, Morphology of Neoplasms Begins with M followed by 5 digits –M8400/0, Sweat gland adenoma First four digits: Histologic type of neoplasm Fifth digit: Behavior (e.g., 0 = benign)
Appendix B, Glossary of Mental Disorders Deleted in 2004 Most psychiatric disorders are classified using: –The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
Appendix C, Drugs American Hospital Formulary Service (AHFS) publishes list of all drugs Tracks drugs nationally; used by pharmacists Each drug coded with up to six-digit code (e.g., 84:04.04)
Appendix C, Drugs AHFS listing correlated to ICD-9-CM Table of Drugs and Chemicals New drugs not identified by name –Rather listed under heading Drug in Table of Drugs and Chemicals –Example: 84:04.04 antibiotics
Appendix D, Industrial Accidents Three-digit codes that identify occupational hazards Not placed on insurance or billing form Used by state and federal organizations (OSHA) Occupational Safety and Health Administration to summarize industrial accident data
Appendix E, Three-Digit Categories Presented by chapter Categories are labeled 1 through 17 Provides quick overview of ICD-9-CM contents
Volume 2, Sections Section 1, Index to Diseases Section 2, Table of Drugs and Chemicals Section 3, Index to External Causes of Injuries and Poisonings (E Codes) –Never primary diagnosis –Medicare does not accept for professional billing
Section 1, Index to Diseases Largest part of Volume 2Index First step in coding, locate main bold term in the Index Subterms indented 2 spaces to the right May have more than one subterm 3 digits = category codes 4 digits = subcategory 5 digits = subclassification codes
A Word of Caution About the Alphabetic Index (Section I, Vol. 2) Some words in Index do not appear in Tabularsaves space Exact word may not be in code Tabular description –But found in Alphabetic Index –That is why you must locate term in Index and then locate Tabular (follow where Index directs)
Section 2, Table of Drugs and Chemicals Drug name placed alphabetically on left under heading Substance Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Table of Drugs and Chemicals (…Contd) First column: Poisoning code for substance involved, wrong substance given or taken First-listed before manifestation condition Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Table of Drugs and Chemicals E codes identify how poisoning occurred –Example: If analgesics poisoning occurred by accident, E850.9 Correct order poisoning –3 codes required: Identify agent analgesic Conditioncoma Accidental poison E850.9 Correct order adverse effect –2 codes required Conditioncoma Therapeutic E935.9
Table of Drugs and Chemicals: Headings Accident: Unintentional Therapeutic: Correct dosage, correctly administered, with adverse effects (example, allergic reaction) Suicide attempt: (must be documented) Assault: Intentionally inflicted by another person Undetermined: Unknown intent
E Codes (E000-E999) Supplementary Classification of External Causes of Injury and Poisoning Alpha-numerical designations for injuries and poisonings
E Codes (E000-E999) Provides additional information about external causes Never a principal (inpatient) diagnosis Separate E code index –Locate the E Code index in your ICD-9-CM now
Section 3, E Codes Alphabetic Index to External Causes of Injuries and Poisonings Provide additional information about the nature of injury/poisoning and locality Never a principal (inpatient) or first-listed (outpatient) diagnosis
Section 3, E Codes Separate Index to External Causes Alphabetical, main terms in bold Subterms are indented 2 to right under main term Some words in Index not in Tabularsaves space That is why you must locate the term in the Index, then locate in Tabular
Index to External Causes: Example Main terms are type of accident (Collision) Subterms are circumstances of the accident (motor vehicle) Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Volume 2, Neoplasm In Volume 2, Index, locate Neoplasm Table under the alphabetic entry N Do not reference Neoplasm table when diagnostic statement statesmass From Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Volume 2, Terms Main terms (bold typeface) –Subterms –Indented two spaces to right –Not bold Example Pain (Main term in bold) orbital region (subterm indented)
Volume 2, Alphabetic Index Nonessential modifiers enclosed in parentheses (does not have to be in diagnostic statement) Have no effect on code selection Clarify diagnosis –Example: Ileus (adynamic) (bowel)….
ICD-9-CM Conventions Punctuation: [ ] ( ) : } italicized and bold type [ ] Symbols: § Abbreviations: NEC, NOS Notations: Includes, Excludes, Use Additional Code, And/With, Code if Applicable
Abbreviations NEC: Not elsewhere classifiable –No more specific code exists NOS: Not otherwise specified –Unspecified in documentation
[ ] Brackets Enclose synonyms, alternative wording, or explanatory phrases Used to identify manifestation codes Helpful, additional information Can affect code Found only in Tabular List ( )
Volume 2, Etiology and Manifestation of Disease Etiology = cause of disease Manifestation = symptom Etiology + Manifestation = Combination codes
Combination Code Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Slanted Brackets [ ] Enclose manifestations of underlying condition –Code first underlying disease Used in the Alphabetic Index-Volume 2
Multiple Coding No combination code, use individual code(s) in this order –250.4x – Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
( ) Parentheses Contain non-essential modifiers –Take them or leave them –Informational descriptive terms Found in Tabular List and Index Does not affect code selection
Colon and Brace : Colon: In Tabular List, completes a statement with one or more modifiers } Brace: In Tabular List, modifies statements to the right of the brace
Italicized and Bold Type Italicized –All Excludes notes –Codes not used as principal diagnosis Bold –Codes and code titles in Tabular List, Volume 1
Lozenge and Section Mark Lozenge: Indicates codes unique to ICD-9-CM § Section: Can be footnote indicator
Includes, Excludes, and Use Additional Code Includes notes: In chapter, section, or category Excludes notes: Conditions are coded elsewhere Use Additional Code: Assignment of other code(s) is necessary
And/With And: Means and/or –Example: 237.0, Neoplasm of uncertain behavior of pituitary gland and/or craniopharyngeal duct With: Means one condition with (in addition to) another condition –Example: , acute hepatitis C with hepatic coma
Volume 2, Cross References Directs you: see, see also, see category see directs you to specific term –Example: Panotitissee Otitis media see also directs you to another term for more information –Example: Perivaginitis (see also Vaginitis)
Volume 2, Cross References see category Volume 1, Tabular List, specific information about use of code –Example: Mesencephalitis (see also Encephalitis) 323.9; late effectsee category 326
Code, If Applicable, Any Causal Condition First May be primary diagnosis if no causal condition applicable or known or documented Instructional note in Tabular List
Code, If Applicable, Any Causal Condition First Example: , Ulcer of lower limb, except decubitus; states: –Chronic venous hypertension with ulcer (459.31) If ulcer caused by chronic venous hypertension: –First: chronic venous hypertension –Second: ulcer of lower limb
Volume 2, Notes Define terms Give further coding instructions –Example: Index: Melanoma, Note: Except where otherwise indicated….
Volume 2, Notes Mandatory fifth digits also appear as notes (one reason to never code from Index) (…Contd) (…Contd) Figure: 2.13 From Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Volume 2, Eponyms Disease or syndrome named for person –Example: Arnold-Chiari (see also Spina bifida) Sturge-Weber Prader-Willi
Volume 3, Procedures 90% of codes refer to surgical procedures (Contd…) Figure: 2.14 Volume 3, Surgical procedures. (Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.)
Volume 3, Procedures 10% refer to diagnostic and therapeutic procedures (Contd…) (…Contd) Figure: 2.15 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Volume 3, Procedures Procedures done in physicians office or outpatient ASC are coded using CPT codes –Surgeon uses CPT to report services to inpatients Volume 3, Procedure codes are used by hospitals to code facility services provided to inpatients
Chapter 0 –Procedures and Interventions, Not Elsewhere Classified Chapters 1-15 –Operations on organ systems Chapter 16 –Miscellaneous Diagnostic and Therapeutic Procedures –Most nonsurgical codes Volume 3, Table of Contents …
(…Contd) Figure: 2.16 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Volume 3, Tabular List Conventions in Volume 3 same as those in Volumes 1 and 2 Code also... Volume 3 –Additional information about coding various components or special adjunctive services or procedures –…any synchronous means occurring at the same time
Volume 3, Alphabetic Index Contains terms that do not appear in Volume 3 Tabular List –Example: In Index, the entry Gastrostomy, subterm Janeway, directs you to –Janeway not mentioned in Tabular List
Volume 3, Alphabetic Index Terms in bold Subterms not in bold Never code directly from Index Index example follows Includes non-essential modifiers, as in Volume 1
Example Figure: 2.17 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Volume 3, Alphabetic Index Index alphabetical Ignores single spaces and hyphens –Example: Opening and open reduction –Opening appears before open reduction because space between two words ignored
Volume 3, Alphabetic Index Often necessary and permissible to code individual components of procedure –Example: During a procedure, a portion of intestine was removed and reconstruction of urinary bladder was done Both reconstruction (57.87) and resection (45.51) are coded
Volume 3, Alphabetic Index Cross references of see, see also, and see category appear as they did in Volume 1 Many operations named for surgeon who developed procedure (eponyms) –These procedures located under persons name or name of operation
Volume 3, Tabular List Format same as Volume 1, Tabular List of Diseases, except Volume 3 codes have two digits before decimal
Volume 3, Tabular List Category, subcategory, and subclassification Figure: 2.18 Modified from Buck CJ: 2011 ICD-9-CM for Hospitals, Volumes 1, 2, & 3, Professional Edition, St. Louis, 2011, Saunders.
Bundling Included in all surgical procedures opening and closing of surgical site –Do not unbundle and code these separately –If closure takes place during separate surgical procedure, closure can be reported separately