1. 4 Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM Lecture 2

2. 4.4 The Tabular List 4-12 The Tabular List: – Diseases and injuries are organized into chapters according to etiology or body system – Supplementary codes and appendices cover other special situations – Each chapter is divided into sections with titles that indicate the types of related diseases or conditions they cover

3. 4.4 The Tabular List (Continued) 4-13 Category—three-digit code that covers a single disease or related condition Subcategory—four-digit subdivision of a category Subclassification—five-digit subdivision of a subcategory

4. 4.4 The Tabular List (Continued) 4-14 NOS (not otherwise specified)—indicates the code to use when no information is available for assigning the illness or condition a more specific code Unspecified—incompletely described condition that must be coded with an unspecified ICD code

5. 4.4 The Tabular List (Continued) 4-15 Ten conventions are used in the Tabular List: 1.Fifth-digit requirement symbol 2.Includes and excludes notes 3.Colons in notes 4.Parentheses around supplementary terms 5.Brackets around supplementary synonyms, alternative wording, or explanations 6.Braces to group related terms 7.Lozenge for nonWHO codes

6. 4.4 The Tabular List (Continued) 4-16 Ten conventions are used in the Tabular List (continued): 8.The abbreviation NOS to indicate the code to use when a condition is not completely described, and the abbreviation NEC for the code to use when the diagnosis does not match any other available code 9.Bullet ( ● ) for new codes or entries, single triangle ( ► ) or facing triangles ( ►◄ ) for new or revised descriptions 10.Phrases for multiple code requirements: codes that are not used as primary appear in italics and are usually followed by an instruction to code first underlying disease or use an additional code

7. 4.5 Tabular List of Chapters 4-17 The Chapters of the Tabular List: – Infectious and Parasitic Diseases—Codes 001–139 – Neoplasms—Codes 140–239 – Endocrine, Nutritional, and Metabolic Diseases, and Immunity Disorders—Codes 240–279 – Diseases of the Blood and Blood-Forming Organs— Codes 280–289 – Mental Disorders—Codes 290–319 – Diseases of the Nervous System and Sense Organs— Codes 320–389 – Diseases of the Circulatory System—Codes 390–459 – Diseases of the Respiratory System—Codes 460–519

8. 4.5 Tabular List of Chapters (Continued) 4-18 The Chapters of the Tabular List (Continued): – Diseases of the Digestive System—Codes 520–579 – Diseases of the Genitourinary System—Codes 580– 629 – Complications of Pregnancy, Childbirth, and the Puerperium—Codes 630–677 – Diseases of the Skin and Subcutaneous Tissue—Codes 680–709 – Diseases of the Musculoskeletal System and Connective Tissue—Codes 710–739 – Congenital Anomalies—Codes 740–759

9. 4.5 Tabular List of Chapters (Continued) 4-19 The Chapters of the Tabular List (Continued): – Certain Conditions Originating in the Perinatal Period—Codes 760–779 – Symptoms, Signs, and Ill-Defined Conditions— Codes 780–799 – Injury and Poisoning—Codes 800–999

10. 4.6 V Codes and E Codes 4-20 V Code—alphanumeric ICD code that identifies factors influencing health status and encounters not due to illness or injury – Use for healthy patients to receive routine service, for therapeutic encounters, for a problem that is not currently affecting the patient’s condition, and for preoperative evaluations E Code—alphanumeric ICD code for an external cause of injury or poisoning – Never used as primary codes

11. 4.6 V Codes and E Codes (Continued) 4-21 Adverse effect—patient’s unintentional, harmful reaction to a proper dosage of a drug Table of Drugs and Chemicals—reference listing of drugs and chemicals in the ICD-9-CM Alphabetic Index

12. 4.7 Coding Steps 4-22 The correct process for assigning accurate diagnosis codes has five steps: Step 1 – Review complete medical documentation Step 2 – Abstract the medical conditions from the visit documentation Step 3 – Identify the main term for each condition Step 4 – Locate the main terms in the Alphabetic Index Step 5 – Verify the code in the Tabular List

13. 4.7 Coding Steps (Continued) 4-23 Chief complaint (CC)—patient’s description of the symptoms or reasons for seeking medical care Primary diagnosis—represents the patient’s major illness or condition for an encounter Coexisting condition—additional illness that either affects the primary illness or is also treated during an encounter