1. Chapter 5 Diagnostic Coding Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2. 2 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.

3. 3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

4. 4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Sequencing of Diagnostic Codes  Primary diagnosis (first-listed)  Related 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

5. 5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

6. 6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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  Required, per HIPAA standards  Diagnostic codes should tie into the services rendered to the patient  Indicated by procedure codes (in Ch. 6)  Physician’s fee profile

7. 7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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)  Current: Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)

8. 8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. International Classification of Diseases  17 th century: ICD developed in England  18 th century: ICD use began in U.S.  1950s: ICD used in hospitals to classify and index disease  Current: ICD-9 (9 th revision) in use

9. 9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

10. 10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Outline of Volumes 1 and 2 of ICD-9-CM

11. 11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-9-CM Conventions

12. 12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-9-CM Conventions

13. 13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-9-CM Conventions

14. 14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. General Coding Guidelines  Code only conditions or problems that are actively managed at the visit  First, look up condition in Volume 2  Main term is the condition  Second, go to Volume 1 to assign the code  Follow instructions from Volume 2 and conventions in Volume 1

15. 15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Illustration of Main Terms, Subterms, and Nonessential Modifiers

16. 16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Code Digits  ICD-9-CM contains at least three digits  Fourth 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  In a fourth-digit subcategory

17. 17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Codes & E Codes  V Codes are used when a person who is not currently sick encounters health services for some specific purpose.  E Codes are used when some circumstance or problem is present that influences the person’s health status but is not in itself a current illness or injury.

18. 18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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, 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  When it is necessary to indicate the birth status of a newborn

19. 19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Examples

20. 20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Examples (cont’d.)

21. 21Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Examples (cont’d.)

22. 22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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  E codes are NEVER the primary diagnosis

23. 23Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Codes (cont’d.)

24. 24Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Table of Drugs and Chemicals

25. 25Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Coding Examples

26. 26Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Coding Examples (cont’d.)

27. 27Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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  Provisional diagnosis for a patient who does not return for further care  A patient is referred for treatment before a definite diagnosis is made

28. 28Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Sterilization  V25.2 should be used for sterilization for contraceptive purposes  Elective sterilization: only V25.2  Elective sterilization after obstetric delivery: V25.2 as secondary  Sterilization for other reasons does not require a V code

29. 29Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Neoplasm Terminology  Benign tumor: one that does not have properties of invasion and metastasis and is usually 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 tissues

30. 30Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Coding for Neoplasms

31. 31Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Neoplasm Coding Examples

32. 32Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Neoplasm Coding Examples (cont’d.)

33. 33Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

34. 34Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Classification of Diabetes Mellitus

35. 35Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Pregnancy, Delivery, and Abortion  Many codes in this category require five-digit subclassifications  Follow guidelines for coding deliveries and complications

36. 36Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Admitting Diagnosis  Criteria for admitting inpatient diagnosis  One or more significant findings representing patient distress or abnormal findings on examination  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

37. 37Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Burns  Percentage of body area for code assignment  The Rule of Nines  Severity of burn  First degree  Second degree  Third degree

38. 38Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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  Fractures are coded as closed if there is no indication of “open” or “closed”  The word “with” indicates involvement of both sites, and the word “and” indicates involvement of one or two sites when multiple injury sites are given

39. 39Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Common Injury Medical Terms

40. 40Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-10-CM and ICD-10-PCS  ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 (diagnosis codes)  ICD-10-PCS will replace ICD-9-CM Volume 3 (procedure codes)  Reasons for development  ICD-9-CM was not expandable, comprehensive, or multiaxial  ICD-9-CM did not have standardized terminology and included diagnostic information

41. 41Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-10-CM vs. ICD-9-CM  Change in code book organization  New categories and chapters  New six- to seven-digit alphanumeric codes  Old 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  misadventure  early complication  late complication  sequela  transient postoperative condition  New activity code category  ICD-10-PCS is more specific than CPT

42. 42Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-10-CM Coding Conventions  Braces and brackets are not applicable  Added conventions  “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

43. 43Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

44. 44Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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.  Look for appropriate sub-subterm.  Follow any cross-reference instructions.  Write down the code.

45. 45Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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.  Read complete description and assign the code to the highest specificity.

46. 46Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Coding Chronic Alcoholic Liver Disease

47. 47Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Tabular List Coding Examples

48. 48Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Tabular List Coding Examples (cont’d.)

49. 49Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Coding by Etiology

50. 50Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Four-Digit Residual Subcategories

51. 51Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Combination Coding

52. 52Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Special Points to Remember in Volume 1  Use two or more codes if necessary to completely describe a diagnosis.  Search for one code when two diagnoses or a diagnosis with an associated secondary process or complication is present. See Figure 5-8.  Use category codes only if there are no subcategory codes.

53. 53Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Special Points to Remember in Volume 2  Notice that appropriate sites or modifiers are listed in alphabetic order under the main terms, with further subterm listings as needed.  Examine all modifiers that appear in parentheses next to the main term.  Check for nonessential modifiers that apply to any of the qualifying terms used in the statement of the diagnosis found in the patient’s medical record

54. 54Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Special Points to Remember in Volume 2 (cont’d)  Notice that eponyms appear as both main term entries and modifiers under main terms such as “disease” or “syndrome” and “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 see and see also.

55. 55Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Excerpt from Alphabetic Index of ICD-9-CM Volume 2

56. 56Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Excerpt from Tabular List of ICD-9-CM Volume 1