Diagnosis Coding

Objectives Explain the purposes of ICD coding Demonstrate proper ICD coding procedures Explain what agency is responsible for creating/updating ICD codes. Explain the format of the ICD code book. Explain the purpose of the ICD conventions.

Key Terms Alphabetic Index Alphanumeric Characters Centers for Disease Control (CDC) Code Exclusion Notes Guidelines Inclusion Notes International Classification of Diseases (ICD) Main Term Subterm Tabular List World Health Organization (WHO)

Medical Coding Assigns a numeric or alphanumeric code to a procedure and diagnosis that has been treated Use same language as each code has a specific meaning Standardized coding purposes Easier, faster processing of insurance claims Gather statistics Can help plan for health care needs Further medical education and research Without a system of standardized codes, it would be difficult to establish uniformity in the description of diseases and the procedures used to treat them.

What is the ICD ICD – International Classification of Diseases Developed by World Health Organization Current is the 10th Edition On October 1, 2015 the U.S. transitioned to ICD-10 Two sections: ICD-CM Clinical Management (Physician Office) ICD-PCS Procedural Coding Systems (Hospital) The WHO is the World’s CDC. They track the mortalities and morbidities (what kills instantly versus over time) across the world.

What is the ICD (contd) ICD Uses: for diagnosis coding “what’s wrong with the patient.” Tracking Mortality and Morbidity rates across the globe. (WHO and Centers for Disease Control) The WHO is the World’s CDC. They track the mortalities and morbidities (what kills instantly versus over time) across the world.

Format of the ICD-10-CM Manual Volume 1, Tabular List of Diseases (in numerical order) Volume 2, Alphabetic Index (in alphabetic order)

Format of the ICD-10-CM Manual (Cont.) The structure of I-10 includes Category Consists of three characters A character can be a number or a letter Subcategory Can be either four or five characters. Each sublevel after a category is a subcategory Code A code can be three to seven characters A code is the final level of coding The placeholder character is an “X” and does exactly that – it marks a place where another character is not required but a subsequent character is.

Conventions Used in ICD-10 Conventions are the rules of when codes can and cannot be used. Conventions point out special conditions related to codes. Alert the coder to any special notations or conditions associated with selecting a particular code. Each ICD-10 manual provides detailed instructions for all conventions used in that manual. Pay attention to the conventions, they provide a guide to when a code is allowed and when a code is to be excluded.

Basics of Diagnosis Coding with ICD-10-CM When coding a patient’s diagnosis Main term of the diagnosis is first located in the alphabetic index Subterms are then used to refine the code. Once the code is located in the Alphabetic Index locate the code in the Tabular List for verification. Review the conventions for any Excluded or Included codes that could be used. The index and tabular must be used; otherwise, coding errors are likely to happen.

V, W, X, and Y Codes – Chapter 20 Used to identify circumstances surrounding an injury event Secondary diagnosis codes Cannot be used as a first- listed diagnosis If a patient has sustained an injury, it is acceptable to assign multiple external cause codes to fully describe the injury.

Z Codes – Chapter 21 An encounter with a physician without having any physical complaints Physical examinations Screenings for disease Immunizations Follow-up or aftercare The main terms for Z codes are located in the main alphabetic index

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