Chapter 4 ICD-9-CM Medical Coding

Definition of Diagnosis Coding Describes services and procedures diagnoses ICD-9-CM: Volumes are now used for coding the appropriate medical conditions

Coding History Bills of mortality 1665: some of the earliest uses of coding Warnings of plague epidemics Diagnoses were often wrong or vague 18th century: Cause of death was noted

Purpose of the ICD-9-CM Establishes medical necessity Translates written terminology into common language Provides data for statistical analysis

The Yearly Addenda Includes the addition of new codes Deletes old codes Includes descriptor revisions

The Three Volumes of the ICD-9-CM Volume 1: Tabular/numerical list of diseases Volume 2: Alphabetic index of disease Volume 3: Tabular and alphabetic index of procedures

ICD-10-CM Replaces volumes 1 and 2 of the ICD-9-CM Uses alphanumeric codes Is much more detailed than ICD-9-CM Includes ambulatory and managed care encounters Contains injury codes

ICD-10-CM Combines many codes to give a more detailed description of the injury or illness No implementation date has been set yet for the ICD-10-CM. Implementation will be based on the process for adoption of standards under HIPAA.

Common Terminology Encounter: Refers to all healthcare settings Provider: Physician or qualified healthcare provider Diagnostic statement: The main reason for encounter Primary diagnosis: The main reason for visit or encounter

Common Terminology Principal diagnosis: The final diagnosis Manifestation: The sign or symptom of a disease NEC: Not elsewhere classified NOS: Not otherwise specified

Symbols and Typeface and Terms Boldface: Main term Subterms: Indented two spaces to the right Supplementary term: Assists coder in finding correct term ( ): Parentheses enclose supplementary words

Symbols and Typeface and Terms Colon (:) is used after incomplete phrase or term requiring indented term(s) [ ]: used to enclose synonyms, alternate wordings, or explanatory phrases Instructional terms: Assists coder in finding most specific term

Volume 2, The Alphabetical Index Use this volume first to search for the correct code or condition. After you find the code, use Volume 1 (tabular list) to research the specific code.

Volume 1, The Tabular List Used to research the specific code Punctuation has various meanings. A colon : is used after an incomplete phrase or when a modifier is needed. Square brackets, [ ], are used to enclose synonyms, alternate wordings, or explanations.

Volume 1, The Tabular List Punctuation has various meanings. Parentheses () are used to enclose supplementary words that may be present or absent in a statement of disease without affecting the code assignment

Three Steps for Accurate Coding Determine the reason for the encounter. Locate the term in alphabetic index Volume 2. Verify the code in the tabular list (Volume 1).

Key Coding Guidelines Code the primary diagnosis first, followed by current coexisting conditions. Code to the highest level of certainty. Code to the highest level of specificity.

Code to the Highest Level of Certainty Code condition of encounter. Sign: Objective Symptom: Subjective Signs, symptoms, ill-defined conditions Use Volume 2, alphabetic index, for sign or symptom Use Volume 1, Chapter 16, to verify

Code to Highest Degree of Specificity Assign three-digit codes if there are no four-digit codes in the category. Assign four-digit codes if there are no five-digit codes in the category. Claims submitted with three- or four-digit codes will be returned if four- to five-digit codes are available.

Proper Order for Coding Main reason for encounter Any current coexisting condition Do not code conditions that were previously treated and no longer exist.

Subsequent Coding Surgical coding: Diagnosis for which surgery is performed Late effects/residual effects: Condition that remains after an acute illness or injury Acute and chronic conditions Combination codes

Subsequent Coding V codes: Supplemental code that describes problems, services, or facts E codes: Supplemental classifications of external causes of injuries and poisonings

Nine Steps of Accurate ICD-9-CM Coding Locate main term in the diagnostic statement. Locate the main term in Volume 2, the alphabetic index. Refer to all notes under the main term. Use instructions in any notes appearing in a box after the main term.

Nine Steps of Accurate ICD-9-CM Coding Examine any modifiers. Note any subterms that provide greater specificity.

Nine Steps of Accurate ICD-9-CM Coding Follow any cross-reference instructions. Confirm the code selection in the tabular list (Volume 1). Follow the instructional terms in Volume 1. Assign the correct code number.