General Guidelines

 Term first-listed diagnosis, rather than principal diagnosis  Outpatient Surgery: Reason for surgery ◦ Even if surgery is cancelled due to contraindication

 Observation Stay: Medical condition that occasioned admission ◦ Assign a code from medical condition  Observation Stay: Complications from outpatient surgery lead to observation report:  Reason for surgery as first reported diagnosis  Codes for complications necessitating observation

 Condition for encounter ◦ Why patient presented, not necessarily most serious condition noted  Documented  Chiefly responsible for services provided  Also list co-existing conditions

 Diagnosis and procedure MUST correlate  Medical necessity must be established through documentation  No correlation = No reimbursement

 Can be the first-listed diagnosis if no more specific diagnosis available  Diagnoses often are not established at the time of the initial encounter/visit

 Use codes through V89.09 to code: ◦ Diagnosis ◦ Symptoms ◦ Conditions ◦ Problems ◦ Complaints ◦ Or other reason(s) for visit

 Documentation should describe patient's condition, using terminology that includes: ◦ Specific diagnoses ◦ Symptoms ◦ Problems ◦ Reasons for encounter

 Selection of codes through (Chapters 1-17) frequently used to describe reason for encounter

 Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when ◦ An established diagnosis has NOT been determined by physician

 V codes deal with encounters for circumstances other than disease or injury ◦ Example: Well-baby checkup  See Section I.C.18 for information on V codes

 Located after in Tabular  Two digits before decimal (e.g., V10.1X)  Index for V codes is Alphabetic Index to Diseases  Main terms: ◦ Contraception ◦ Counseling ◦ Dialysis ◦ Status ◦ Examination

 Not sick BUT receives health care (e.g., vaccination)  Services for known/resolving disease/injury (e.g., chemotherapy)  Codes for “aftercare” (e.g., surgery or fracture)  Indicate birth status/outcome of delivery (Cont’d…)

(…Cont’d)  A circumstance/problem that influences patient’s health BUT NOT current illness/injury ◦ Example: Organ transplant status ◦ Example: Birth status and outcome of delivery (newborn)  Section I.18.e. of Guidelines contains the V Code Table ◦ Identifies if V code can be listed as first, first/additional, additional only

 V10 Personal history of malignant neoplasm  V12 Personal history of certain other diseases  V13 Personal history of other diseases  V14 Personal history of allergy to medicinal agents  V15 Other personal history presenting hazards to health  V16 Family history of malignant neoplasm  V17 Family history of certain chronic disabling diseases  V18 Family history of certain other specific diseases  V19 Family history of other conditions Condition no longer present or treated

 Codes have either 3, 4, or 5 digits  4 and/or 5 digit codes provide greater specificity (detail) (Cont’d…)

(…Cont’d)  3-digit code used ONLY if no 4 or 5 digit  Where 4 and/or 5 digits provided, must be assigned  Diagnoses NOT coded to full digits available invalid  Claims bounce!

 List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided  List additional codes that describe any coexisting conditions  Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis

 Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses  Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit

 Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)

 Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management  Do NOT code conditions previously treated, no longer existing (Cont’d…)

(…Cont’d)  “History of” codes (V10-V19) may be used as secondary codes if: ◦ Impacts current care or treatment

 For patients receiving diagnostic services ONLY  Sequence first ◦ Diagnosis ◦ Condition ◦ Problem OR ◦ Other reason shown in medical record to be chiefly responsible for encounter (…Cont’d)

 Codes for other diagnoses (e.g., chronic conditions) ◦ May be sequenced as secondary diagnoses  Exception: Therapeutic Services ◦ Patients receiving chemotherapy (V58.11), radiation therapy (V58.0), or rehabilitation (V57.0- V57.9) ◦ V code first diagnosis and problem for which service being performed second

 For patients receiving preoperative evaluations ONLY ◦ Code from category V72.8 (Other specified examinations) ◦ Assign secondary code for reason for surgery ◦ Code also any findings related to preoperative evaluation

 Code diagnosis which required ambulatory surgery  Pre- and post-op diagnosis different ◦ Code the post-op diagnosis

 Code routine prenatal visits with no complications: ◦ V22.0 (Supervision of normal first pregnancy) ◦ V22.1 (Supervision of other normal pregnancy) ◦ DO NOT use these codes with pregnancy complication codes (Chapter 11, ICD-9-CM)

Conclusion – General Guidelines