1 Chapter 5 Unit 4 Presentation ICD-9-CM Hospital Inpatient, Outpatient, and Physician Office Coding Shatondra Surulere, MBA, RHIA, CCS

2 Inpatient Coding  Settings  Reimbursement systems  Indexes and data entry  Coding guidelines and rules of coding

3 Sequencing of Diagnoses  Uniform Hospital Discharge Data Set (UHDDS) Principal diagnosis Additional diagnoses Principal procedure Other significant procedures

4 Inpatient Health Care Settings  Acute care facilities (hospitals)  Behavioral health care facilities  Hospice inpatient care  Long-term care

5 Acute Care Facility (ACF)  Range of services  Ancillary services  Single hospital versus multi-hospital system  Bed size (bed count)  Short term versus long term

6 Hospital Categories  Critical access  General  Long-term acute care (LTAC)  Specialty  Behavioral health care

7 Hospital Patients  Inpatients  Newborn patients  Sub-acute care patients

8 Patient Coding Guidelines  Sequencing  Principal diagnosis  Other (additional) diagnoses Complications Comorbidities  Principal procedure  Significant other procedures (secondary)

9 Codes for Symptoms, Signs and Ill- defined Conditions  Codes from Chapter 16 are not reported as the principal diagnosis when a related definitive diagnosis has been established  Chest Pain vs. Myocardial Infarction  Short of Breath vs. Emphysema

10 Two or More interrelated Conditions that meet Definition of Principal Diagnosis  When two or more interrelated conditions potentially meet the definition of principal diagnosis, either condition can be sequenced first (unless the ICD-9 book indicates otherwise).

11 Two or More Diagnoses that equally Meet Definition of Principal Diagnosis  Circumstances of admission  Diagnostic work up and/or therapy provided  Alphabetic index tabular list or coding guidelines

12 Two or More Comparative or Contrasting Conditions  When you have two or more comparative or contrasting diagnoses they are coded as confirmed diagnoses.  Sequence them according to coding rules. Either can be first.  Patient has chest pain, shortness or breath and doctor documents “acute asthma or acute pneumonia” you code both.

13 Symptoms Followed by Contrasting/Comparative Diagnosis  When a symptom is followed by contrasting/comparative diagnosis, the symptom code is sequenced first. Contrasting and comparative diagnoses are coded as secondary codes.  Overflow incontinence (symptom), Rule Out neurogenic bladder, rule out urinary stones  Code incontinence and all rule out diagnoses.

14 Original Treatment Plan not Carried Out  Patient was supposed to have surgery for salpingo-oophorectomy for cystic ovaries and after anesthesia the patient’s blood pressure drops and surgery is cancelled. Still code the cystic ovaries as principal.

15 Complications of Surgery and Other Medical Care  When patients is admitted for complications of previous surgery or other medical care the complication is sequenced first.

16 Uncertain Diagnosis  Probable  Suspected  Likely  Questionably  Possible  Still to be ruled out Code the condition as if it existed!!!!!

17 Reviewing the Patient Record  Assumption coding  Physician query

18 Other Key Terms  Optimizing reimbursement Permitted  Maximizing reimbursement Not permitted  Consolidated bill

19 Principal Diagnosis for Admission Following Observation Care  Admission following observation, principal diagnosis is medical condition that led to hospital admission

20 Principal Diagnosis for Admission Following Observation Care  Admission following post- operative observation, principal diagnosis is: Complication of outpatient surgery If no complication, then reason for outpatient surgery If another condition unrelated to surgery, assign unrelated condition

21 Chapter 6 ICD-9-CM Outpatient and Physician Office Coding

22 Outpatient Care (Ambulatory Care)  Primary care  Point of first contact  Primary care provider

23 Hospital Outpatient Services  Ambulatory patients (outpatients)  Ambulatory surgery patients  Emergency care patients  Observation patients

Freestanding Ambulatory Care Facilities  Ambulatory surgical center  Cardiovascular center  Clinical laboratory  Imaging center  Industrial health clinic  Infusion center  Neighborhood health center  Pain management center  Physician office  Primary care center  Public health department  Radiology center  Rehabilitation facility 24 (continued)

25 Other Ambulatory Care Facilities  Staff model health maintenance organization  Student health center  Urgent care center

26 Hospital-Based Departments  Ambulatory surgery  Outpatient department  Emergency department  Partial hospitalization program

27 Hospital-Owned Facilities  Hospital-owned physician practice  Satellite clinics

28 Outpatient Coding and Reporting Guidelines  Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) Selection of first-listed diagnosis ICD-9-CM Tabular List of Diseases (001.0 through V89) Accurate reporting of ICD-9-CM codes Always code to greatest degree of accuracy and completeness

29 Outpatient Coding Guidelines  Reason for encounter (001.0– 999.9)  Reporting signs and symptoms  Factors Influencing Health Status and Contact with Health Services (V codes)  Level of detail in coding  Sequencing diagnoses

30 Outpatient Coding Guidelines  Reporting qualified diagnoses (e.g., suspected pneumonia; questionable)  Reporting chronic diseases  Reporting coexisting conditions  Encounter for diagnostic services (continued)

31 Outpatient Coding Guidelines  Encounter for therapeutic services  Encounter for preoperative evaluations  Ambulatory surgery  Routine outpatient prenatal visits

32 Outpatient Diagnostic Tests  Determining first-listed diagnosis (e.g., due to signs and/or symptoms)  Instruction to determine reason for test  Information unavailable from physician  Incidental findings  Always code to greatest degree of accuracy and completeness

33 Outpatient Diagnostic Tests  Unrelated/Coexisting conditions  Tests ordered in absence of signs and/or symptoms  If order communicated via telephone, both treating provider and testing facility must document the call

34 Routine Laboratory and Radiology Encounters  In the absence of any signs, symptoms, or associated diagnosis, assign: V72.5 for radiology exam V72.6 for laboratory exam

35 Outpatient Surgery  Code reason for surgery as first- listed diagnosis Even if surgery is cancelled due to contraindication

36 Observation Stay  When admitted for observation of a medical condition, code as first- listed diagnosis  When admitted after outpatient surgery, code for reason for surgery as first-listed diagnosis and complication as secondary

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