Chapter 4 ICD-9-CM Medical Coding C OMPREHENSIVE H EALTH I NSURANCE B ILLING, C ODING, AND R EIMBURSEMENT

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes D EFINITION OF D IAGNOSIS C ODING  Describes services and procedures diagnoses  ICD-9-CM:  Volumes are now used for coding the appropriate medical conditions

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C ODING H ISTORY  Bills of mortality 1665: some of the earliest uses of coding  Warnings of plague epidemics  Diagnoses were often wrong or vague  18 th century: Cause of death was noted

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes P URPOSE OF THE ICD-9-CM  Establishes medical necessity  Translates written terminology into common language  Provides data for statistical analysis

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes T HE Y EARLY A DDENDA  Includes the addition of new codes  Deletes old codes  Includes descriptor revisions

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes T HE T HREE V OLUMES 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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes 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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes 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.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C OMMON T ERMINOLOGY  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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C OMMON T ERMINOLOGY  Principal diagnosis: The final diagnosis  Manifestation: The sign or symptom of a disease  NEC: Not elsewhere classified  NOS: Not otherwise specified

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S YMBOLS AND T YPEFACE AND T ERMS  Boldface: Main term  Subterms: Indented two spaces to the right  Supplementary term: Assists coder in finding correct term  ( ): Parentheses enclose supplementary words

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S YMBOLS AND T YPEFACE AND T ERMS  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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes V OLUME 2, T HE A LPHABETICAL I NDEX  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.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes V OLUME 1, T HE T ABULAR L IST  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.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes V OLUME 1, T HE T ABULAR L IST  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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes T HREE S TEPS FOR A CCURATE C ODING 1. Determine the reason for the encounter. 2. Locate the term in alphabetic index Volume Verify the code in the tabular list (Volume 1).

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes K EY C ODING G UIDELINES  Code the primary diagnosis first, followed by current coexisting conditions.  Code to the highest level of certainty.  Code to the highest level of specificity.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C ODE TO THE H IGHEST L EVEL OF C ERTAINTY  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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C ODE TO H IGHEST D EGREE OF S PECIFICITY  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.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes P ROPER O RDER FOR C ODING  Main reason for encounter  Any current coexisting condition  Do not code conditions that were previously treated and no longer exist.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S UBSEQUENT C ODING  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

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S UBSEQUENT C ODING  V codes: Supplemental code that describes problems, services, or facts  E codes: Supplemental classifications of external causes of injuries and poisonings

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes N INE S TEPS OF A CCURATE ICD-9-CM C ODING  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.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes N INE S TEPS OF A CCURATE ICD-9-CM C ODING  Examine any modifiers.  Note any subterms that provide greater specificity.

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes N INE S TEPS OF A CCURATE ICD-9-CM C ODING  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.