Chapter 5 Diagnostic Coding Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2 Importance of Correct Diagnostic Coding  Diagnostic coding must be accurate because payment for inpatient services rendered to a patient may be based on the diagnosis.  In the outpatient setting, the diagnosis code must correspond to the treatment or services rendered to the patient or payment may be denied.

3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. The Diagnostic Coding System  Guidelines for diagnostic coding must be followed when assigning codes  Only diagnoses that currently relate to patient state should be coded  Payment for services may be tied into diagnostic coding, due to medical necessity requirements

4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Sequencing of Diagnostic Codes  Primary diagnosis (first-listed)  Related to the chief complaint  Main reason for the encounter  Secondary diagnosis  May contribute to the primary diagnosis  Not the underlying cause (etiology)  Principal diagnosis  Only applicable to inpatient cases/claims  Similar to primary diagnosis for outpatient

5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Reasons for the Development and Use of Diagnostic Codes  Tracking of disease processes  Classification of causes of mortality  Medical research  Evaluation of hospital service utilization

6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Use of Standard Transaction Code Sets  Each transaction must include the use of medical and other code sets  ICD-9-CM must be used for when assigning diagnostic codes  Required, per HIPAA standards  Diagnostic codes should tie into the services rendered to the patient  Indicated by procedure codes (in Ch. 6)  Physician’s fee profile

7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. History of Coding Diseases  1869: American Nomenclature of Diseases (AMA)  1903: Bellevue Hospital Nomenclature of Diseases  Standard Nomenclature of Diseases and Operations  1960s-1991: Current Medical Information and Terminology (CMIT) (AMA)  Current: Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)

8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. International Classification of Diseases  17 th century: ICD developed in England  18 th century: ICD use began in U.S.  1950s: ICD used in hospitals to classify and index disease  Current: ICD-9 (9 th revision) in use

9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Organization and Format  Three volumes  Volume 1: Tabular List of Diseases  Volume 2: Alphabetic Index of Diseases  Volume 3: Tabular List and Alphabetic Index of Procedures  Volumes 1 and 2 are used in physician offices and hospitals for diagnoses  Volume 3 is used in hospitals for procedures

10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Outline of Volumes 1 and 2 of ICD-9-CM

11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-9-CM Conventions

12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-9-CM Conventions

13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-9-CM Conventions

14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. General Coding Guidelines  Code only conditions or problems that are actively managed at the visit  First, look up condition in Volume 2  Main term is the condition  Second, go to Volume 1 to assign the code  Follow instructions from Volume 2 and conventions in Volume 1

15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Illustration of Main Terms, Subterms, and Nonessential Modifiers

16Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Code Digits  ICD-9-CM contains at least three digits  Fourth or fifth digits can also be appended  Provides greater specificity  Must be used if available  Fifth digit codes can appear:  At the beginning of the chapter  At the beginning of a section  At the beginning of a three-digit category  In a fourth-digit subcategory

17Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Codes & E Codes  V Codes are used when a person who is not currently sick encounters health services for some specific purpose.  E Codes are used when some circumstance or problem is present that influences the person’s health status but is not in itself a current illness or injury.

18Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Use  V codes are used in four circumstances  When a person who is not currently sick encounters health services for a specific purpose (vaccination, etc.)  When a person with a resolving disease or injury seeks aftercare  When a circumstance influences an individual’s health status but the illness is not current  When it is necessary to indicate the birth status of a newborn

19Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Examples

20Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Examples (cont’d.)

21Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. V Code Examples (cont’d.)

22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Codes  Used to explain the mechanism for the injury  Used to gather data about injury causes  Should be reported in addition to the appropriate procedural/diagnostic codes  E codes are NEVER the primary diagnosis

23Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Codes (cont’d.)

24Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Table of Drugs and Chemicals

25Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Coding Examples

26Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. E Coding Examples (cont’d.)

27Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Signs, Symptoms, and Ill-Defined Conditions  Signs and symptoms codes can be used:  No precise diagnosis can be made  Signs and symptoms are transient, and a specific diagnosis was not made  Provisional diagnosis for a patient who does not return for further care  A patient is referred for treatment before a definite diagnosis is made

28Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Sterilization  V25.2 should be used for sterilization for contraceptive purposes  Elective sterilization: only V25.2  Elective sterilization after obstetric delivery: V25.2 as secondary  Sterilization for other reasons does not require a V code

29Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Neoplasm Terminology  Benign tumor: one that does not have properties of invasion and metastasis and is usually surrounded by a fibrous capsule  Malignant tumor: has the properties of invasion and metastasis  Carcinoma: refers to a cancerous or malignant tumor  Carcinoma in situ: cancer confined to the site of origin without invasion of neighboring tissues

30Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Coding for Neoplasms

31Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Neoplasm Coding Examples

32Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Neoplasm Coding Examples (cont’d.)

33Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Cardiovascular System Conditions  Hypertension  Malignant vs. benign  Cause should be coded when specified  Myocardial infarctions  Chronic rheumatic heart disease  Conditions presumed to be caused by rheumatic fever  Arteriosclerotic cardiovascular/heart disease  Cardiovascular vs. heart

34Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Classification of Diabetes Mellitus

35Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Pregnancy, Delivery, and Abortion  Many codes in this category require five-digit subclassifications  Follow guidelines for coding deliveries and complications

36Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Admitting Diagnosis  Criteria for admitting inpatient diagnosis  One or more significant findings representing patient distress or abnormal findings on examination  A diagnosis established on an ambulatory care basis or previous hospital admission  An injury or poisoning  A reason or condition not classifiable as an illness or injury

37Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Burns  Percentage of body area for code assignment  The Rule of Nines  Severity of burn  First degree  Second degree  Third degree

38Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Injuries and Late Effects  Multiple injuries  List diagnosis in order of importance  Most severe problem listed first  Guidelines for coding injuries  Decide whether a diagnosis represents a current injury or late effect  Fractures are coded as closed if there is no indication of “open” or “closed”  The word “with” indicates involvement of both sites, and the word “and” indicates involvement of one or two sites when multiple injury sites are given

39Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Common Injury Medical Terms

40Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-10-CM and ICD-10-PCS  ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 (diagnosis codes)  ICD-10-PCS will replace ICD-9-CM Volume 3 (procedure codes)  Reasons for development  ICD-9-CM was not expandable, comprehensive, or multiaxial  ICD-9-CM did not have standardized terminology and included diagnostic information

41Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-10-CM vs. ICD-9-CM  Change in code book organization  New categories and chapters  New six- to seven-digit alphanumeric codes  Old injuries are to use S and T codes, by site  Expanded explanatory notes and instructions  Expanded dual classification system  E and V codes are now separate chapters  New procedures get unique codes  Combination diagnosis/symptom codes added  Postoperative complication codes describe type and site or complication  misadventure  early complication  late complication  sequela  transient postoperative condition  New activity code category  ICD-10-PCS is more specific than CPT

42Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. ICD-10-CM Coding Conventions  Braces and brackets are not applicable  Added conventions  “and”  Excludes 1  Excludes 2  Acute and chronic conditions can be assigned together  Acute should be sequenced first  Bilateral sites  Right side is character 1; Left side is character 2  Bilateral is character 3  Unidentified side requires unspecified code

43Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Transition to ICD-10-CM  Implementation could be October 2010  Requires higher level of clinical knowledge  Training is necessary  Different ICD-10-CM books will be offered

44Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Basic Steps in Coding  Locate the main term in the Alphabetic Index in Volume 2.  Refer to any notes under the main term.  Read any terms enclosed in parentheses after the main term.  Look for appropriate subterm.  Look for appropriate sub-subterm.  Follow any cross-reference instructions.  Write down the code.

45Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Basic Steps in Coding (cont’d.)  Verify the code number in the Tabular List in Volume 1.  Read and be guided by any instructional terms in the Tabular List.  Read complete description and assign the code to the highest specificity.

46Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Coding Chronic Alcoholic Liver Disease

47Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Tabular List Coding Examples

48Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Tabular List Coding Examples (cont’d.)

49Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Coding by Etiology

50Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Four-Digit Residual Subcategories

51Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Combination Coding

52Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Special Points to Remember in Volume 1  Use two or more codes if necessary to completely describe a diagnosis.  Search for one code when two diagnoses or a diagnosis with an associated secondary process or complication is present. See Figure 5-8.  Use category codes only if there are no subcategory codes.

53Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Special Points to Remember in Volume 2  Notice that appropriate sites or modifiers are listed in alphabetic order under the main terms, with further subterm listings as needed.  Examine all modifiers that appear in parentheses next to the main term.  Check for nonessential modifiers that apply to any of the qualifying terms used in the statement of the diagnosis found in the patient’s medical record

54Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Special Points to Remember in Volume 2 (cont’d)  Notice that eponyms appear as both main term entries and modifiers under main terms such as “disease” or “syndrome” and “operation.”  Look for sublisted terms in parentheses that are associated with the eponym.  Locate closely related terms, code categories, and cross-referenced synonyms indicated by see and see also.

55Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Excerpt from Alphabetic Index of ICD-9-CM Volume 2

56Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Excerpt from Tabular List of ICD-9-CM Volume 1