1. Diagnosis Coding

2. Objectives Explain the purposes of ICD coding
Demonstrate proper ICD coding procedures
Explain what agency is responsible for creating/updating ICD codes.
Explain the format of the ICD code book.
Explain the purpose of the ICD conventions.

3. Key Terms Alphabetic Index Alphanumeric Characters
Centers for Disease Control (CDC)
Code
Exclusion Notes
Guidelines
Inclusion Notes
International Classification of Diseases (ICD)
Main Term
Subterm
Tabular List
World Health Organization (WHO)

4. Medical Coding
Assigns a numeric or alphanumeric code to a procedure and diagnosis that has been treated
Use same language as each code has a specific meaning
Standardized coding purposes
Easier, faster processing of insurance claims
Gather statistics
Can help plan for health care needs
Further medical education and research
Without a system of standardized codes, it would be difficult to establish uniformity in the description of diseases and the procedures used to treat them.

5. What is the ICD ICD – International Classification of Diseases
Developed by World Health Organization
Current is the 10th Edition
On October 1, 2015 the U.S. transitioned to ICD-10
Two sections:
ICD-CM Clinical Management (Physician Office)
ICD-PCS Procedural Coding Systems (Hospital)
The WHO is the World’s CDC. They track the mortalities and morbidities (what kills instantly versus over time) across the world.

6. What is the ICD (contd) ICD Uses:
for diagnosis coding “what’s wrong with the patient.”
Tracking Mortality and Morbidity rates across the globe. (WHO and Centers for Disease Control)
The WHO is the World’s CDC. They track the mortalities and morbidities (what kills instantly versus over time) across the world.

7. Format of the ICD-10-CM Manual
Volume 1, Tabular List of Diseases (in numerical order)
Volume 2, Alphabetic Index (in alphabetic order)

8. Format of the ICD-10-CM Manual (Cont.)
The structure of I-10 includes
Category
Consists of three characters
A character can be a number or a letter
Subcategory
Can be either four or five characters.
Each sublevel after a category is a subcategory
Code
A code can be three to seven characters
A code is the final level of coding
The placeholder character is an “X” and does exactly that – it marks a place where another character is not required but a subsequent character is.

9. Conventions Used in ICD-10
Conventions are the rules of when codes can and cannot be used.
Conventions point out special conditions related to codes.
Alert the coder to any special notations or conditions associated with selecting a particular code.
Each ICD-10 manual provides detailed instructions for all conventions used in that manual.
Pay attention to the conventions, they provide a guide to when a code is allowed and when a code is to be excluded.

10. Basics of Diagnosis Coding with ICD-10-CM
When coding a patient’s diagnosis
Main term of the diagnosis is first located in the alphabetic index
Subterms are then used to refine the code.
Once the code is located in the Alphabetic Index locate the code in the Tabular List for verification.
Review the conventions for any Excluded or Included codes that could be used.
The index and tabular must be used; otherwise, coding errors are likely to happen.

11. V, W, X, and Y Codes – Chapter 20
Used to identify circumstances surrounding an injury event
Secondary diagnosis codes
Cannot be used as a first- listed diagnosis
If a patient has sustained an injury, it is acceptable to assign multiple external cause codes to fully describe the injury.

12. Z Codes – Chapter 21
An encounter with a physician without having any physical complaints
Physical examinations
Screenings for disease
Immunizations
Follow-up or aftercare
The main terms for Z codes are located in the main alphabetic index

13. Questions?