1. Chapter 4 ICD-9-CM Medical Coding

2. Definition of Diagnosis Coding
Describes services and procedures diagnoses
ICD-9-CM:
Volumes are now used for coding the appropriate medical conditions

3. Coding History
Bills of mortality 1665: some of the earliest uses of coding
Warnings of plague epidemics
Diagnoses were often wrong or vague
18th century: Cause of death was noted

4. Purpose of the ICD-9-CM Establishes medical necessity
Translates written terminology into common language
Provides data for statistical analysis

5. The Yearly Addenda Includes the addition of new codes
Deletes old codes
Includes descriptor revisions

6. The Three Volumes 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

7. 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

8. 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.

9. Common Terminology 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

10. Common Terminology Principal diagnosis: The final diagnosis
Manifestation: The sign or symptom of a disease
NEC: Not elsewhere classified
NOS: Not otherwise specified

11. Symbols and Typeface and Terms
Boldface: Main term
Subterms: Indented two spaces to the right
Supplementary term: Assists coder in finding correct term
( ): Parentheses enclose supplementary words

12. Symbols and Typeface and Terms
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

13. Volume 2, The Alphabetical Index
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.

14. Volume 1, The Tabular List
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.

15. Volume 1, The Tabular List
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

16. Three Steps for Accurate Coding
Determine the reason for the encounter.
Locate the term in alphabetic index Volume 2.
Verify the code in the tabular list (Volume 1).

17. Key Coding Guidelines
Code the primary diagnosis first, followed by current coexisting conditions.
Code to the highest level of certainty.
Code to the highest level of specificity.

18. Code to the Highest Level of Certainty
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

19. Code to Highest Degree of Specificity
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.

20. Proper Order for Coding
Main reason for encounter
Any current coexisting condition
Do not code conditions that were previously treated and no longer exist.

21. Subsequent Coding
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

22. Subsequent Coding
V codes: Supplemental code that describes problems, services, or facts
E codes: Supplemental classifications of external causes of injuries and poisonings

23. Nine Steps of Accurate ICD-9-CM Coding
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.

24. Nine Steps of Accurate ICD-9-CM Coding
Examine any modifiers.
Note any subterms that provide greater specificity.

25. Nine Steps of Accurate ICD-9-CM Coding
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.