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Medical Coding Chapter 3.

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Presentation on theme: "Medical Coding Chapter 3."— Presentation transcript:

1 Medical Coding Chapter 3


3 Section IV Diagnostic Coding
Physician’s office Hospital-based outpatient services Part of Official Guidelines for Coding and Reporting, Section IV Outpatient guidelines do not address specific sequencing or diseases as inpatient guidelines do. Follow the inpatient coding guidelines in situations in which there are no clear outpatient coding guidelines. In the outpatient setting, the term “first-listed diagnosis [primary]” is used instead of “principal diagnosis.” SXS11ierPPT-INTC03_P1

4 Section IV Diagnostic Coding
Guidelines do not address specific sequencing or diseases as inpatient do Though not stated, if there is no outpatient guideline, follow inpatient guidelines SXS11ierPPT-INTC03_P1 4

5 Diagnostic Coding Guideline A
Term first-listed diagnosis, rather than principal diagnosis Outpatient Surgery: Reason for surgery Even if surgery is cancelled due to contraindication Primary diagnosis is synonymous with first-listed diagnosis. Either term can replace the term principle diagnosis. SXS11ierPPT-INTC03_P1

6 Diagnostic Coding Guideline A
Observation Stay: Medical condition that occasioned admission Assign a code from medical condition Observation Stay: Complications from outpatient surgery lead to observation report: Reason for surgery as first reported diagnosis Codes for complications necessitating observation SXS11ierPPT-INTC03_P1 6

7 Selection of First-Listed Diagnosis
Condition for encounter Why patient presented, not necessarily most serious condition noted Documented Chiefly responsible for services provided Also list co-existing conditions In an outpatient setting, coders should indicate the main reason for the visit as the primary diagnosis, as well as subsequent diagnoses to substantiate other services provided, such as laboratory or radiology. Sequence the primary diagnosis first. SXS11ierPPT-INTC03_P1

8 Diagnosis and Services
Diagnosis and procedure MUST correlate Medical necessity must be established through documentation No correlation = No reimbursement What is the reason for the use of ICD-9 codes? (They establish medical necessity for the documentation.) SXS11ierPPT-INTC03_P1

9 Symptoms, Signs, and Ill-Defined Conditions
Can be the first-listed diagnosis if no more specific diagnosis available Diagnoses often are not established at the time of the initial encounter/visit Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when the physician has not confirmed an established diagnosis. SXS11ierPPT-INTC03_P1

10 Diagnostic Coding Guideline B
Use codes through V91.99 to code: Diagnosis Symptoms Conditions Problems Complaints Or other reason(s) for visit You will use all different codes from to V86.1. Many clinics are specialized so you may use some codes more than others but it is important to be familiar with all. If your facility is more specialized (cardiology), other than family practice, you may only use a minimum of diagnosis codes, but if you follow the guidelines, you would be able to properly code any diagnosis. SXS11ierPPT-INTC03_P1

11 Diagnostic Guideline C
Documentation should describe patient's condition, using terminology that includes: Specific diagnoses Symptoms Problems Reasons for encounter There are ICD-9-CM codes to describe all of these items. If no specific diagnosis is given by the physician what should you code as the diagnosis? (the symptoms the patient came in with or the reason for the encounter) SXS11ierPPT-INTC03_P1

12 Diagnostic Guideline D
Selection of codes through (Chapters 1-17) frequently used to describe reason for encounter These codes are from the section of ICD-9-CM for the classification of disease and injuries. SXS11ierPPT-INTC03_P1

13 Diagnostic Guideline E
Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when An established diagnosis has NOT been determined by physician Chapter 16 contains many, but not all, codes for symptoms. This is the chapter that you would refer to when there is no definitive diagnosis given. These codes would still be referenced in the index prior to the tabular section of your coding book. SXS11ierPPT-INTC03_P1

14 Diagnostic Guideline F
V codes deal with encounters for circumstances other than disease or injury Example: Well-baby checkup See Section I.C.18 for information on V codes Encounters for reasons other than a disease or injury. These have been discussed earlier. What are some other encounters that would be coded with V codes? (postoperative visit, immunization only, birth control counseling) SXS11ierPPT-INTC03_P1

15 V01-V91 Assigned as first-listed diagnosis for:
Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service V01-V91 Assigned as first-listed diagnosis for: Admissions for evaluation Following an accident that would ordinarily result in health problem, BUT there is none Car accident, driver hits head, no apparent injury, admit to R/O head trauma Never a secondary diagnosis There are four primary circumstances for the use of V codes: When a person who is not sick obtains health services, such as vaccination, health screening, or testing to act as an organ donor. When a person with a resolving disease or injury or a chronic condition requiring continuous care receives specific aftercare. When circumstances or problems influence a person’s health status but are not in themselves a current illness or injury. For newborns, to indicate birth status. Can be a first-listed or a secondary code, depending on the circumstances of the encounter. SXS11ierPPT-INTC03_P1

16 Located after 999.9 in Tabular
V Codes Located after in Tabular Two digits before decimal (e.g., V10.1X) Index for V codes is Alphabetic Index to Diseases Main terms: Contraception Counseling Dialysis Status Examination V codes can be located in the Index, similar to any other code. Where is the V code index listed? (The V codes are enclosed in the main index of CPT.) Like other diagnosis codes you would find the main term that you are looking for in the Alphabetical Index. What are some main terms of V codes? (Status (post), absence, history of, Counseling) SXS11ierPPT-INTC03_P1

17 Not sick BUT receives health care (e.g., vaccination)
Uses of V Codes Not sick BUT receives health care (e.g., vaccination) Services for known/resolving disease/injury (e.g., chemotherapy) Codes for “aftercare” (e.g., surgery or fracture) Indicate birth status/outcome of delivery • There are four uses of V codes: When a patient isn’t currently sick but needs to go to the doctor. What would be an example of this? (When a child goes in for immunizations only.) A patient with a known disease who receives health services. What would be an example of this? (A patient who is receiving radiation therapy.) SXS11ierPPT-INTC03_P1

18 Section I.C.18.e. of Guidelines contains the V Code Table
Uses of V Codes A circumstance/problem that influences patient’s health BUT NOT current illness/injury Example: Organ transplant status Example: Birth status and outcome of delivery (newborn) Section I.C.18.e. of Guidelines contains the V Code Table Identifies if V code can be listed as first, first/additional, additional only When there is not a current illness or injury. What would be an example of this? (Patient is status post a procedure) To indicate birth status or outcome of surgery. What would be an example of this? (Outcome of delivery) SXS11ierPPT-INTC03_P1

19 History V Code Categories in Tabular
V10 Personal history of malignant neoplasm V11 Personal history of mental illness V12 Personal history of certain other diseases V13 Personal history of other diseases V14 Personal history of allergy to medicinal agents V15 Other personal history presenting hazards to health V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V18 Family history of certain other specific diseases V19 Family history of other conditions Condition no longer present or treated “History of” codes are separated by whether it is personal history or family history. Are there only “History of” neoplasm codes? (No) What other “History of” codes are there? (ASHD, asthma, gout, mental disorders) SXS11ierPPT-INTC03_P1

20 Diagnostic Guideline G
Codes have either 3, 4, or 5 digits 4 and/or 5 digit codes provide greater specificity (detail) Codes with three digits are included as the heading for a category of codes. Never code a three digit code if it requires a fourth or fifth digit. Why should you never code a three digit code if forth or fifth digits are required for that code? (You should always code to the greatest level of specificity. This would also, ultimately, be denied by the third party payer as an incorrect diagnosis and delay reimbursement.) SXS11ierPPT-INTC03_P1

21 Diagnostic Guideline G
3-digit code used ONLY if no 4 or 5 digit Where 4 and/or 5 digits provided, must be assigned Diagnoses NOT coded to full digits available invalid Claims bounce! A three-digit code is to be used only if it is not further subdivided. A three-digit code has the heading of a category code (example: 462). SXS11ierPPT-INTC03_P1

22 Diagnostic Guideline H
List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided List additional codes that describe any coexisting conditions Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis List first the reason for the encounter and then any coexisting conditions. A patient comes into the clinic and his or her chief complaint is a severe cough for greater than a week. Associated signs and symptoms are extreme fatigue and sore throat. No definitive diagnosis is given. Which symptom would be the first coded, as it was the main reason the patient came into the clinic? (Cough) What would be the coexisting conditions? (fatigue and sore throat) SXS11ierPPT-INTC03_P1

23 Diagnostic Guideline I
Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit Note that this differs from the coding practices used by hospital medical record departments for coding the diagnosis of acute care, short-term hospital inpatients. SXS11ierPPT-INTC03_P1

24 Diagnostic Guideline J
Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s) A patient who has a chronic disease and is seen at the physician’s office multiple times, the same diagnosis can be used for each encounter. What might be some examples of this? (Hypertension, Diabetes, Arteriosclerotic heart disease, Asthma, COPD) SXS11ierPPT-INTC03_P1

25 Diagnostic Guideline K
Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management Do NOT code conditions previously treated, no longer existing All diagnoses that co-exist with primary diagnosis should be coded. If a patient was previously diagnosed with pneumonia, and now the patient comes into the clinic for an asthma check, and the physician lists in his assessment that they are status post pneumonia, but they no longer have symptoms or are being treated, would the pneumonia be coded out as a diagnosis? Why or why not? (No because even though pneumonia pertains to the lung and the patient is in for an asthma check, the patient no longer has pneumonia or is being treated for it so this should not be coded) SXS11ierPPT-INTC03_P1

26 Diagnostic Guideline K
“History of” codes (V10-V19) may be used as secondary codes if: Impacts current care or treatment What are some examples of situations that would require use of a history code? (Personal history of malignant neoplasm or Personal history of allergy. Family history of malignant neoplasm or Family history of certain chronic disabling diseases.) SXS11ierPPT-INTC03_P1

27 Special Note About “History of”
Index to Disease, MAIN term “History” Entries between “family” and “visual loss V19.0” = “family history of” (FHO) Entries before “family” and after “visual loss” = “personal history of” (PHO) Personal history = V10-V15 Family history = V16-V19 If the patient record states that there is a “history of” a disease, such as diabetes, it does not mean that the patient no longer has the disease; but that the patient’s medical history includes the disease. A V code is not assigned to indicate a previous history of diabetes; rather, the code for the current disease (250.0X) is used. Ask students to use a highlighter and mark their Index where family history begins and ends. SXS11ierPPT-INTC03_P1

28 Diagnostic Guidelines L and M
For patients receiving diagnostic services ONLY Sequence first Diagnosis Condition Problem OR Other reason shown in medical record to be chiefly responsible for encounter Do not code related signs and symptoms as additional diagnoses. How does this coding guideline differ from the inpatient guideline? (In the outpatient setting, related signs and symptoms are not coded as additional diagnoses. In the inpatient setting, abnormal findings on test results are coded.) SXS11ierPPT-INTC03_P1

29 Diagnostic Guidelines L and M
Codes for other diagnoses (e.g., chronic conditions) May be sequenced as secondary diagnoses Exception: Therapeutic Services Patients receiving chemotherapy (V58.11), radiation therapy (V58.0), or rehabilitation (V57.0-V57.9) V code first diagnosis and problem for which service being performed second For outpatient encounters for diagnostic tests that have been interpreted by a physician with the final report available at the time of coding, code any documented confirmed or definitive diagnoses. Diagnosis is listed second only when the patient is receiving chemotherapy, radiation therapy, or rehabilitation when the V code must be listed first. SXS11ierPPT-INTC03_P1

30 Diagnostic Guideline N
For patients receiving preoperative evaluations ONLY Code from category V72.8 (Other specified examinations) Assign secondary code for reason for surgery Code also any findings related to preoperative evaluation A patient receiving only a preoperative evaluation should first be coded with a code from the V72.8 category. The secondary code would be the reason the patient is having the procedure or surgery. If the patient was found to have a fever on the preoperative evaluation, should this be coded for this visit? (Yes, because it was found on evaluation and may require further looking into, or delay the procedure or surgery.) SXS11ierPPT-INTC03_P1

31 Diagnostic Guideline O, Ambulatory Surgery
Code diagnosis which required ambulatory surgery Pre- and post-op diagnosis different Code the post-op diagnosis The postoperative diagnosis is the most definitive. SXS11ierPPT-INTC03_P1

32 Diagnostic Guideline P
Code routine prenatal visits with no complications: V22.0 (Supervision of normal first pregnancy) V22.1 (Supervision of other normal pregnancy) DO NOT use these codes with pregnancy complication codes (Chapter 11, ICD-9-CM) Routine outpatient prenatal visits with no complications are coded with V22.0. A normal first pregnancy is V22.1. SXS11ierPPT-INTC03_P1

33 V91 Multiple Gestation Placenta Status
New in 2011 Identifies twins, triplets, quadruplets, other multiples


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