1.  What is coding? Transformation of verbal descriptions into numbers Describes:  Diseases  Injuries  Procedure

2.  Official Guidelines for Coding and Reporting  Appendix I  Used by ALL healthplans  Volumes 1-2  Cover diseases, injuries, impairments  Cover other health problems  Cover Causes of injury and disease  Volume 3 covers procedures or other actions taken for disease, injury, or impairments  HCPCS and CPT-4 are used for physicians and other healthcare services (i.e. ambulance, tests, therapy)

3.  Classifications of Diseases and Injuries  Supplementary Classifications ( V and E )  Appendices  17 Chapters/categories  Volume 1  Sections (groups of 3 digits) Single disease or group of similar conditions  Categories (3 digit) More specific than sections  Subcategories (4 th digit) More specific re:signs, symptoms, secondary illness)

4.  Fifth digit – Even greater specificity. ◦ (See page 5 in your book)  Includes notes – further defines or provides an example.  Excludes notes – directs you to look elsewhere  Two supplementary classifications V Codes – Factors influencing Health Status and contact with Health Services E Codes – External Cause of Injury and Poisoning

5.  Appendix A: Morphology of Neoplasms M code  Appendix B: Abbreviations  Appendix C: Mocroorganisms  Appendix D: Commonly Used Drugs  Appendix E: Morphology Terminology  Appendix F: Sample Billing Forms  Appendix G: Ethics in Coding  Appendix H: Data Quality  Appendix I: Previous slide - Guidelines

6.  Index to Diseases and Injuries Main terms- boldface type Subterms- indented (modifiers) affect selection Carryover lines- needed to fit long term onto another line Nonessention modifiers- in parentheses- no effect on selection Eponyms – named after discovering physician, etc. Not all terms are in Tabular list that are in Alphabetic Index Cross-reference – item states see to send to alternate term. Direction must be followed. See also requires viewing another main term for best info.

7.  Table of Drugs and Chemicals  Alphabetic Index to External Causes of Injury and Poisoning (E codes)

8.  Mandatory Multiple Coding – need to use more than one code to fully identify a given condition; includes “due to”, “secondary to”, or “with” – these may require multiple codes. When no combination codes available – use multiple codes. AVOID indiscriminate multiple coding.  Not Elsewhere Classifiable Use with ill-defined terms More precise info is not available  Not Otherwise Specified (Unspecified)  Symbols Lozenge – square IDs code as unique to US Parentheses – enclose words or info that may or may not b present in statement of diagnosis Square brackets – enclose alternate words or phrases.

9.  Volume 3 – includes Tabular and Alphabetic  Combines with HCPCS  Connecting words – subterms with as, by, or with  Code also – reminder to code additional procedures when they have been performed  Omit code – only used in volume 3 – no code is to be assigned  Code incomplete procedures  Code failed procedures

10.  Principal procedure – was performed for definitive treatment rather than for diagnosis or exploratory purposes or for treatment of a complication

11.  Minimum core data needed for payment: Personal ID – number assigned to patient DOBSexRaceEthnicityResidence Hospital ID – assigned to physician Disposition of patient – to home, AMA, another hospital, long-term, short-term, deceased Principal diagnosis – condition established after study to be chiefly responsible for the admission of patient Other diagnosis – All must be listed Complication Comorbidity (preexisting) Procedures w/dates - significant or principal

12.  Principal Diagnosis: selection depends on the circumstances of admission, diagnostic tests, studies, symptom or illness could be changed after admission.  Pages 51-55 CAREFULLY read the guidelines for principal diagnosis