1. The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 3 General Guidelines and Notations Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

2. Learning Outcomes ·Correctly interpret the format of ICD-9-CM, volumes 1 and 2. ·Apply the guidelines for properly coding from ICD-9-CM, volumes 1 and 2. ·Identify the manner in which to report codes with the greatest specificity. 3 - 2

3. Learning Outcomes ·Use the punctuation presented to clarify code choices. ·Abstract physician’s notes to pinpoint key terms related to the diagnoses. ·Determine the most accurate diagnosis code. 3 - 3

4. Introduction ·ICD-9-CM codes are THREE, FOUR, or FIVE digits in length. ·Five-digit codes contain more details, or specificity, than four-digit codes. ·ICD-9-CM will tell you what is needed. 3 - 4

5. Three-Digit Codes ·A three-digit code is complete and requires no further information or detail. ·Example: 325 Phlebitis and thrombophlebitis of intracranial venous sinuses 3 - 5

6. Four-Digit Codes ·Symbol next to the three-digit code will instruct you that a FOURTH DIGIT IS REQUIRED. ·This is not optional! ·Example: 285 Other and unspecified anemias ·285.0 Sideroblastic anemia 3 - 6

7. Four-Digit Codes ·When the alphabetic index directs you to a four-digit code, you MUST read all the notations and instructions under the three- digit version of that code, as well. 3 - 7

8. Five-Digit Codes ·Symbol next to the four-digit code will instruct you that a FIFTH DIGIT IS REQUIRED. ·This is not optional! ·Example: 346.0 Classic migraine ·346.00 Classic migraine without mention of intractable migraine 3 - 8

9. Five-Digit Codes ∙When the alphabetic index directs you to a five-digit code, you MUST read all the notations and instructions under the three- digit version of that code, as well. 3 - 9

10. Finding the Digits ·When a fourth digit or fifth digit is required, you may find it BELOW the shorter version or ABOVE the shorter version. 3 - 10

11. Notations ·INCLUDES: ·Lists alternate terms for the same or similar conditions also reported with this code 3 - 11

12. Notations ·EXCLUDES: ·Lists related or similar conditions that are NOT reported with this code and must be reported with another code 3 - 12

13. Notations ·CODE FIRST: ·Instructs you to also code the underlying disease of this diagnosis AND ·Instructs you to list the code for the underlying disease before this code on the claim form 3 - 13

14. Notations ·USE ADDITIONAL CODE: ·Instructs you to include another code on the claim form to specifically identify the manifestation of this diagnosis 3 - 14

15. Notations ·CODE IF APPLICABLE: ·If the documentation notes another condition, this notation instructs you to include the code on the claim. 3 - 15

16. Notations ·Category Notes: ·Additional information and direction that will help you code correctly and accurately 3 - 16

17. Notations ·AND: ·In the ICD-9-CM book, the term AND within a code description should be interpreted as AND/OR. 3 - 17

18. Notations ·NEC (not elsewhere classified), ·Other Specified: ·These notations both indicate that the documentation identifies details that the ICD- 9-CM book does not specify. 3 - 18

19. Notations ·NOS (not otherwise specified), ·Unspecified: ·Both of these notations indicate that the documentation was incomplete. 3 - 19

20. Punctuation ·Brackets [ ] show alternate terms. ·Italicized brackets [ ] show additional codes that must be included with the first. ·Parentheses ( ) show alternate terms. 3 - 20

21. Punctuation ·A colon : indicates that the description continues with one of the following list of terms. ·A brace } indicates that a list of descriptors all relate to one term. 3 - 21

22. Combination Code ·One code that reports two or more diagnoses or multiple versions of one diagnosis 3 - 22

23. What to Code ·Only those diagnoses, signs, symptoms, conditions, problems, or complaints directly addressed by the provider during this encounter 3 - 23

24. What to Code ·In an outpatient encounter, do NOT code any condition identified as probable, possible, suspected, or as a rule out. 3 - 24

25. Multiple Codes ·The first-listed or principal diagnosis is the condition that is the primary reason for this encounter. 3 - 25

26. Multiple Codes ·List codes in order of severity with the most severe first. ·List confirmed diagnoses before signs and symptoms of other conditions. 3 - 26

27. Chapter Summary ·Coders must always report codes with the most specificity. ·All guidelines and notations must be followed. 3 - 27