1. Chapter 4 ICD-9-CM Medical Coding C OMPREHENSIVE H EALTH I NSURANCE B ILLING, C ODING, AND R EIMBURSEMENT

2. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes D EFINITION OF D IAGNOSIS C ODING  Describes services and procedures diagnoses  ICD-9-CM:  Volumes are now used for coding the appropriate medical conditions

3. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C ODING H ISTORY  Bills of mortality 1665: some of the earliest uses of coding  Warnings of plague epidemics  Diagnoses were often wrong or vague  18 th century: Cause of death was noted

4. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes P URPOSE OF THE ICD-9-CM  Establishes medical necessity  Translates written terminology into common language  Provides data for statistical analysis

5. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes T HE Y EARLY A DDENDA  Includes the addition of new codes  Deletes old codes  Includes descriptor revisions

6. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes T HE T HREE V OLUMES 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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes 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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes 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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C OMMON T ERMINOLOGY  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C OMMON T ERMINOLOGY  Principal diagnosis: The final diagnosis  Manifestation: The sign or symptom of a disease  NEC: Not elsewhere classified  NOS: Not otherwise specified

11. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S YMBOLS AND T YPEFACE AND T ERMS  Boldface: Main term  Subterms: Indented two spaces to the right  Supplementary term: Assists coder in finding correct term  ( ): Parentheses enclose supplementary words

12. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S YMBOLS AND T YPEFACE AND T ERMS  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes V OLUME 2, T HE A LPHABETICAL I NDEX  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes V OLUME 1, T HE T ABULAR L IST  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes V OLUME 1, T HE T ABULAR L IST  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes T HREE S TEPS FOR A CCURATE C ODING 1. Determine the reason for the encounter. 2. Locate the term in alphabetic index Volume 2. 3. Verify the code in the tabular list (Volume 1).

17. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes K EY C ODING G UIDELINES  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C ODE TO THE H IGHEST L EVEL OF C ERTAINTY  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes C ODE TO H IGHEST D EGREE OF S PECIFICITY  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes P ROPER O RDER FOR C ODING  Main reason for encounter  Any current coexisting condition  Do not code conditions that were previously treated and no longer exist.

21. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S UBSEQUENT C ODING  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes S UBSEQUENT C ODING  V codes: Supplemental code that describes problems, services, or facts  E codes: Supplemental classifications of external causes of injuries and poisonings

23. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes N INE S TEPS OF A CCURATE ICD-9-CM C ODING  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. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes N INE S TEPS OF A CCURATE ICD-9-CM C ODING  Examine any modifiers.  Note any subterms that provide greater specificity.

25. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes N INE S TEPS OF A CCURATE ICD-9-CM C ODING  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.