1. Chapter 3
DIAGNOSTIC CODING

2. DIAGNOSTIC CODING Learning Objectives
Explain how diagnostic coding affects the payment process.
Label the primary and coexisting conditions.
Explain the ICD format and identify sections used by medical insurance specialists in physician practices.
Identify the purpose and correct use of V codes and E codes.
Use a five-step process to analyze diagnoses and locate the correct ICD code.
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3. Key Terms Alphabetic Index Chief complaint (CC) Coexisting condition
Conventions
Cross reference
Diagnosis code Dx
E code
Etiology
International Classification of Diseases (ICD)
Main term
Primary diagnosis
Subterm
Supplementary term
Tabular List
V code
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4. Introduction to Diagnostic Coding
During Office Encounters:
Physicians documents their evaluation of patients’ condition in their medical records.
A section of the medical record is called ROS (review of body system).
Patients’ responses to each question the physician ask about the body system is recorded.
When Examination is conducted, physicians summarize the findings under various heading, such as “neck” or Neurologic” (for the nervous system).
Findings
When a diagnosis (Dx) is made by the physician, it is documented in the patients’ medical record.
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5. Introduction to Diagnostic Coding
Diagnosis - Physician’s opinion of the patient’s specific illness(es), sign(s), symptom(s), and complaint(s).
Diagnostic Code(s) - are numbers assigned to the physician’s diagnosis in the International Classification of Diseases (ICD).
It is based on the physician’s opinion of the patient’s specific illness, signs & symptom and complaints.
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6. Introduction to Diagnostic Coding
Diagnostic Code(s)
Affects the medical insurance payment process.
Translates medical words to standardized numbers
Clearly defines diagnosis
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7. Introduction to Diagnostic Coding
The ICD-9-CM
International Classification of Diseases (ICD)
List codes according to a system assigned by the “World Health Organization (WHO) of the United Nations”.
Volumes are Distributed by U.S. Government Printing Office in Washington, D.C. and by Commercial Publishers
Origination
The ICD was originated in the1600s in England
Used in the U. S. by the late 1800s for reporting:
Morbidity (illnesses)
Mortality ( causes of death)
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8. Diagnostic Coding (cont’d)
The ICD-9-CM
ICD-9 refers to 9th revision; updated yearly.
ICD-9 – is a coding system that describes diseases, conditions and related issues.
CM = Clinical Modification for more precise terms
The Medicare Catastrophic Coverage Act of 1988 requires the use of codes from the ICD-9-CM on Medicare Claims.
ICD=9 Codes are updated yearly.
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9. Diagnostic Coding (cont’d)
The ICD-9-CM system
Written as XXX.XX
3-digit categories for diseases, injuries, and symptoms
4-digit sub-categories
5-digit sub-classifications
Goal is to report the most specific dx possible
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10. Coding Basics for Physician Practices
Primary Diagnosis - A diagnosis that represents the patient’s major illness or condition for an encounter.
EXAMPLE:
If a Patient has Cancer, the disease is probably the patient’s major health problem.
But if the patient sees the physician for an ear infection that is not related to Cancer, the Primary diagnosis for this encounter is the ear infection.
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11. Coding Basics for Physician Practices
Chief Complaint (CC) - a description of symptoms or other reasons a patient seeks medical care on a particular visit to a physician.
Coexisting Conditions - additional diagnosis that occurs at the same time as the primary diagnosis and that affects its treatment.
May have more than one dx code
May list up to three additional codes
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12. Using the ICD Volume 1—Diseases: Tabular List
Volume 2—Diseases: Alphabetic Index
Volumes 1 & 2 used in medical offices
Volume 3—Procedures: Tabular List and Alphabetic Index
Volume 3 used only for hospital tests and treatments
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13. Using the ICD Volume 2—Diseases: Alphabetic Index Main Terms Subterms
In bold type
Subterms
Always indented 2 spaces under main terms
Carry-over Lines
Indented more than 2 spaces from level of preceding line
Modifiers
In parentheses (can be present or absent)
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14. Using the ICD (cont’d) Alphabetic Index Section 1 Section 2 Section 3
Alphabetic-order
Never used alone
Section 1
Index to diseases and injuries
Section 2
Table of drugs and chemicals
Section 3
External causes of injuries and poisoning (E codes)
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15. Using the ICD (cont’d) Main terms Supplementary terms Subterm
Listed by condition
Hernia, hernial (acquired) (recurrent)
with
gangrene (obstructed) NEC
obstruction NEC
and gangrene
abdomen (wall) - see Hernia, ventral
abdominal, specified site NEC
gangrene (obstructed)
obstruction
and gangrene
Supplementary terms
In parentheses ()
Don’t affect the code selection
Subterm
Indented
Listed by etiology
Affect code selection
Cross-reference
Anatomical sites, or alternate main terms to help locate appropriate codes
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16. Using the ICD Volume 1 (Tabular List) For four & five digit codes:
Categories - 3 digits
Subcategories - 4th digit
Subclassifications - 5th digit
For four & five digit codes:
Add decimal point after 3rd digit
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17. Using the ICD (cont’d) Tabular List Numerical order
Ordered by body system or etiology
V and E Codes follow tabular list
V Codes can be used as primary dx
E Codes used in addition to another code
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18. Using the ICD Volume 1—Diseases: Tabular List
Numeric listing with 17 Chapters
Half devoted to conditions affecting a body system
Remainder classify conditions according to etiology (the origin of the disease)
2 Supplementary Classifications
V codes
Classification of factors influencing health status and contact with health services.
E codes
Classify external causes of injury and poisonings
Appendix A-E
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19. The Coding Process Volume 1/Tabular List
Numerical -order
Never used alone
Fifth-digit Subclassifications
Five-digit code numbers
Subcategories
Four-digit code numbers
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20. Organization of ICD-9 Volume 1 (17 Chapters Plus Appendices)
A Morphology of Neoplasms
B Glossary of Mental Disorders
C Classification of Drugs by American Hospital Formulary Service List Number and ICD-9-CM Equivalents
D Classification of Industrial Accidents According to Agency
E List of Three-Digit Categories
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21. Coding Basics for Physician Practices
V Codes
Supplementary Classification of Factors Influencing Health Status and Contact with Health Services
Wellness code, such as physical exam (reason for the encounter)
V01-V83
E Codes
Supplementary classification of External causes of Injury & Poisoning
E800-E999
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22. Using The ICD (cont’d) V Codes E Codes
Encounters for reasons other than illness or injury
For example, routine physicals, flu shots, vaccinations
Remember— PreVentive medicine
E Codes
Indicate the external cause of injury or poisoning
For example, fall from bicycle, car accident
Remember— External cause
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23. Using the ICD (cont’d) ICD-9-CM Conventions are:
A list of abbreviations, punctuation, symbols, type faces, and instructional notes
Appear at the beginning of the ICD
Provide guidelines for using the ICD coding system
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24. Using the ICD (cont’d) ICD-9-CM Conventions NOS NEC [] Brackets
() Parentheses
: Colon
} Brace
Includes
Excludes
Use additional code
Code first underlying disease
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25. Using The Diagnostic Codebook ICD-9-CM Conventions
NEC Not elsewhere classified
4 condition doesn’t have a specific code
4 may have 4th digit of .8
NOS Not Otherwise Specified
4 code is unspecified
4 often coded with 4th digit of .9
4 continue looking for more specific code
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26. Using The Diagnostic Codebook ICD-9-CM Conventions
Parentheses ( )
Non-essential modifiers
Can be present or absent without affecting code number
Square brackets [ ]
Enclose synonyms, alternate wordings, or explanatory phrases
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27. Using The Diagnostic Codebook ICD-9-CM Conventions
Colon :
Used after an incomplete term
Term needs one or more modifiers to make it assignable
Braces { }
Encloses a series of terms
Term modified by statement to the right
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28. Excludes (What it is not)
Using The Diagnostic Codebook ICD-9-CM Conventions (Includes and Excludes)
Includes (What it is)
Further defines or gives examples
Excludes (What it is not)
Look for code elsewhere
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29. Using The Diagnostic Codebook (See, See Also, and See Category)
Cross-reference and directs the coder to look elsewhere for closely related terms, code categories and synonyms.
See
An explicit direction to look elsewhere
See also
Look under another main term
See category
Review entire category before assigning code
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30. Using The Diagnostic Codebook ICD-9-CM Conventions
Code First Underlying Disease
Underlying disease is always the primary diagnosis
Use additional code
Need more than one code to give a complete picture of diagnosis
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31. Using The Diagnostic Codebook ICD-9-CM Conventions
Provide instructions or guidelines
Further define terms, clarify information, or list choices for additional digits
Volume 2 notes appear in a box
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32. Five Steps to Dx Coding
Step 1 Locate the statement of the dx in the medical record
Step 2 Find the dx in the Alphabetic Index
Step 3 Locate the code in the Tabular List
Step 4 Read all information; note 4th and 5th digit requirements and exclusions
Step 5 Record the dx code on the insurance claim; PROOFREAD numbers
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33. Preview of the ICD-10-CM
Published by WHO (World Health Organization) in mid-1990s
Still in review by health care professionals.
Expected to be put into use by 2008.
Major Changes Include:
2,033 categories of diseases
855 more than ICD9 to permit more specific reporting of diseases & newly recognized conditions.
Codes are alpha-numeric, containing a letter followed by up to 5 numbers.
6th digit is added to capture clinical details
Codes added to show which side of body is affected in cases of Left, Right or Bilateral conditions.
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34. Basic Coding Steps & Exercise
Part 2
Basic Coding Steps & Exercise
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35. Basic Steps In Coding Finding the Main Term is the key to coding
Coding Step 1
Finding the Main Term is the key to coding
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36. Basic Steps In Coding What are Main Terms? Diseases Conditions Nouns
Adjectives
Do not look under anatomical sites.
Example: Liver disorder – look under Disorder (not Liver)
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37. Basic Steps In Coding Common Main Terms Syndrome Anomaly Insufficiency
Infection (itis)
Injury
History (of)
Anomaly
Disease
Disorder
Findings (abnormal)
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38. Basic Steps In Coding Coding Steps 2 and 3
Step 2 - Look for notes and modifiers under main term
No effect on code selection
Step 3 - Note indented subterms
Can effect code selection
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39. Basic Steps In Coding ALWAYS verify the code in Volume 1 Coding Step 4
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40. Basic Steps In Coding Coding Steps 5, 6 and 7
Follow instructional terms
Step 6
Code to highest level of specificity
Use 5th digit when necessary
Step 7
Follow cross references
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41. Coding Exercise Bronchitis with acute or subacute 466.0
Nervous system complication, unspecified
997.00
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42. Coding Exercise Diagnostic Statement - Well Child Exam V20.2 V70.0
General Physical
V70.0
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43. Coding Exercise Pre-employment screening V70.5
Family history of congenital defects
V19.5
Bipolar disorder, manic phase, mild
296.41
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44. Coding Exercise Adverse effects from digoxin taken correctly
Injury from electric can opener
E920.2
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45. Coding Exercise Unspecified localized salmonella infection 003.20
Acute pulmonary manifestations due to radiation
508.0
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46. Practice Exercise ICD-9-CM Conventions/”Code First”
Italics used:
In both Volumes
Highlight all exclusion notes
Identify codes that should not be used as the primary code for a condition or problem.
Code: Diabetes neuropathy
Primary Dx: Diabetes with neurological manifestations
Secondary Dx: [357.2] Polyneuropathy
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