Post on 19-Jan-2016
HS225 Medical Coding I
Unit 9 Seminar
Chapters 3 & 4
Index to Diseases, Tabular List of Diseases, and Index to Procedures
Format Spacing
Eponyms
Diseases or syndromes that are named for persons For example, Meniere’s disease Colle’s Fracture Grave’s Disease
Abbreviations
NEC (not elsewhere classifiable) “Other specified” For example, 250.8
Diabetes with other specified manifestations
NOS (not otherwise specified) Equivalent to unspecified For example, 250.9
Diabetes with unspecified complication
Punctuation
Slanted brackets [ ]
Square brackets [ ]
Parentheses ( )
Colon :
Slanted Brackets [ ]
Located in Index to Diseases Identify manifestation codes For example, 277.3 [357.4]
Square Brackets [ ]
Located in Tabular List of Diseases and Tabular List of Procedures
Enclose synonyms, alternative wording, or explanatory phrases
For example:253.3 Pituitary dwarfism Isolated deficiency of (human) growth Hormones [HGH]
Parentheses ( )
May be present or absent in the doctor’s diagnostic statement
Enclose nonessential modifiers For example, (acute) (chronic)
Diverticulitis (acute) Hypertension (essential, vascular, crisis)
Colon :
Used after an incomplete term in Tabular List of Diseases and Tabular List of Procedures
Indicates when one or more additional terms (modifiers) located after the colon are to be included in diagnostic statement
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Colon :
For example:380.22 Other acute otitis externa Acute otitis externa: actinic chemical contact eczematoid reactive
Boxed Notes
Define terms Provide coding instruction List fifth-digit subclassifications
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Boxed Notes
For example:249 Secondary diabetes melltusThe following fifth digit sub-classification is for use with 249: 0 not stated as uncontrolled or unspecified 1 uncontrolled
Tables
Organize sub-terms, second qualifiers, third qualifiers, and their codes in columns and rows to make it easier to select proper code
Examples of tables: Hypertension, hypertensive Neoplasms Table of Drugs and Chemicals
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Includes Notes
Located immediately below ICD-9-CM Tabular List of Diseases and Tabular List of Procedures Codes
Further defines or provides examples
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Includes Notes
For example:023 Brucellosis
Fever: Malta Mediterranean undulant
INCLUDES
Excludes Notes
Located in ICD-9-CM Tabular List of Diseases and Tabular List of Procedures
Directs coder to another location in the tabular list to classify conditions
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Excludes Notes
For example:010.8 Other primary progressive tuberculosis
tuberculous erythema nodosum (017.1)
Excludes
Inclusion Terms
Listed below certain four- and five-digit ICD-9-CM codes
Include conditions or procedures for which that code number is to be assigned
May be synonyms for code title Include terms that do not appear in
tabular list
Other and Other Specified Codes
Assigned when documentation provides detail for a code that does not exist in ICD-9-CM
Usually represented by a fourth and/or fifth digit of 8 and/or 9
Unspecified Codes
Assigned because documentation is insufficient to assign a more specific code
Usually represented by a fourth digit of 9 and/or a fifth digit of 0
Etiology and Manifestation Rules
Include the following notes in the Tabular List of Diseases: Code first underlying disease If applicable, code any causal condition
first Use additional code In diseases classified elsewhere
And
Located in category titles and code descriptions in Tabular List of Diseases and Tabular List of Procedures
Interpreted as meaning “and/or” 464 Acute laryngitis and tracheitis
Means Acute laryngitis and/or tracheitis
Due To
Located in Index to Diseases as sub-term
Alphabetic order Causal relationship For example, meningitis due to
adenovirus
In
Located in Index to Diseases in alphabetic order below main term
For example, pneumonia in candidiasis
With
Located in Index to Diseases or Index to Procedures immediately below main term
Physician must document both conditions or procedures for code to be assigned
Cross-References
See See also See category See condition
Chapter 4 Coding Guidelines
Guidelines
Signs and symptoms that are integral to the disease should not be assigned as additional codes.
The etiology and manifestation convention requires two codes to be reported to completely describe a single condition.
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Guidelines
Multiple coding for a single condition Use additional code Code first If applicable, code any causal condition
first
Acute (or subacute) and chronic conditions
Combination code versus multiple code
Late Effect
Residual condition that develops after acute phase of illness or injury has ended No time limit on reporting these codes
Combination code assigned For example, painful cicatrix following
severe burn to the elbow or left-sided paralysis due to previous cerebrovascular accident (CVA)
General Procedure Guidelines
Based on anatomy rather than surgical specialty
Numeric codes Use both Index to Procedures and
Tabular List of Procedures
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General Procedure Guidelines
Index to Procedures main terms organized in alphabetic order according to type of procedure
Report codes using highest number of digits available
— omit code
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General Procedure Guidelines
Common key terms: Application Closure Correction Destruction Division Incision
Insertion Operation Procedure Release Removal Repair
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General Procedure Guidelines
Common key terms: Resection Revision Suture Test Therapy Transfer
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General Procedure Guidelines
Combination codes Multiple codes And/Or Open procedure versus closed
procedure Endoscopic procedures Biopsies Canceled surgery
Questions