DIAGNOSTIC CODING Chapter 3. 2 DIAGNOSTIC CODING Learning Objectives diagnostic coding Explain how...

DIAGNOSTIC DIAGNOSTIC CODINGCODING

Chapter 3Chapter 3

Chapter 3 2

DIAGNOSTIC CODING

Learning Objectives Explain how diagnostic codingdiagnostic coding affects the payment

process. Label the primaryprimary and coexisting conditionscoexisting conditions. Explain the ICD formatICD format and identify identify sectionssections used by used by

medical insurance specialists in physician practices.medical insurance specialists in physician practices. Identify the purpose and correct use of V codesV codes and E E

codes.codes. Use a five-step processfive-step process to analyze diagnoses and locate the

correct ICD code.

Chapter 3 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

Chapter 3 4

Introduction to Diagnostic Coding

During Office Encounters: Physicians documents their evaluation of patients’ conditionpatients’ condition

in their medical records. A section of the medical record is called ROSROS (review of body (review of body

system).system). Patients’ responses to each question the physician ask about the body

system is recorded. When ExaminationExamination is conducted, physicians summarize the findings

under various heading, such as “neck”“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.

Chapter 3 5


Diagnosis - Physician’s opinion of the patient’s specific illness(es),illness(es), sign(s),sign(s), symptom(s),symptom(s), and complaint(s).complaint(s).

Diagnostic Code(s) - are numbers assigned to the physician’s diagnosis in the International Classification of Diseases International Classification of Diseases (ICD).(ICD). It is based on the physician’s opinion of the

patient’s specific illness, signs & symptom illness, signs & symptom and complaintsand complaints..

Chapter 3 6


Diagnostic Code(s) Affects the medical insurance payment process. Translates medical words to standardized medical words to standardized

numbersnumbers Clearly defines diagnosis

Chapter 3 7


The ICD-9-CM International Classification of Diseases (ICD)(ICD) List codes according to a system system assigned by the “World Health “World Health

OrganizationOrganization (WHO)(WHO) of the United Nations”.of the United Nations”. Volumes are Distributed by U.S. Government Printing OfficeU.S. Government Printing Office in

Washington, D.C. and by Commercial PublishersCommercial Publishers

Origination The ICD was originated in the1600s in EnglandEngland Used in the U. S.U. S. by the late 1800s for reporting:

Morbidity (illnesses)(illnesses) Mortality ( causes of death)( causes of death)

Chapter 3 8

Diagnostic Coding (cont’d)

The ICD-9-CM ICD-9ICD-9 refers to 9th revision9th revision; updated yearly.

ICD-9 –ICD-9 – is a coding system that describes diseases, conditions and related issues.

CM =CM = Clinical ModificationClinical Modification for more precise terms The Medicare Catastrophic Coverage Act of Medicare Catastrophic Coverage Act of

19881988 requires the use of codes from the ICD-9-CM on Medicare Claims.

ICD=9 ICD=9 Codes are updated yearly.

Chapter 3 9

Diagnostic Coding (cont’d)

The ICD-9-CM system Written as XXX.XX

3-digit3-digit categories for diseases, injuries, and symptoms

4-digit4-digit sub-categories 5-digit5-digit sub-classifications

GoalGoal is to report the most specific dx most specific dx possiblepossible

716.09

E814

553.9

075 V39

.20

Chapter 3 10

Primary Diagnosis - A diagnosis that represents the patient’s major illness or condition for an encounter.

EXAMPLE:EXAMPLE:

Coding Basics forPhysician Practices

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.

Chapter 3 11

Chief Complaint (CC) - a description a description of symptomsof symptoms or other reasonsother reasons a patient seeks medical care on a particular visit to a physician.

Coexisting Conditions - additional additional diagnosisdiagnosis that occurs at the same time as the primary diagnosis and that affects its affects its treatment.treatment. May have more than one dx codeone dx code May list up to threeup to three additional codes


Chapter 3 12

Using the ICD Volume 1—Diseases: Tabular ListTabular List Volume 2—Diseases: Alphabetic IndexAlphabetic Index

Volumes 1 & 2 used in medical officesmedical offices

Volume 3—Procedures: Tabular List Tabular List andand Alphabetic IndexAlphabetic Index Volume 3 used only for hospital tests hospital tests and and

treatmentstreatments

Chapter 3 13

Using the ICD

Volume 2Volume 2—Diseases: Alphabetic IndexAlphabetic Index Main Terms

In bold type Subterms

Always indented 2 spaces2 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)

Chapter 3 14

Using the ICD (cont’d)

Alphabetic Index Alphabetic-order

Section 2 Table of

drugs and chemicals

Section 1 Index to

diseases and injuries

Section 3 External

causes of injuries and poisoning (E codes)

Never used alone

Chapter 3 15


Hernia, hernial (acquired) (recurrent) 553.9

with

gangrene (obstructed) NEC 551.9

obstruction NEC 552.9

and gangrene 551.9

abdomen (wall) - see Hernia, ventral

abdominal, specified site NEC 553.8

with

gangrene (obstructed) 551.8

obstruction 552.8

and gangrene 551.8

Main terms Listed by condition

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

Chapter 3 16

Using the ICD

Volume 1 Volume 1 (Tabular List) Categories - 3 digits3 digits Subcategories - 4th digit4th digit Subclassifications - 5th digit5th digit

For four & five digit codes: Add decimal point after 3rd digit

Chapter 3 17


Tabular List Numerical order Ordered by body system

or etiology VV and E CodesE Codes follow

tabular list V CodesV Codes can be used as

primary dx E CodesE Codes used in addition

to another code

Chapter 3 18

Using the ICD Volume 1—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

Chapter 3 19

The Coding Process

Volume 1/Volume 1/Tabular ListTabular List Numerical -order

Fifth-digit Subclassifications Five-digit code

numbers

Subcategories Four-digit code

numbers

Never used alone

Chapter 3 20

AA Morphology of Neoplasms B B Glossary of Mental Disorders

CC Classification of Drugs by American Hospital Formulary Service List Number and ICD-9-CM Equivalents

DD Classification of Industrial Accidents According to Agency

EE List of Three-Digit Categories

Organization of ICD-9 Organization of ICD-9 Volume 1Volume 1(17 Chapters Plus (17 Chapters Plus AppendicesAppendices))

Chapter 3 21

V CodesV Codes Supplementary Classification of Factors Influencing Factors Influencing

Health Status and Contact with Health ServicesHealth Status and Contact with Health Services Wellness code, such as physical exam (reason for the

encounter) V01-V83

E CodesE Codes Supplementary classification of External causes of Injury External causes of Injury

& Poisoning& Poisoning E800-E999


Chapter 3 22

Using The ICD (cont’d)

V CodesV Codes Encounters for reasons

other than illness or injury

For example, routine routine physicals, physicals, flu shots, flu shots, vaccinationsvaccinations

Remember— PreVVentive medicine

E CodesE Codes Indicate the external

cause of injury or poisoning

For example, fall fall from bicycle,from bicycle, car car accidentaccident

Remember— EExternal cause

Chapter 3 23


ICD-9-CM Conventions Conventions are: A list ofA list of abbreviations, abbreviations, punctuation,punctuation, symbols,

type faces,type faces, and instructional notesinstructional notes

Appear at the beginningbeginning of the ICD

Provide guidelinesguidelines for using the ICD coding system

Chapter 3 24


NOS NEC [] Brackets () Parentheses : Colon } Brace

Includes Excludes Use additional code Code first underlying

disease

ICD-9-CM ConventionsConventions

Chapter 3 25

Using The Diagnostic CodebookICD-9-CM ConventionsConventions

NEC NEC Not elsewhere classified condition doesn’t have a specific code may have 4th digit of .8.8

NOSNOS Not Otherwise Specified code is unspecified often coded with 4th digit of .9.9 continue looking for more specific

code

Chapter 3 26

Using The Diagnostic Codebook ICD-9-CM ConventionsConventions

Parentheses ( )( )Non-essential modifiersCan be present or absent without affecting code number

Square brackets [ ][ ]Enclose synonyms, alternate wordings, or explanatory phrases

Chapter 3 27


Colon ::Used after an incomplete termTerm needs one or more modifiers to make it assignable

Braces { }{ }Encloses a series of termsTerm modified by statement to the right

Chapter 3 28

Using The Diagnostic Codebook ICD-9-CM Conventions Conventions (Includes and Excludes)Includes and Excludes)

Includes (What it is)(What it is)Further defines or gives examples

Excludes (What it is not)(What it is not)Look for code elsewhere

Chapter 3 29

Using The Diagnostic Codebook((See, See Also, and See Category)

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

SeeSee alsoalsoLook under another main term

SeeSee categorycategoryReview entire category before assigning code

Chapter 3 30


Code First Underlying DiseaseCode First Underlying DiseaseUnderlying disease is always the primary diagnosisprimary diagnosis

Use additional codeUse additional codeNeed more than one code to give a complete picture of diagnosis

Chapter 3 31


ConventionsConventionsProvide instructions or guidelines

Further define terms, clarify information, or list choices for additional digits

Volume 2 notes appear in a box

Chapter 3 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 IndexStep 3 Locate the code in the Tabular ListStep 4 Read all information; note 4th and 5th

digit requirements and exclusionsStep 5 Record the dx code on the insurance

claim; PROOFREAD numbers

Chapter 3 33

Preview of the ICD-10-CMPreview of the ICD-10-CM

Published by WHOWHO (World Health Organization) in mid-1990s

Still in review by health care professionals. Expected to be put into use by 2008.2008.

Major Changes Include: 2,033 2,033 categories of diseases 855 855 more than ICD9 ICD9 to permit more specific reporting of more specific reporting of

diseases & newly recognized conditions.diseases & newly recognized conditions. Codes are alpha-numeric,alpha-numeric, containing a letter followed by up containing a letter followed by up

to 5 numbers.to 5 numbers. 6th digit is added to capture clinical details Codes added to show which side of body is affected in cases which side of body is affected in cases

of Left, Right or Bilateral conditions.of Left, Right or Bilateral conditions.

Chapter 3 34

Chapter 3 35

Basic Steps In Coding

Coding Step 1Coding Step 1

Finding the Main Main

TermTerm is the key to coding

Chapter 3 36


What are Main Terms?

Diseases Conditions Nouns Adjectives

Do not look under anatomical sites.Do not look under anatomical sites.Example:Example: Liver disorder – look under Disorder (not Liver)

Chapter 3 37


Common Main TermsMain Terms

Anomaly Disease Disorder Findings (abnormal)

Syndrome Insufficiency Infection (itis) Injury History (of)

Chapter 3 38


Coding Steps 2 and 3Coding 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

Chapter 3 39

Basic Steps In Coding Coding Step 4 ALWAYS

verify verify the code in Volume 1Volume 1

Chapter 3 40


Coding Steps 5, 6 and 7 Step 5

Follow instructional terms

Step 6 Code to highest level of specificity Use 5th digit when necessary

Step 7Follow cross references

Chapter 3 41

Bronchitis with acute or subacute

466.0466.0

Nervous system complication, unspecified

997.00997.00

Coding ExerciseCoding Exercise

Chapter 3 42


Diagnostic Statement - Diagnostic Statement - Well Child Well Child ExamExam

V20.2V20.2

V70.0V70.0

General Physical

Chapter 3 43

Pre-employment screeningPre-employment screening

V70.5V70.5

Bipolar disorder, manic phase, mild

296.41296.41


Family history of congenital defects

V19.5

Chapter 3 44

Adverse effects from digoxin taken correctly

972.1/E942.1972.1/E942.1


Injury from electric can opener

E920.2E920.2

Chapter 3 45

Unspecified localized salmonella infection

003.20003.20


Acute pulmonary manifestations due to radiation

508.0508.0

Chapter 3 46

Practice ExerciseICD-9-CM Conventions/ICD-9-CM Conventions/”Code First””Code First”

Primary Dx:Primary Dx: 250.6250.6 Diabetes with neurological manifestations

Secondary Dx:Secondary Dx: [357.2][357.2] Polyneuropathy

Code:Code: Diabetes neuropathy

Italics used: In both Volumes Highlight all exclusion notes Identify codes that should not be used as the

primary codeprimary code for a condition or problem.

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