Medical Coding Chapter 3. CHAPTER 3 ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES.
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Transcript of Medical Coding Chapter 3. CHAPTER 3 ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES.
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Medical Coding Chapter 3
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CHAPTER 3CHAPTER 3ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES
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Section IV Diagnostic CodingSection IV Diagnostic Coding
● Physician’s office● Hospital-based outpatient services● Part of Official Guidelines for Coding and Reporting,
Section IV
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Section IV Diagnostic CodingSection IV Diagnostic Coding
● Guidelines do not address specific sequencing or diseases as inpatient do
● Though not stated, if there is no outpatient guideline, follow inpatient guidelines
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Diagnostic Coding Guideline ADiagnostic Coding Guideline A
● Term first-listed diagnosis, rather than principal diagnosis● Outpatient Surgery: Reason for surgery
– Even if surgery is cancelled due to contraindication
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Diagnostic Coding Guideline ADiagnostic Coding Guideline A
● Observation Stay: Medical condition that occasioned admission– Assign a code from medical condition
● Observation Stay: Complications from outpatient surgery lead to observation report:
Reason for surgery as first reported diagnosis Codes for complications necessitating observation
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Selection of First-Listed DiagnosisSelection of First-Listed Diagnosis
● Condition for encounter– Why patient presented, not necessarily most serious condition
noted
● Documented● Chiefly responsible for services provided● Also list co-existing conditions
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Diagnosis and ServicesDiagnosis and Services
● Diagnosis and procedure MUST correlate● Medical necessity must be established through
documentation● No correlation = No reimbursement
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Symptoms, Signs, and Ill-Defined Conditions
Symptoms, Signs, and Ill-Defined Conditions
● Can be the first-listed diagnosis if no more specific diagnosis available
● Diagnoses often are not established at the time of the initial encounter/visit
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Diagnostic Coding Guideline BDiagnostic Coding Guideline B
● Use codes 001.0 through V91.99 to code: – Diagnosis– Symptoms– Conditions– Problems– Complaints– Or other reason(s) for visit
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Diagnostic Guideline CDiagnostic Guideline C
● Documentation should describe patient's condition, using terminology that includes:– Specific diagnoses – Symptoms– Problems– Reasons for encounter
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Diagnostic Guideline DDiagnostic Guideline D
● Selection of codes 001.0 through 999.9 (Chapters 1-17) frequently used to describe reason for encounter
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Diagnostic Guideline EDiagnostic Guideline E
● Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when – An established diagnosis has NOT been determined by
physician
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Diagnostic Guideline FDiagnostic Guideline F
● V codes deal with encounters for circumstances other than disease or injury– Example: Well-baby checkup
● See Section I.C.18 for information onV codes
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Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service
Section I.C.18. Classification of Factors Influencing Health Status and Contact with Health Service
● V01-V91– Assigned as first-listed diagnosis for:
Admissions for evaluation Following an accident that would ordinarily result in health problem,
BUT there is none
– Car accident, driver hits head, no apparent injury, admit to R/O head trauma
– Never a secondary diagnosis
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V CodesV Codes
● Located after 999.9 in Tabular● Two digits before decimal (e.g., V10.1X)● Index for V codes is Alphabetic Index
to Diseases● Main terms:
– Contraception
– Counseling
– Dialysis
– Status
– Examination
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Uses of V CodesUses of V Codes
● Not sick BUT receives health care (e.g., vaccination)
● Services for known/resolving disease/injury (e.g., chemotherapy)
● Codes for “aftercare” (e.g., surgery or fracture)● Indicate birth status/outcome of delivery
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Uses of V CodesUses of V Codes
● A circumstance/problem that influences patient’s health BUT NOT current illness/injury – Example: Organ transplant status
– Example: Birth status and outcome of delivery (newborn)
● Section I.C.18.e. of Guidelines contains the V Code Table– Identifies if V code can be listed as first,
first/additional, additional only
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History V Code Categories in Tabular
History V Code Categories in Tabular
● V10 Personal history of malignant neoplasm● V11 Personal history of mental illness● V12 Personal history of certain other diseases● V13 Personal history of other diseases● V14 Personal history of allergy to medicinal agents● V15 Other personal history presenting hazards to health● V16 Family history of malignant neoplasm● V17 Family history of certain chronic disabling diseases● V18 Family history of certain other specific diseases● V19 Family history of other conditionsCondition no longer present or treated
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Diagnostic Guideline GDiagnostic Guideline G
● Codes have either 3, 4, or 5 digits● 4 and/or 5 digit codes provide greater
specificity (detail)
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Diagnostic Guideline GDiagnostic Guideline G
● 3-digit code used ONLY if no 4 or 5 digit● Where 4 and/or 5 digits provided, must be assigned ● Diagnoses NOT coded to full digits available invalid● Claims bounce!
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Diagnostic Guideline HDiagnostic Guideline H
● List first code for diagnosis, condition, problem, or other reason for encounter/visit shown in medical record to be chiefly responsible for services provided
● List additional codes that describe any coexisting conditions
● Assign V72.5 and/or V72.6x for routine lab/radiology test ordered without signs, symptoms, or associated diagnosis
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Diagnostic Guideline IDiagnostic Guideline I
● Do NOT code diagnoses documented as probable, suspected, questionable, rule out, or working diagnoses
● Rather, code condition(s) to suspected highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for visit
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Diagnostic Guideline JDiagnostic Guideline J
● Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)
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Diagnostic Guideline KDiagnostic Guideline K
● Code all documented conditions that coexist at time of visit, that require or affect patient care, treatment, or management
● Do NOT code conditions previously treated, no longer existing
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Diagnostic Guideline KDiagnostic Guideline K
● “History of” codes (V10-V19) may be used as secondary codes if:– Impacts current care or treatment
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Special Note About “History of”
Special Note About “History of”
● Index to Disease, MAIN term “History” ● Entries between “family” and “visual loss V19.0” = “family
history of” (FHO)● Entries before “family” and after
“visual loss” = “personal history of” (PHO)● Personal history = V10-V15● Family history = V16-V19
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Diagnostic Guidelines L and MDiagnostic Guidelines L and M
● For patients receiving diagnostic services ONLY● Sequence first
– Diagnosis – Condition – Problem OR– Other reason shown in medical record to be chiefly
responsible for encounter
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Diagnostic Guidelines L and MDiagnostic Guidelines L and M
● Codes for other diagnoses (e.g., chronic conditions) – May be sequenced as secondary diagnoses
● Exception: Therapeutic Services– Patients receiving chemotherapy (V58.11), radiation
therapy (V58.0), or rehabilitation (V57.0-V57.9)– V code first diagnosis and problem for which service
being performed second
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Diagnostic Guideline NDiagnostic Guideline N
● For patients receiving preoperative evaluations ONLY– Code from category V72.8 (Other specified examinations) – Assign secondary code for reason for surgery– Code also any findings related to preoperative evaluation
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Diagnostic Guideline O, Ambulatory Surgery
Diagnostic Guideline O, Ambulatory Surgery
● Code diagnosis which required ambulatory surgery● Pre- and post-op diagnosis different
– Code the post-op diagnosis
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Diagnostic Guideline PDiagnostic Guideline P
● Code routine prenatal visits with no complications: – V22.0 (Supervision of normal first pregnancy) – V22.1 (Supervision of other normal pregnancy) – DO NOT use these codes with pregnancy complication codes
(Chapter 11, ICD-9-CM)
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V91 Multiple Gestation Placenta StatusV91 Multiple Gestation Placenta Status
● New in 2011● Identifies twins, triplets, quadruplets, other multiples
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ConclusionCHAPTER 3Conclusion
CHAPTER 3ICD-9-CM OUTPATIENT CODING AND REPORTING GUIDELINES