CHAPTER 18 Diagnostic Coding 18-2 Learning Outcomes (cont.) 18.1Recall the six ways that ICD codes...
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Transcript of CHAPTER 18 Diagnostic Coding 18-2 Learning Outcomes (cont.) 18.1Recall the six ways that ICD codes...
CHAPTER
© 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
18Diagnostic Coding
18-2
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Learning Outcomes (cont.)
18.1 Recall the six ways that ICD codes are used today.
18.2 Describe the conventions used by ICD-9-CM.
18.3 Outline the steps to code a diagnosis using ICD-9-CM.
18.4 Explain the purpose and usage of V codes and E codes.
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Learning Outcomes (cont.)
18.5 Name the appendixes found in ICD-9-CM.
18.6 Compare ICD-9-CM and the ICD-10-CM.
18.7 Summarize the ICD-10-CM general coding guidelines.
18.8 Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes.
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Introduction
• Diagnosis – translated into ICD codes
• Reimbursement is based on codes entered so you must– Understand what the codes mean
– Know how to chose correct codes
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The Reasons for Diagnostic Codes
• Chief complaint (CC)
– Diagnosis (DX)• Proves medical necessity of treatment• Diagnostic code
– Coexisting conditions
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The Reasons for Diagnostic Codes
• International Classification of Diseases– 9th edition ~ ICD-9-CM– 10th edition ~ ICD-10-CM
• Original purpose of ICD-9-CM– Classification of morbidity and mortality
statistics– Medical research, education, and
administration
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The Reasons for Diagnostic Codes (cont.)
• Current uses – Facilitation of payment
– Evaluation of utilization patterns
– Study healthcare costs
– Research
– Prediction of trends
– Planning for future
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Apply Your Knowledge
How are ICD codes used?
ANSWER: ICD codes are used for:•Facilitation of payment for medical services•Evaluation of utilization patterns •Study of healthcare costs•Research regarding quality of healthcare •Prediction of healthcare trends•Planning for future healthcare needs
18-9
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An Overview of the ICD-9-CM
• Diseases and Injuries Tabular List (Volume 1)– 17 chapters of disease descriptions and codes– V codes – E codes
• Alphabetic Index (Volume 2)
• Volume 3 ~ edition for hospitals
• Appendices
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Conventions
NOS – not otherwise specified
NEC – not elsewhere classified
[ ] – brackets
[ ] – slanted bracket
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Conventions (cont.)
( ) Parentheses
: Colon
} Brace
Includes
Excludes
Use additional code
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Conventions (cont.)
• Code first underlying disease
• Code, if applicable, any causal condition first.
• Be aware of– Boldface type– Italicized typeface
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Conventions (cont.)
• Alphabetic Index– Omit Code– See Condition– See Also
• Read Coding Guidelines
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The Alphabetic Index
• Contains terms needed to locate codes
• Organized by condition
• Main terms
• Subterms
• Nonessential terms
• Cross-references
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The Tabular List
• Organized by source or body system
• Code structure - categories– Rubrics ~ three digit
– Subcategories ~ four digit
– Subclassifications ~ five digit
• Code to highest level of specificity
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The Tabular List (cont.)
• V codes– Encounters not related to illness or injury
– Primary or supplemental codes
– May not be covered by insurance carrier
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The Tabular List (cont.)
• E codes– External causes of injuries and poisoning
– “How did that happen?”
– Only a supplemental code
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Apply Your Knowledge
Matching
___ contains synonyms or alternative wordings A. NOS
___ surround nonessential or supplementary terms B. NEC
___ used after an incomplete term C. [ ]
___ ICD-9 does not contain a code specific enough D. [ ]
___ used if condition cannot be better descriped E. ( )
___ a directive; refers you to a different term F. :
___ indicates that 2 codes are needed G. See Also
___ a suggestion; you might find a better code H. See Condition
ANSWER:
H
G
F
E
D
C
B
A
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Locate the patient’s diagnosis
Find the diagnosis in the Alphabetic Index
Locate the code from the Alphabetic Index in the Tabular List
Read to find the best code
Record the code
Coding with ICD-9
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Coding with ICD-9 (cont.)
• Acute vs. chronic conditions – list acute code first
• Combination codes – used in place of single codes
• Multiple coding – more than one code required to describe diagnosis
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Coding with ICD-9 (cont.)
• Coding unclear diagnoses
• Principal vs. primary diagnosis– Principal diagnosis
– Primary diagnosis
– Secondary diagnosis
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Apply Your Knowledge
What are the steps to code a diagnosis?
ANSWER: 1.Locate the diagnosis in the medical record2.Find the diagnosis in the Alphabetic Index3.Locate the correct code in Alphabetic Index and then in the Tabular Index4.Read all instructions to find the best code5.Record the code
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V Codes and E Codes
• V codes – Supplementary Classification of Factors Influencing Health Status and Contact with Health Services
• E codes – Supplementary Classification of External Causes of Injury and Poisoning
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V Codes
• Outpatient use
• Examples:– V04.81 Influenza vaccination – V58.11 (Encounter for) Chemotherapy
treatment– V14.0 History (personal) of allergy to penicillin
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E Codes
• General use– Initial treatment only, except fractures– Use as many codes as required
• Poisonings and Adverse Effects– Refer to poisoning column then to
how it occurred– Must be documented in the medical
record to code
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E Codes (cont.)
• Poisoning – Accidental
– Therapeutic
– Suicide attempt
– Assault
• Burns– Degree of burn
– Extent (% of body burned)
– How it occurred (E code)
E Codes are never the primary codeE Codes are never the primary code
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patient required stitches to close a wound from a knife
patient was exposed to a chemical that caused a rash
patient was seen for a shingles vaccination
patient had an annual physical
patient presented with a fractured wrist
child came to office for a sports exam
patient is requesting birth control pills
Apply Your Knowledge
Determine whether a V code or E code should be used: ANSWER:
V code
V code
V code
V code
E code
E code
E code
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Appendices of ICD-9
A. Morphology of Neoplasms
B. Deleted
C. Classification of Drugs
D. Classification of Industrial Accidents
E. List of the Three Digit Categories
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Apply Your Knowledge
List the appropriate Appendix:
deleted in 2004
Classification of Drugs
Three Digit Categories
Morphology of Neoplasms
Classification of Industrial Accidents
ANSWER:
A
D
E
C
B
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Basic Comparison of ICD-9-CM and ICD-10-CM
• Internal List of Causes of Death – 1893
• ICD-9 ~ 1975
– 14,200 codes
– No expansion
– Volume 3 for hospital codes
• ICD-10-CM– Over 68,000
diagnostic codes– Greater specificity– Provides for expansion
• ICD-10-PCS – hospital codes
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ICD-10 Information
• Alpha Index
• Tabular (numeric) List– 21 chapters
– Category ~ 3 characters
– Subcategory ~ 4-5 characters
– Final code ~ up to 7 characters
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Characters and Specificity
• Codes begin with an Alpha character
• Possible characters ~ 3-7
• More precise clinical picture
• Enhances trending analysis
ICD-9 (limited specificity) ICD-10 (expanded specificity)
Code: 233.0 Carcinoma in situ breast (vague as to cancer type)
Code: D05.01 Lobular carcinoma in situ of right breast
ORCode: D05.11 Intraductal carcinoma in site of right breast
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Placeholders
• “x” – placeholder for future expansion of code’s specificity
• Do not drop placeholder when adding characters
ICD-9-CM ICD-10-CM
910.0 Face, neck, and scalp; abrasion or friction burn without mention of infection
S00.01 Abrasion of scalp (code noted to √x7th)
910.1 Face, neck, and scalp; abrasion or friction burn, infected
S00.01xA Abrasion of scalp, initial encounter S00.01xD Abrasion of scalp, subsequent encounter S00.01xS Abrasion of scalp, sequela
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Combination Codes
• More combination codes available
• Decreased need for multiple codes
ICD-9-CM ICD-10-CM
995.92 Severe sepsis
and
785.52 Septic shock
R65.21 Severe sepsis with septic shock
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Apply Your Knowledge
List at least two ways that the ICD-10 is an improvement over the ICD-9.
ANSWER:
The ICD-10 contains many more codes, allows for expansion; has more combination codes, and incorporates placeholders all of which enables more precise coding.
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Basic Coding Guidelines for ICD-10
Locate term in Alphabetic
Index
Locate term in Alphabetic
Index
Refer to notes
Refer to notes
Read and follow terms in ( ) and [ ]
Read and follow terms in ( ) and [ ]
Go to Tabular list
Go to Tabular list
Follow instructional
terms to appropriate code
Follow instructional
terms to appropriate code
Assign the appropriate code with highest
degree of specificity
Assign the appropriate code with highest
degree of specificity
Assign additional code for s/s not associated
with disease
Assign additional code for s/s not associated
with disease
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Basic Coding Guidelines for ICD-10 (cont.)
• Conventions are similar to ICD-9
• ICD-10 – More detailed documentation by physician
– Never code from the Alpha Index
– Verify codes in Tabular list
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3-38
Apply Your Knowledge
What are the general coding guidelines for the ICD-10?
ANSWER: Locate the diagnosis in the Alphabetic IndexRead and follow all notes and conventions.Locate in Tabular list.Follow instructions to the appropriate code.Assign the code with highest degree of specificity.
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Synopsis of ICD-10 Coding Guidelines by Chapter
• Chapter 1 – HIV coding– R75 ~ inconclusive laboratory evidence
– B20 ~ positive serology
– Z21 ~ HIV positive, asymptomatic
– Z71.7 ~ counseling provided
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Synopsis of ICD-10 Coding Guidelines by Chapter
• Chapter 2 – Neoplasms – Type of neoplasm
– Location
– Additional codes
– Primary vs. secondary neoplasms
– Treatments
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 4 – Diabetes mellitus
– Type
– Body system affected
– Complications
– Use of insulin
• Chapter 5 – Pain
– Psychological
– F45.41
– Appropriate code from
G89 category
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 6– Eye and ear not
included
– G89 ~ pain diagnoses
– If present, list underlying cause first then the pain code
• Chapter 9 – Hypertension
– I10 ~ essential hypertension
– Code underlying etiology then code hypertension
– R030.3 ~ transient hypertension
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 10– Avian or H1N1
influenza
– Other types of influenza
• Chapter 13 – Fractures– Laterality
• Unilateral – 4th digit “1”• Designated by 5th digit
– Required 7th character• Initial• Subsequent • Sequela
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 14– Four stages of chronic kidney disease– ESRD
• Chapter 15– 7th digit– Read instructions carefully
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 17– Congenital or chromosomal – Primary or secondary diagnosis
• Chapter 18 (NEC)– R codes – No definitive diagnosis– Multiple combination codes
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 19– Poisoning
• 5th digit – placeholder “x”• 6th digit – how occurred• 7th digit – type of encounter
– Burns and Corrosions• Depth, extent, agent• Corrosive material sequenced first
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 20– Replaces E codes
– Accidents or injuries
– Research and prevention
– Abuse codes take priority
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Chapter 21– Z codes replace V codes
– Expanded to include• Chemo, radiation, and immunotherapy
• After care
• Administrative exams
• Family history
• Personal history
18-49
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Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
• Practice
• Read guidelines carefully
• Ask questions
18-50
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Apply Your Knowledge
When a code requires a 7th code, what does it indicate?
ANSWER: The 7th character of a code indicates the type of encounter: initial, subsequent, or sequela.
18-51
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In Summary
18.1 ICD codes are used to facilitate payment for medical services; evaluate utilization patterns; study
healthcare costs; research quality of healthcare; predict healthcare trends; and plan for future healthcare needs.
18.2 There are conventions used in the ICD.
Bold and italics are used in both the Alphabetic Index and Tabular List.
Instructions to omit code, see condition, and see also are found exclusively in the Alphabetic Index.
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In Summary (cont.)
18.3 To choose an ICD code, locate all applicable diagnoses.
Find the key term in the Alphabetic Index and any applicable subterms.
Verify the code’s description in the Tabular List, reading all applicable notations for other coding options and instructions.
Document each code carefully using instructions as to code sequencing on the CMS-1500 claim form.
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In Summary (cont.)
18.4 V codes are used for patients who, though not ill, are seeking healthcare.
E codes are used to explain how an illness or injury came about.
18.5 The following appendices are found in ICD-9-CM: • Appendix A • Appendix B • Appendix C • Appendix D • Appendix E
18-54
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In Summary (cont.)
18.6 ICD-10-CM is intended to provide a more precise clinical picture of the patient and enhanced trending analysis for data reporting.
The number of codes increases in the ICD-10 and the characters change from 3–5 numerical to 3–7 alphanumeric.
Both contain the Alphabetic Index of the diseases, conditions, and related terms.
The I-10 Tabular List incorporates 21 chapters
Many codes use an “x” as a placeholder for future expansion; which was not possible with ICD-9.
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In Summary (cont.)
18.7 The technique of coding with ICD-10 is very similar to that of coding with ICD-9-CM.
Locate the diagnosis or symptom in the Alphabetic Index and consider all notes.
You then move to the Tabular List as instructed in the Alpha Index.
After following terms, abbreviations and symbols, the appropriate code with the highest specificity supported by medical record documentation is
selected.
18-56
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In Summary (cont.)
18.8 The majority of ICD-10 CM codes follow the general guidelines.
However, unique coding applications do exist and chapter guidelines must be followed.
These include but are not limited to the chapters on neoplasms, diabetes mellitus, fractures, R codes, poisonings, and the new Z codes.
18-57
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End of Chapter 18
Fraud and falsehood only dread examination. Truth invites it.
~ Samuel Johnson