In this chapter students will be able to: Explain the purpose and format of the ICD9CM volumes that are used by medical offices, describe how to analyze diagnoses and locate correct codes using the ICD9CM, identify the purpose and format of the CPT, name three key factors that determine the level of Evaluation and Management codes that are selected,...
CHAPTER 18 Diagnostic Coding 18-2 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 18-3 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 18-4 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 18-5 The Reasons for Diagnostic Codes • Chief complaint (CC) – Diagnosis (DX) • Proves medical necessity of treatment • Diagnostic code – Coexisting conditions 18-6 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 18-7 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 18-8 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 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 ~ edition for hospitals • Appendices 18-10 Conventions NOS – not otherwise specified NEC – not elsewhere classified [ ] – brackets [ ] – slanted bracket 18-43 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 18-44 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 18-45 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 18-46 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 18-47 Synopsis of ICD-10 Coding Guidelines by Chapter (cont.) • Chapter 20 – Replaces E codes – Accidents or injuries – Research and prevention – Abuse codes take priority 18-48 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 Synopsis of ICD-10 Coding Guidelines by Chapter (cont.) • Practice • Read guidelines carefully • Ask questions 18-50 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 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 18-52 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 18-53 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 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 18-55 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 In Summary (cont.) 18.8 The majority of ICD-10 CM codes follow the general guidelines However, unique coding applications 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 End of Chapter 18 Fraud and falsehood only dread examination Truth invites it ~ Samuel Johnson ... ICD-9-CM 18. 4 Explain the purpose and usage of V codes and E codes 18- 3 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... 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 18- 4 Introduction • Diagnosis... Understand what the codes mean – Know how to chose correct codes 18- 5 The Reasons for Diagnostic Codes • Chief complaint (CC) – Diagnosis (DX) • Proves medical necessity of treatment • Diagnostic