Mary Jo Bowie MS, BS, AAS, RHIA, RHIT

Steps in Diagnostic Code Selection CHAPTER 4 Steps in Diagnostic Code Selection

Steps in Code Selection For proper code selection to occur, coders must: Understand the coding conventions Have specific written diagnoses to code Use both the Index and Tabular List

Necessary Documentation Coders need to review the medical documentation prior to selecting codes. This includes: For inpatients, the Face Sheet For outpatients, Encounter Form Problem List Testing Results Operative Reports Discharge Summary/Final Notes

Points to Remember Review test results, as the results can confirm a diagnosis. If information contained in the record conflicts, query the attending physician. Follow coding policies established by the organization in regard to coding before or after the test results have been received.

Granularity of ICD-10-CM When compared to ICD-9-CM, ICD-10-CM has greater granularity. Diagnoses will have to be recorded with greater detail for proper code selection. Provider education may be necessary. Coders should select codes at the highest level of detail.

Laterality in ICD-10-CM For bilateral sites, ICD-10-CM indicates the specific site. EXAMPLE: At the 5th character level the codes for a femoral fracture indicate the following: Unspecified fracture of unspecified femur—S72.90 Unspecified fracture of right femur—S72.91 Unspecified fracture of left femur—S72.92 An additional 6th character of x is added and an additional 7th character is added to indicate the type of encounter: initial, subsequent, or sequelae.

Steps in Coding Step 1 Locate the Main Term in the Alphabetic Index. The main term is the condition that is present. In the statement “acute allergic sinusitis” the main term is sinusitis.

Steps in Coding (cont.) Step 2 Scan the main term entry in the Alphabetical Index for any Instructional Notations. Step 3 In the diagnostic phrase being coded, identify in terms that modify the main term.

Steps in Coding (cont.) Step 4 Follow any cross-reference notes found in the Alphabetical Index. Step 5 Always verify the code in the Tabular List.

Steps in Coding (cont.) Step 6 Follow any Instructional Notes found in the Tabular List. Step 7 Select the code.

Identifying Main Terms For the following diagnostic statements, identify the main terms: Compound fracture of the left tibia Acute reticulosis of infancy Ulcerative esophagitis with bleeding

The main terms for the diagnostic statements are in bold. Compound fracture of the left tibia Acute reticulosis of infancy Ulcerative esophagitis with bleeding

Key Points to Remember The Alphabetic Index and the Tabular List must both be used when assigning codes. All instructional notations must be read. The instructional notations should be used as a guide when selecting codes.

Key Points Continued ICD-10-CM provides greater granularity than ICD-9-CM. Medical documentation needs to be detailed. Providers should be queried if information conflicts.

What should you do? You are attempting to code an inpatient record and the fact sheet and the discharge summary record different diagnoses. What action should you take?

Alphabetic Index Main terms and Nonessential Modifiers Reference the main term Cellulitis in the Alphabetical Index. What are the nonessential modifiers that appear for this entry?

The nonessential modifiers that appear for Cellulitis are: Answer The nonessential modifiers that appear for Cellulitis are: Diffuse Phlegmonous Septic Suppurative

Alphabetic Index Main terms and Subterms Reference the main term Cellulitis in the Alphabetical Index. What are the first three subterms that appear for this entry?

Ankle- see Cellulitis, lower limb Answer The first three subterms that appear for the main term entry of Cellulitis are: Abdominal wall Anaerobic Ankle- see Cellulitis, lower limb