ICD-9-CM Coding ICD-9-CM Coding PMI Online Education

Introduction READ THOROUGHLY Office Visit Service Procedure A thorough knowledge of the ICD-9-CM layout is essential READ THOROUGHLY Every word and term has weight and meaning Be familiar with: Conventions Eponyms Non-essential modifiers 5th digit specificity Office Visit Index & Tabular List Notes/Explanations Notes and explanations can direct you to: Additional codes Exclusions Other special instructions A thorough knowledge of the layout of the ICD-9-CM is essential to correct coding. Every procedure, office visit, and service must have a corresponding diagnosis code to validate it, so be familiar with conventions, eponyms, non-essential modifiers, and 5th digit specificity.   In order to successfully pass the certification exam, you must read thoroughly because every word and term literally has weight and meaning. The notes and explanations in the index and the tabular list can direct the coder to additional codes, exclusions, and other special instructions.  Service Procedure CODE CODE CODE

S O A P S.O.A.P. S.O.A.P. Principle Diagnosis Primary Diagnosis ubjective Chief complaint Headache, fatique and nausea Represent the Primary diagnosis Signs and symptoms become a risk factor O bjective Principle Diagnosis (Objective, Assessment) Primary Diagnosis (Subjective) Physical examination, lab data, etc. Derives the Principle diagnosis Use the S.O.A.P. note format to determine whether a Primary or Principle diagnosis is required A ssessment As you read through the test questions, you will have to determine whether a Primary or Principle diagnosis is required. For that, recall the SOAP note format: S stands for Subjective. This contains the patient’s chief complaint. Items such as headache, fatigue, and nausea are described by the patient and represent the Primary diagnosis.   O stands for Objective. Factual data is obtained here by the physician to include Physical Exam, Lab data, and other findings. This information derives the Principle diagnosis that is listed in the assessment. A stands for Assessment. This represents the Principle diagnosis after all the data is reviewed by the physician. Issues that cannot be described by the patient such as a Subarachnoid Hemorrhage or Uncontrolled Type I Diabetes. P stands for Plan. This refers to the physician’s recommended treatment for this patient. A hospital coder would refer exclusively to the Principle Diagnosis, unless the signs and symptoms (pain in particular) become a risk factor. If the objective data has been considered in the outpatient setting, the physician coder would also refer to diagnosis from the assessment when available. Represents the Principle diagnosis Issues cannot be described by patient such as a Subarachnoid Hemorrhage If objective data has been considered in the outpatient setting, the coder would also refer to the assessment P lan Physician’s recommended treatment

History and Physical report Abstraction Process Let’s review a History and Physical report Let’s review a History and Physical report. We will focus solely on the diagnosis described.

signs and symptoms descriptions Primary Diagnosis Headache 784.0 Fatigue 780.79 Blurred vision 368.8 The headache, fatigue, and vision blurring is what Mr. Black describes to the physician. They represent the Primary Diagnosis and are coded thus:   Headache: 784.0 Fatigue: 780.79 Blurred vision: 368.8 Notice they represent signs and symptoms descriptions. These codes represent signs and symptoms descriptions

Headache and fatigue may not need to be coded Principle Diagnosis Postsurgical hypopituitarism 253.7 Complication of Medical care 999.9 IDDM, not uncontrolled 250.01 Headache and fatigue may not need to be coded After the factual findings are obtained, the physician indicates the Principle Diagnosis in the assessment portion of the SOAP note. Notice the headache and fatigue did come forward to this part and may not need to be coded. Therefore, the Principle Diagnosis can be coded as:   Postsurgical hypopituitarism: 253.7 Complication of Medical care: 999.9 IDDM, not uncontrolled: 250.01

Conclusion TEST QUESTIONS REFERENCING will define what codes to apply will cut significant time on researching Ultimately, the test question description will define what codes to apply. It may refer to “Code the diagnosis only,” discounting any references to procedures. A question may state, “What is the primary diagnosis for this patient?” This would be found in the subjective portion of the SOAP note. This referencing will cut significant time spent on researching any given question and increase your chances for overall success. “What is the primary diagnosis for this patient?” “Code the diagnosis only.” SUBJECTIVE

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