General Guidelines
Term first-listed diagnosis, rather than principal diagnosis Outpatient Surgery: Reason for surgery ◦ Even if surgery is cancelled due to contraindication
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
Condition for encounter ◦ Why patient presented, not necessarily most serious condition noted Documented Chiefly responsible for services provided Also list co-existing conditions
Diagnosis and procedure MUST correlate Medical necessity must be established through documentation No correlation = No reimbursement
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
Use codes through V89.09 to code: ◦ Diagnosis ◦ Symptoms ◦ Conditions ◦ Problems ◦ Complaints ◦ Or other reason(s) for visit
Documentation should describe patient's condition, using terminology that includes: ◦ Specific diagnoses ◦ Symptoms ◦ Problems ◦ Reasons for encounter
Selection of codes through (Chapters 1-17) frequently used to describe reason for encounter
Codes that describe symptoms and signs, as opposed to diagnoses, acceptable for reporting purposes when ◦ An established diagnosis has NOT been determined by physician
V codes deal with encounters for circumstances other than disease or injury ◦ Example: Well-baby checkup See Section I.C.18 for information on V codes
Located after 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
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 (Cont’d…)
(…Cont’d) 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.18.e. of Guidelines contains the V Code Table ◦ Identifies if V code can be listed as first, first/additional, additional only
V10 Personal history of malignant neoplasm 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 conditions Condition no longer present or treated
Codes have either 3, 4, or 5 digits 4 and/or 5 digit codes provide greater specificity (detail) (Cont’d…)
(…Cont’d) 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!
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
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
Chronic diseases treated on an ongoing basis may be coded and reported as many times as patient receives treatment and care for condition(s)
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 (Cont’d…)
(…Cont’d) “History of” codes (V10-V19) may be used as secondary codes if: ◦ Impacts current care or treatment
For patients receiving diagnostic services ONLY Sequence first ◦ Diagnosis ◦ Condition ◦ Problem OR ◦ Other reason shown in medical record to be chiefly responsible for encounter (…Cont’d)
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
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
Code diagnosis which required ambulatory surgery Pre- and post-op diagnosis different ◦ Code the post-op diagnosis
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)
Conclusion – General Guidelines