4 Diagnostic Coding: Introduction to ICD-9- CM and ICD-10-CM

Learning Outcomes When you finish this chapter, you will be able to: 4.1 Discuss the purpose of the ICD-9-CM. 4.2 Compare ICD-9-CM Volumes 1, 2, and Summarize the structure, content, and the five conventions that are followed in the Alphabetic Index. 4.4 Summarize the structure, content, and ten conventions that are followed in the Tabular List. 4.5 Recognize the chapters that make up the Tabular List. 4.6 Identify the purpose and correct use of V codes and of E codes. 4-2

Learning Outcomes (Continued) When you finish this chapter, you will be able to: 4.7 List the five steps in the process of assigning diagnosis codes. 4.8 Describe and provide examples of three key coding guidelines that are included in the ICD-9-CM Official Guidelines for Coding and Reporting. 4.9 Explain five differences and two similarities between ICD-10-CM and ICD-9-CM. 4-3

Key Terms acute addenda adverse effect Alphabetic Index category chief complaint (CC) chronic coexisting condition combination code convention crosswalk 4-4 diagnostic statement E code eponym etiology ICD-9-CM ICD-9-CM Official Guidelines for Coding and Reporting ICD-10-CM late effect main term

Key Terms (Continued) manifestation NEC (not elsewhere classified) NOS (not otherwise specified) primary diagnosis subcategory subclassification subterm supplementary term Table of Drugs and Chemicals 4-5 Tabular List unspecified V code

4.1 The ICD-9-CM 4-6 The diagnosis codes used in the United States are based on the International Classification of Diseases (ICD) The U.S. version of the ninth edition is called the ICD-9’s Clinical Modification, or ICD-9-CM – Used to code and classify morbidity data from patient medical records, physician offices, and surveys Addenda—updates to the ICD-9-CM

4.2 Organization of the ICD-9-CM 4-7 The ICD-9-CM has three parts (or volumes): 1.Diseases and Injuries: Tabular List—Volume 1: Tabular List—section of the ICD-9-CM listing diagnosis codes numerically 2.Diseases and Injuries: Alphabetic Index—Volume 2: Alphabetic Index—section of the ICD-9-CM listing diseases and injuries with corresponding diagnosis codes alphabetically 3.Procedures: Tabular List and Alphabetic Index— Volume 3: covers procedures chiefly in hospitals+ 4.

4.3 The Alphabetic Index 4-8 The Alphabetic Index: – Contains all the medical terms in the Tabular List classifications – Organized by the condition, not body part – Medical term describing the condition for which a patient is receiving care is located in the physician’s diagnostic statement—a physician’s description of the main reason for a patient’s encounter

4.3 The Alphabetic Index (Condition) 4-9 Main term—boldfaced entry that identifies a disease or condition in the ICD-9-CM Alphabetic Index Subterm—word or phrase that describes a main term in the ICD-9-CM Alphabetic Index Etiology—cause or origin of a disease Supplementary term—nonessential word or phrase that helps define a code in the ICD-9-CM Convention—typographic techniques or standard practices that provide visual guidelines for understanding printed material

4.3 The Alphabetic Index (Condition) 4-10 NEC (not elsewhere classified)—indicates the code to use when an illness or condition cannot be placed in any other category Manifestation—characteristic sign or symptom of a disease Combination code—single code that classifies both the etiology and the manifestation of an illness or injury Eponym—name or phrase formed from or based on a person’s name

4.3 The Alphabetic Index (Continued) 4-11 Five conventions apply to using the Alphabetic Index correctly: 1.Turnover lines are indented farther to the right than subterms 2.See cross-references lead the coder to another main term; see also suggest additional possible key terms 3.Notes provide information on code selection 4.The abbreviation NEC appears with main terms for which no specific code exists 5.Some conditions may require two codes