Chapter 3 DIAGNOSTIC CODING

DIAGNOSTIC CODING Learning Objectives Explain how diagnostic coding affects the payment process. Label the primary and coexisting conditions. Explain the ICD format and identify sections used by medical insurance specialists in physician practices. Identify the purpose and correct use of V codes and E codes. Use a five-step process to analyze diagnoses and locate the correct ICD code. Chapter 3

Key Terms Alphabetic Index Chief complaint (CC) Coexisting condition Conventions Cross reference Diagnosis code Dx E code Etiology International Classification of Diseases (ICD) Main term Primary diagnosis Subterm Supplementary term Tabular List V code Chapter 3

Introduction to Diagnostic Coding During Office Encounters: Physicians documents their evaluation of patients’ condition in their medical records. A section of the medical record is called ROS (review of body system). Patients’ responses to each question the physician ask about the body system is recorded. When Examination is conducted, physicians summarize the findings under various heading, such as “neck” or Neurologic” (for the nervous system). Findings When a diagnosis (Dx) is made by the physician, it is documented in the patients’ medical record. Chapter 3

Introduction to Diagnostic Coding Diagnosis - Physician’s opinion of the patient’s specific illness(es), sign(s), symptom(s), and complaint(s). Diagnostic Code(s) - are numbers assigned to the physician’s diagnosis in the International Classification of Diseases (ICD). It is based on the physician’s opinion of the patient’s specific illness, signs & symptom and complaints. Chapter 3

Introduction to Diagnostic Coding Diagnostic Code(s) Affects the medical insurance payment process. Translates medical words to standardized numbers Clearly defines diagnosis Chapter 3

Introduction to Diagnostic Coding The ICD-9-CM International Classification of Diseases (ICD) List codes according to a system assigned by the “World Health Organization (WHO) of the United Nations”. Volumes are Distributed by U.S. Government Printing Office in Washington, D.C. and by Commercial Publishers Origination The ICD was originated in the1600s in England Used in the U. S. by the late 1800s for reporting: Morbidity (illnesses) Mortality ( causes of death) Chapter 3

Diagnostic Coding (cont’d) The ICD-9-CM ICD-9 refers to 9th revision; updated yearly. ICD-9 – is a coding system that describes diseases, conditions and related issues. CM = Clinical Modification for more precise terms The Medicare Catastrophic Coverage Act of 1988 requires the use of codes from the ICD-9-CM on Medicare Claims. ICD=9 Codes are updated yearly. Chapter 3

Diagnostic Coding (cont’d) The ICD-9-CM system Written as XXX.XX 3-digit categories for diseases, injuries, and symptoms 4-digit sub-categories 5-digit sub-classifications Goal is to report the most specific dx possible Chapter 3

Coding Basics for Physician Practices Primary Diagnosis - A diagnosis that represents the patient’s major illness or condition for an encounter. EXAMPLE: If a Patient has Cancer, the disease is probably the patient’s major health problem. But if the patient sees the physician for an ear infection that is not related to Cancer, the Primary diagnosis for this encounter is the ear infection. Chapter 3

Coding Basics for Physician Practices Chief Complaint (CC) - a description of symptoms or other reasons a patient seeks medical care on a particular visit to a physician. Coexisting Conditions - additional diagnosis that occurs at the same time as the primary diagnosis and that affects its treatment. May have more than one dx code May list up to three additional codes Chapter 3

Using the ICD Volume 1—Diseases: Tabular List Volume 2—Diseases: Alphabetic Index Volumes 1 & 2 used in medical offices Volume 3—Procedures: Tabular List and Alphabetic Index Volume 3 used only for hospital tests and treatments Chapter 3

Using the ICD Volume 2—Diseases: Alphabetic Index Main Terms Subterms In bold type Subterms Always indented 2 spaces under main terms Carry-over Lines Indented more than 2 spaces from level of preceding line Modifiers In parentheses (can be present or absent) Chapter 3

Using the ICD (cont’d) Alphabetic Index Section 1 Section 2 Section 3 Alphabetic-order Never used alone Section 1 Index to diseases and injuries Section 2 Table of drugs and chemicals Section 3 External causes of injuries and poisoning (E codes) Chapter 3

Using the ICD (cont’d) Main terms Supplementary terms Subterm Listed by condition Hernia, hernial (acquired) (recurrent) 553.9 with gangrene (obstructed) NEC 551.9 obstruction NEC 552.9 and gangrene 551.9 abdomen (wall) - see Hernia, ventral abdominal, specified site NEC 553.8 gangrene (obstructed) 551.8 obstruction 552.8 and gangrene 551.8 Supplementary terms In parentheses () Don’t affect the code selection Subterm Indented Listed by etiology Affect code selection Cross-reference Anatomical sites, or alternate main terms to help locate appropriate codes Chapter 3

Using the ICD Volume 1 (Tabular List) For four & five digit codes: Categories - 3 digits Subcategories - 4th digit Subclassifications - 5th digit For four & five digit codes: Add decimal point after 3rd digit Chapter 3

Using the ICD (cont’d) Tabular List Numerical order Ordered by body system or etiology V and E Codes follow tabular list V Codes can be used as primary dx E Codes used in addition to another code Chapter 3

Using the ICD Volume 1—Diseases: Tabular List Numeric listing with 17 Chapters Half devoted to conditions affecting a body system Remainder classify conditions according to etiology (the origin of the disease) 2 Supplementary Classifications V codes Classification of factors influencing health status and contact with health services. E codes Classify external causes of injury and poisonings Appendix A-E Chapter 3

The Coding Process Volume 1/Tabular List Numerical -order Never used alone Fifth-digit Subclassifications Five-digit code numbers Subcategories Four-digit code numbers Chapter 3

Organization of ICD-9 Volume 1 (17 Chapters Plus Appendices) A Morphology of Neoplasms B Glossary of Mental Disorders C Classification of Drugs by American Hospital Formulary Service List Number and ICD-9-CM Equivalents D Classification of Industrial Accidents According to Agency E List of Three-Digit Categories Chapter 3

Coding Basics for Physician Practices V Codes Supplementary Classification of Factors Influencing Health Status and Contact with Health Services Wellness code, such as physical exam (reason for the encounter) V01-V83 E Codes Supplementary classification of External causes of Injury & Poisoning E800-E999 Chapter 3

Using The ICD (cont’d) V Codes E Codes Encounters for reasons other than illness or injury For example, routine physicals, flu shots, vaccinations Remember— PreVentive medicine E Codes Indicate the external cause of injury or poisoning For example, fall from bicycle, car accident Remember— External cause Chapter 3

Using the ICD (cont’d) ICD-9-CM Conventions are: A list of abbreviations, punctuation, symbols, type faces, and instructional notes Appear at the beginning of the ICD Provide guidelines for using the ICD coding system Chapter 3

Using the ICD (cont’d) ICD-9-CM Conventions NOS NEC [] Brackets () Parentheses : Colon } Brace Includes Excludes Use additional code Code first underlying disease Chapter 3

Using The Diagnostic Codebook ICD-9-CM Conventions NEC Not elsewhere classified 4 condition doesn’t have a specific code 4 may have 4th digit of .8 NOS Not Otherwise Specified 4 code is unspecified 4 often coded with 4th digit of .9 4 continue looking for more specific code Chapter 3

Using The Diagnostic Codebook ICD-9-CM Conventions Parentheses ( ) Non-essential modifiers Can be present or absent without affecting code number Square brackets [ ] Enclose synonyms, alternate wordings, or explanatory phrases Chapter 3

Using The Diagnostic Codebook ICD-9-CM Conventions Colon : Used after an incomplete term Term needs one or more modifiers to make it assignable Braces { } Encloses a series of terms Term modified by statement to the right Chapter 3

Excludes (What it is not) Using The Diagnostic Codebook ICD-9-CM Conventions (Includes and Excludes) Includes (What it is) Further defines or gives examples Excludes (What it is not) Look for code elsewhere Chapter 3

Using The Diagnostic Codebook (See, See Also, and See Category) Cross-reference and directs the coder to look elsewhere for closely related terms, code categories and synonyms. See An explicit direction to look elsewhere See also Look under another main term See category Review entire category before assigning code Chapter 3

Using The Diagnostic Codebook ICD-9-CM Conventions Code First Underlying Disease Underlying disease is always the primary diagnosis Use additional code Need more than one code to give a complete picture of diagnosis Chapter 3

Using The Diagnostic Codebook ICD-9-CM Conventions Provide instructions or guidelines Further define terms, clarify information, or list choices for additional digits Volume 2 notes appear in a box Chapter 3

Five Steps to Dx Coding Step 1 Locate the statement of the dx in the medical record Step 2 Find the dx in the Alphabetic Index Step 3 Locate the code in the Tabular List Step 4 Read all information; note 4th and 5th digit requirements and exclusions Step 5 Record the dx code on the insurance claim; PROOFREAD numbers Chapter 3

Preview of the ICD-10-CM Published by WHO (World Health Organization) in mid-1990s Still in review by health care professionals. Expected to be put into use by 2008. Major Changes Include: 2,033 categories of diseases 855 more than ICD9 to permit more specific reporting of diseases & newly recognized conditions. Codes are alpha-numeric, containing a letter followed by up to 5 numbers. 6th digit is added to capture clinical details Codes added to show which side of body is affected in cases of Left, Right or Bilateral conditions. Chapter 3

Basic Coding Steps & Exercise Part 2 Basic Coding Steps & Exercise Chapter 3

Basic Steps In Coding Finding the Main Term is the key to coding Coding Step 1 Finding the Main Term is the key to coding Chapter 3

Basic Steps In Coding What are Main Terms? Diseases Conditions Nouns Adjectives Do not look under anatomical sites. Example: Liver disorder – look under Disorder (not Liver) Chapter 3

Basic Steps In Coding Common Main Terms Syndrome Anomaly Insufficiency Infection (itis) Injury History (of) Anomaly Disease Disorder Findings (abnormal) Chapter 3

Basic Steps In Coding Coding Steps 2 and 3 Step 2 - Look for notes and modifiers under main term No effect on code selection Step 3 - Note indented subterms Can effect code selection Chapter 3

Basic Steps In Coding ALWAYS verify the code in Volume 1 Coding Step 4 Chapter 3

Basic Steps In Coding Coding Steps 5, 6 and 7 Follow instructional terms Step 6 Code to highest level of specificity Use 5th digit when necessary Step 7 Follow cross references Chapter 3

Coding Exercise Bronchitis with acute or subacute 466.0 Nervous system complication, unspecified 997.00 Chapter 3

Coding Exercise Diagnostic Statement - Well Child Exam V20.2 V70.0 General Physical V70.0 Chapter 3

Coding Exercise Pre-employment screening V70.5 Family history of congenital defects V19.5 Bipolar disorder, manic phase, mild 296.41 Chapter 3

Coding Exercise Adverse effects from digoxin taken correctly Injury from electric can opener E920.2 Chapter 3

Coding Exercise Unspecified localized salmonella infection 003.20 Acute pulmonary manifestations due to radiation 508.0 Chapter 3

Practice Exercise ICD-9-CM Conventions/”Code First” Italics used: In both Volumes Highlight all exclusion notes Identify codes that should not be used as the primary code for a condition or problem. Code: Diabetes neuropathy Primary Dx: 250.6 Diabetes with neurological manifestations Secondary Dx: [357.2] Polyneuropathy Chapter 3