ICD-9-CM Coding International Classification of Diseases, 9 th Revision, Clinical Modification: For classifying medical diagnoses.

Steps for Coding  Review the diagnosis on the charge slip/encounter form/superbill.  Review the chart notes. The chart notes with the doctor’s diagnosis are what will be audited, and coders should code consistent with the physician documentation.  “Not documented, not done.”

Steps for Coding ICD-9  SOAP = Subjective/Objective/Assessment/Plan.  If the chart is in SOAP format, the diagnosis usually is in the A= Assessment, but may also be listed in the Subjective and Objective information.  Identify the Primary diagnosis for physician bills. Principal diagnosis is only for inpatient hospital facility bills.  The Primary diagnosis is the one that was the condition primarily the reason for the encounter or that involved most of the doctor’s time/effort.  Identify any secondary diagnoses.

Steps for Coding ICD-9  A diagnosis listed as “rule out” “possible” “likely” or “suspected” should not be coded on physician claims. The symptom would be coded instead.  HOWEVER: Do not code common symptoms along with the condition they are related to. Example: Myocardial Infarction would not need a secondary diagnosis of “chest pain” but code “chest pain” by itself if the doctor says “suspected Myocardial Infarction”.

Steps for Coding ICD-9  Go to the ICD-9 book, Volume II: Alphabetic Index.  Determine the MAIN term to look up. Main term is usually what’s WRONG, not the body part.  Indented under the Main term will be the sub-term, which gives additional information, such as bodypart.  Subterms are indented and listed alphabetically except that “with” is listed before the other entries.

Steps for Coding ICD-9  If the index lists two codes, the second of which is listed in [slanted brackets] you will need to use both codes in the order listed.  Write down the code suggestions from the index.  Go to ICD-9 book, Volume I: Tabular List and look for the code(s). This is NOT optional!  You cannot just code from the index.  When you locate the code in the tabular list, read any instructions.

Steps for ICD-9 Coding  If there is a highlight, or a circled five or four beside the code, or a bullet/circle you may need to add additional digits to the code. Additional digits may be listed under the code or at the category level.  Go up to the 3-digit category for the code. Review any instructions there. If the additional digits are at the category level, select final digits.

Steps for Coding ICD-9  Excludes notes. Read the notes carefully. It may refer you elsewhere if your diagnoses is excluded from use with this code.  Proof-read your code.  If you have less than 5 digits, verify there was no requirement for 5 th digits.

Tables in ICD-9  Hypertension Table is used to code hypertension. It is located in the Alpha Index under “H”.  Neoplasm Table is used to code tumors and cancers by body part. It is located in the Alpha Index under “N”.  Table of Drugs and Chemicals is used to code poisonings and adverse effects (side effects) of drugs. It is AFTER the Alpha Index, look after “Z”.