The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 1 Introduction to Diagnosis Coding Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes ·Explain the purpose of health care coding. ·Apply correctly the appropriate steps to coding. ·Apply the official guidelines provided to find the best, most accurate code

Learning Outcomes ·Detect the ethical danger zones that might exist in the workplace. ·Know the AHIMA Code of Ethics and the AHIMA Standards of Ethical Coding. ·Know the AAPC Code of Ethics

Introduction ·The purpose of coding is to make every effort to ensure clear and concise communication between all parties involved with the health and well-being of the population

Introduction ·Diagnosis is a physician’s determination of a patient’s condition, illness, or injury. ·WHY the patient came to see the health care provider is translated into diagnosis codes

Introduction ·A SIGN is objective evidence of a disease or condition. ·Example: Fever ·A SYMPTOM is subjective, as related by the patient. ·Example: Feeling tired 1 - 6

Introduction ·Signs and symptoms are only coded when there is no definite diagnosis

Medical Necessity ·Diagnosis codes explain WHY the insurance carrier should pay for the provision of procedures, treatments, and services. ·Medical necessity identifies that the physician was acting within the bounds of good medicine

Medical Necessity ·Procedure codes explain WHAT the the health care professional did for the patient during this encounter. ·Procedure codes are reported from CPT and ICD-9-CM, volume

Steps to Accurate Coding ·Read the notes and superbill completely. ·Highlight key words regarding the diagnoses (WHY) and the procedures (WHAT) that occurred during this encounter

Steps to Accurate Coding ·Query the physician if there is any unclear, conflicting, or missing information. ·Code each diagnosis and/or appropriate signs or symptoms

Steps to Accurate Coding ·Assign codes to the greatest specificity. ·Code only those documented conditions that require or influence treatment at this encounter

Steps to Accurate Coding ·Use as many codes as are necessary to tell the whole story of this encounter. ·Code each procedure, service, and/or treatment provided to the patient during this encounter

Steps to Accurate Coding ·Link each and every procedure code to at least one diagnosis code. ·Double-check your codes!

Superbills versus Notes ·Coding from superbills is faster but often is NOT more ACCURATE. ·The Official Guidelines state that the entire record should be reviewed

Official Guidelines ·Official Guidelines can be found in your ICD-9-CM book for quick reference and reminders. ·Guidelines instruct you how to code accurately

Ethical and Legal Coding ·Don’t use a claim without the supporting documentation. ·Coding for coverage is illegal. ·It is fraud to upcode: using a code that claims a higher level of service or a more severe condition than is true

Ethical and Legal Coding ·It is illegal to unbundle combination codes. ·You must code ALL conditions relevant to the current encounter. ·Codes for one encounter must be shown on one claim form

Ethical and Legal Coding ·It is not worth breaking the law and taking a chance of getting hit with fines, penalties, and possibly prison just to hang onto a job

Resources ·Medical dictionary ·Merck Manual ·Physicians’ Desk Reference (PDR) ·Coding Clinic ·Correct Coding Initiative

Codes of Ethics ·American Health Information Management Association (AHIMA) ·Code of Ethics ·Standards of Ethical Coding

Codes of Ethics ·American Academy of Professional Coders (AAPC) ·Code of Ethical Standards

Chapter Summary ·Once you assign a diagnosis or procedure code to a patient’s claim form, it becomes a legal document. ·Coding is very important to the health care industry