Unit 9 Seminar Chapters 3 & 4 HS225 Medical Coding I Unit 9 Seminar Chapters 3 & 4

Index to Diseases, Tabular List of Diseases, and Index to Procedures Format Spacing Coding Conventions: are general rules used in classification, they are independent of the coding guidelines, they are in all three volumes of the ICD-9 book. Format—refers to “indentations” to make using the book easier to use. All subterms in the Aplhabetic Index are indented two spaces. 2nd and 3rd qualifiers associate with the main term are further indented two and four spaces If an index entry requires more than one line the additonal text is printed on the next line and indented five spaces.

Eponyms Diseases or syndromes that are named for persons For example, Meniere’s disease Colle’s Fracture Grave’s Disease

Abbreviations NEC (not elsewhere classifiable) “Other specified” For example, 250.8 Diabetes with other specified manifestations NOS (not otherwise specified) Equivalent to unspecified For example, 250.9 Diabetes with unspecified complication NEC-Documentation specifies what it is, but there are no specific classifications in the book. NOS-Documentation is not specific. You should contact the doctor to ask for additional documentation.

Punctuation Slanted brackets Square brackets Parentheses Colon [ ] ( ) [ ] Square brackets Parentheses ( ) Colon :

Slanted Brackets [ ] Located in Index to Diseases Identify manifestation codes For example, 277.3 [357.4] Slanted brackets—used to identify manifestation codes. Manifestation is a condition that occurs as the result of another condition and may appear in italics in the Tabular List Manifestations are always reported as a secondary code.

Square Brackets [ ] Located in Tabular List of Diseases and Tabular List of Procedures Enclose synonyms, alternative wording, or explanatory phrases For example: 253.3 Pituitary dwarfism Isolated deficiency of (human) growth Hormones [HGH] Chronic Obstructive Pulmonary Disease [CPOD]

Parentheses ( ) May be present or absent in the doctor’s diagnostic statement Enclose nonessential modifiers For example, (acute) (chronic) Diverticulitis (acute) Hypertension (essential, vascular, crisis) Parentheses—Used in both the index and tabular list as nonessential modifier that are supplementary words that may be present in or absent from the physician’s statement of disease or procedure. It does not affect the code number to which it is assigned.

Colon : Used after an incomplete term in Tabular List of Diseases and Tabular List of Procedures Indicates when one or more additional terms (modifiers) located after the colon are to be included in diagnostic statement Colon—Used after an incomplete term in the Tabular List of disease and Tabular list of procedures when one or more additional terms (called Modifiers) included after the colon Modifier should be are to be included in the diagnostic statement to classify a condition or procedure. (continued)

Colon : For example: 380.22 Other acute otitis externa Acute otitis externa: actinic chemical contact eczematoid reactive

Boxed Notes Define terms Provide coding instruction List fifth-digit subclassifications (continued)

Boxed Notes For example: 249 Secondary diabetes melltus The following fifth digit sub-classification is for use with 249: 0 not stated as uncontrolled or unspecified 1 uncontrolled

Tables Organize sub-terms, second qualifiers, third qualifiers, and their codes in columns and rows to make it easier to select proper code Examples of tables: Hypertension, hypertensive Neoplasms Table of Drugs and Chemicals (continued)

Includes Notes Located immediately below ICD-9-CM Tabular List of Diseases and Tabular List of Procedures Codes Further defines or provides examples (continued)

Includes Notes INCLUDES For example: 023 Brucellosis Fever: Malta Mediterranean undulant INCLUDES

Excludes Notes Located in ICD-9-CM Tabular List of Diseases and Tabular List of Procedures Directs coder to another location in the tabular list to classify conditions (continued)

Excludes Notes For example: 010.8 Other primary progressive tuberculosis tuberculous erythema nodosum (017.1) Excludes

Inclusion Terms Listed below certain four- and five-digit ICD-9-CM codes Include conditions or procedures for which that code number is to be assigned May be synonyms for code title Include terms that do not appear in tabular list

Other and Other Specified Codes Assigned when documentation provides detail for a code that does not exist in ICD-9-CM Usually represented by a fourth and/or fifth digit of 8 and/or 9

Unspecified Codes Assigned because documentation is insufficient to assign a more specific code Usually represented by a fourth digit of 9 and/or a fifth digit of 0

Etiology and Manifestation Rules Include the following notes in the Tabular List of Diseases: Code first underlying disease If applicable, code any causal condition first Use additional code In diseases classified elsewhere Code first-assists the coder in the proper sequence the codes Etiology code followed by manifestation code

And Located in category titles and code descriptions in Tabular List of Diseases and Tabular List of Procedures Interpreted as meaning “and/or” 464 Acute laryngitis and tracheitis Means Acute laryngitis and/or tracheitis

Due To Located in Index to Diseases as sub-term Alphabetic order Causal relationship For example, meningitis due to adenovirus Indicates a (casual) cause-and-effect relationship between two conditions

In Located in Index to Diseases in alphabetic order below main term For example, pneumonia in candidiasis These conditions often appear together

With Located in Index to Diseases or Index to Procedures immediately below main term Physician must document both conditions or procedures for code to be assigned

Cross-References See See also See category See condition

Chapter 4 Coding Guidelines

Guidelines Signs and symptoms that are integral to the disease should not be assigned as additional codes. The etiology and manifestation convention requires two codes to be reported to completely describe a single condition. Signs and symptoms are codes that are used when there is no definitive diagnosis confirmed by a provider. If they are not integral to the disease they should be coded when present. (continued) 28

Guidelines Multiple coding for a single condition Use additional code Code first If applicable, code any causal condition first Acute (or subacute) and chronic conditions Combination code versus multiple code Acute and chronic may be used for the same condition and you must code both when present. Acute conditions should be coded first then the chronic condition. 29

Late Effect Residual condition that develops after acute phase of illness or injury has ended No time limit on reporting these codes Combination code assigned For example, painful cicatrix following severe burn to the elbow or left-sided paralysis due to previous cerebrovascular accident (CVA) 30

General Procedure Guidelines Based on anatomy rather than surgical specialty Numeric codes Use both Index to Procedures and Tabular List of Procedures (continued) 31

General Procedure Guidelines Index to Procedures main terms organized in alphabetic order according to type of procedure Report codes using highest number of digits available — omit code If omit code is found then don’t assign the procedure code (continued) 32

General Procedure Guidelines Common key terms: Application Closure Correction Destruction Division Incision Insertion Operation Procedure Release Removal Repair (continued) 33

General Procedure Guidelines Common key terms: Resection Revision Suture Test Therapy Transfer (continued) 34

General Procedure Guidelines Combination codes Multiple codes And/Or Open procedure versus closed procedure Endoscopic procedures Biopsies Canceled surgery Assign comibation or multiple codes as appropriate Combination: tonsilectomy and adenoidectomy.—use one combination code not two separate codes. Open procedure is when an incision is made through the skin.—abdominal hernia repair or abdominal hysterectomy. Closed procedure done by using an endoscope—colonoscopy, laparoscopic cholecystectomy Biopsy—review the record to determine if it is closed or open. Most closed biopsies are combination codes and the endoscopic procedure is coded first. When a biopsy and subsequent removal of tissue is done at the same time code the removal of the tissue first and then the biopsy code. When the surgeon an aspiration, bristle or brush or needle biopsy is done at the time of another open procedure, assign the closed biopsy code. Cancelled surgery-if a procedure is cancelled after the patient was admitted but has not been prepped for surgery then do not report the procedure code. If the patient has been prepped and/or the procedure had to stop during surgery it is considered an incomplete procedure; IF the doctor makes an incision then code the incision of the site. If the endoscopic approach does not result in the intended procedure then just code the type of endoscopy. If a cavity or anatomic site was entered and the surgery was halts at that point, assign a code for the exploration of the cavity or site. 35

Questions