Coding Update 2006 Primary Care Conference March 29, 2006.

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Presentation transcript:

Coding Update 2006 Primary Care Conference March 29, 2006

ICD-9-CM International Classification of Diseases - 9 th Edition - Clinical Modification ICD-10 already in use internationally –2009 for USA ??

ICD-9-CM Coding Guidelines National Center for Health Statistics website Coding Clinic – issued quarterly by American Hospital Association

Diagnosis Code Tips Do not code diagnoses documented as rule out (R/O), probable, suspected, or consistent with…

Abnormal findings Findings, abnormal, w/o diagnosis –Positive PPD –Prolonged bleeding time –Electrocardiogram –Liver function tests

Signs & Symptoms Fever Dysuria Wheezing Fatigue Knee pain

ICD arranged by Condition Bronchitis Pain Sprain Bursitis Cellulitis

Site or Type Pain, –ankle –knee Arthritis –inflammatory –fingers –multiple sites

Malignancy coding Locate code by histological type; (eg melanoma, astrocytoma) Code as malignancy as long as it is still being treated Code as a history of malignancy once active treatment has ended

Neoplasms Neoplasm Table –Primary –Secondary –Ca in situ –Benign –Uncertain Behavior –Unspecified

Unknown primary malignancy Assign code for unknown primary, if still actively treated

Diabetes – compound coding If using a fourth digit to describe complication – code also the complication as a secondary code

Diabetes Mellitus – 4 th digits 250.0x = w/o mention of complication 250.1x = w/ketoacidosis 250.2x = w/hyperosmolarity 250.3x = w/other coma 250.4x = w/renal manifestations

Diabetes Mellitus – 4 th digit 250.5x = w/ophthalmic manifestations 250.6x = w/neurologic manifestations 250.7x = w/peripheral circulatory disorders 250.8x = w/other specified manifestations 250.9x = w/unspecified complications

Diabetes – 5 th digit 0type II or unspecified, not uncontrolled 1type I, not uncontrolled 2 type II or unspecified, uncontrolled 3type I, uncontrolled

Nursing Facility Codes Skilled Nursing (SNF) Intermediate Care (ICF) Long Term Care (LTCF) Psychiatric Residential Treatment Center

Nursing Facility Services Three levels of service for admissions Four levels for subsequent care Comprehensive annual assessment

Domiciliary, Rest Home or Custodial Care services Section revised to better capture care provided in these settings Increasing number of patients with complex diseases (eg, Alzheimer patients)

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