1. Understanding ICD-9-CM Coding Mary Jo Bowie MS, RHIA, RHIT Regina Schaffer AAS, RHIA, CPC

2. Symptoms, Signs, and Ill-Defined Conditions CHAPTER 21

3. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 3 Chapter 16 of ICD-9-CM Abnormal lab results Ill-defined conditions No diagnosis found elsewhere in ICD-9-CM

4. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 4 Signs or Symptoms Signs –Can be measured –Observed by physician –Objective evidence of disease

5. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 5 Signs or Symptoms Symptoms –Reported by patient –What brings patient to seek attention? –Subjective information

6. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 6 Ill-Defined Conditions NEVER used if more definitive diagnosis is made NO diagnosis found in medical information When there is a definitive diagnosis, this chapter does not apply

7. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 7 Notations Tabular Listing—Categories 780–799 –No more specific diagnosis –Transient signs or symptoms –Provisional diagnoses –Case is referred elsewhere for investigation –Symptoms representing important problems in medical care

8. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 8 Reason for the Encounter Typically used for outpatient coding Patients seek care for relief Results of workups are not always available

9. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 9 Guidelines for Coding Inpatient and outpatient differ ICD-9-CM Official Guidelines for Coding and Billing should be referenced

10. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 10 Inpatient and Outpatient Guidelines Use symptoms and signs for reporting when there is no definitive diagnosis Chapter 16 codes are NOT used when there is a definitive diagnosis for –Inpatient and short-term care –Acute care –Long-term care

11. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 11 Reason for Reporting Coder should ALWAYS go back to reason for encounter When only the symptom is being treated and not the underlying condition, code the symptom as primary diagnosis

12. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 12 Symptoms and Signs as Secondary Codes Signs and symptoms implicit in diagnostic statement are not coded separately Signs and symptoms not associated with a disease should be coded separately

13. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 13 Difference in Inpatient and Outpatient Coding Rule-out, Possible, Suspected Inpatient—YESOutpatient—NO Emergency room and physician office are considered outpatient Admission to hospital is considered inpatient

14. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 14 Multiple Symptoms 780–789 Category Codes –Altered states of consciousness—altered loss of awareness –Syncope—fainting –Coma

15. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 15 Nonspecific Abnormal Findings Main terms –Abnormal findings without definitive diagnosis –Elevation Abnormal, abnormality, abnormalities

16. © 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16 Unknown Causes of Morbidity and Mortality Morbidity—diseased state Mortality—death Review all available records Use definitive diagnosis if determined