1. Mary Jo Bowie MS, BS, AAS, RHIA, RHIT

2. Steps in Diagnostic Code Selection
CHAPTER 4
Steps in Diagnostic Code Selection

3. Steps in Code Selection
For proper code selection to occur, coders must:
Understand the coding conventions
Have specific written diagnoses to code
Use both the Index and Tabular List

4. Necessary Documentation
Coders need to review the medical documentation prior to selecting codes. This includes:
For inpatients, the Face Sheet
For outpatients, Encounter Form
Problem List
Testing Results
Operative Reports
Discharge Summary/Final Notes

5. Points to Remember
Review test results, as the results can confirm a diagnosis.
If information contained in the record conflicts, query the attending physician.
Follow coding policies established by the organization in regard to coding before or after the test results have been received.

6. Granularity of ICD-10-CM
When compared to ICD-9-CM, ICD-10-CM has greater granularity.
Diagnoses will have to be recorded with greater detail for proper code selection.
Provider education may be necessary.
Coders should select codes at the highest level of detail.

7. Laterality in ICD-10-CM
For bilateral sites, ICD-10-CM indicates the specific site.
EXAMPLE:
At the 5th character level the codes for a femoral fracture
indicate the following:
Unspecified fracture of unspecified femur—S72.90
Unspecified fracture of right femur—S72.91
Unspecified fracture of left femur—S72.92
An additional 6th character of x is added and an additional
7th character is added to indicate the type of encounter:
initial, subsequent, or sequelae.

8. Steps in Coding Step 1 Locate the Main Term in the Alphabetic Index.
The main term is the condition that is present.
In the statement “acute allergic sinusitis” the
main term is sinusitis.

9. Steps in Coding (cont.) Step 2
Scan the main term entry in the Alphabetical
Index for any Instructional Notations.
Step 3
In the diagnostic phrase being coded,
identify in terms that modify the main term.

10. Steps in Coding (cont.) Step 4
Follow any cross-reference notes found in
the Alphabetical Index.
Step 5
Always verify the code in the Tabular List.

11. Steps in Coding (cont.) Step 6
Follow any Instructional Notes found in the
Tabular List.
Step 7
Select the code.

12. Identifying Main Terms
For the following diagnostic statements,
identify the main terms:
Compound fracture of the left tibia
Acute reticulosis of infancy
Ulcerative esophagitis with bleeding

13. The main terms for the diagnostic statements are in bold.
Compound fracture of the left tibia
Acute reticulosis of infancy
Ulcerative esophagitis with bleeding

14. Key Points to Remember
The Alphabetic Index and the Tabular List must both be used when assigning codes.
All instructional notations must be read.
The instructional notations should be used as a guide when selecting codes.

15. Key Points Continued
ICD-10-CM provides greater granularity than ICD-9-CM.
Medical documentation needs to be detailed.
Providers should be queried if information conflicts.

16. What should you do? You are attempting to code an inpatient
record and the fact sheet and the discharge
summary record different diagnoses.
What action should you take?

17. Alphabetic Index Main terms and Nonessential Modifiers
Reference the main term Cellulitis in the Alphabetical Index.
What are the nonessential modifiers that appear for this entry?

18. The nonessential modifiers that appear for Cellulitis are:
Answer
The nonessential modifiers that appear for Cellulitis are:
Diffuse
Phlegmonous
Septic
Suppurative

19. Alphabetic Index Main terms and Subterms
Reference the main term Cellulitis in the Alphabetical Index.
What are the first three subterms that appear for this entry?

20. Ankle- see Cellulitis, lower limb
Answer
The first three subterms that appear for the main term entry of Cellulitis are:
Abdominal wall
Anaerobic
Ankle- see Cellulitis, lower limb