1. ICD-9-CM Coding
ICD-9-CM Coding
PMI Online Education

2. Introduction READ THOROUGHLY Office Visit Service Procedure
A thorough knowledge of the ICD-9-CM layout is essential
READ THOROUGHLY
Every word and term has weight and meaning
Be familiar with:
Conventions
Eponyms
Non-essential modifiers
5th digit specificity
Office Visit
Index & Tabular List
Notes/Explanations
Notes and explanations can direct you to:
Additional codes
Exclusions
Other special instructions
A thorough knowledge of the layout of the ICD-9-CM is essential to correct coding. Every procedure, office visit, and service must have a corresponding diagnosis code to validate it, so be familiar with conventions, eponyms, non-essential modifiers, and 5th digit specificity.
In order to successfully pass the certification exam, you must read thoroughly because every word and term literally has weight and meaning. The notes and explanations in the index and the tabular list can direct the coder to additional codes, exclusions, and other special instructions. 
Service
Procedure
CODE
CODE
CODE

3. S O A P S.O.A.P. S.O.A.P. Principle Diagnosis Primary Diagnosis
ubjective
Chief complaint
Headache, fatique and nausea
Represent the Primary diagnosis
Signs and symptoms become a risk factor O
bjective
Principle
Diagnosis
(Objective, Assessment)
Primary
Diagnosis
(Subjective)
Physical examination, lab data, etc.
Derives the Principle diagnosis
Use the
S.O.A.P.
note format to determine whether a
Primary or Principle diagnosis is required A
ssessment
As you read through the test questions, you will have to determine whether a Primary or Principle diagnosis is required. For that, recall the SOAP note format:
S stands for Subjective. This contains the patient’s chief complaint. Items such as headache, fatigue, and nausea are described by the patient and represent the Primary diagnosis.
O stands for Objective. Factual data is obtained here by the physician to include Physical Exam, Lab data, and other findings. This information derives the Principle diagnosis that is listed in the assessment.
A stands for Assessment. This represents the Principle diagnosis after all the data is reviewed by the physician. Issues that cannot be described by the patient such as a Subarachnoid Hemorrhage or Uncontrolled Type I Diabetes.
P stands for Plan. This refers to the physician’s recommended treatment for this patient.
A hospital coder would refer exclusively to the Principle Diagnosis, unless the signs and symptoms (pain in particular) become a risk factor. If the objective data has been considered in the outpatient setting, the physician coder would also refer to diagnosis from the assessment when available.
Represents the Principle diagnosis
Issues cannot be described by patient such as a Subarachnoid Hemorrhage
If objective data has been considered in the outpatient setting, the coder would also refer to the assessment P
lan
Physician’s recommended treatment

4. History and Physical report
Abstraction Process
Let’s review a
History and Physical report
Let’s review a History and Physical report. We will focus solely on the diagnosis described.

5. signs and symptoms descriptions
Primary Diagnosis
Headache
784.0
Fatigue
780.79
Blurred vision
368.8
The headache, fatigue, and vision blurring is what Mr. Black describes to the physician. They represent the Primary Diagnosis and are coded thus:
Headache:
Fatigue:
Blurred vision:
Notice they represent signs and symptoms descriptions.
These codes represent
signs and symptoms descriptions

6. Headache and fatigue may not need to be coded
Principle Diagnosis
Postsurgical hypopituitarism
253.7
Complication of Medical care
999.9
IDDM,
not uncontrolled
250.01
Headache and fatigue may not need to be coded
After the factual findings are obtained, the physician indicates the Principle Diagnosis in the assessment portion of the SOAP note. Notice the headache and fatigue did come forward to this part and may not need to be coded. Therefore, the Principle Diagnosis can be coded as:
Postsurgical hypopituitarism:
Complication of Medical care:
IDDM, not uncontrolled:

7. Conclusion TEST QUESTIONS REFERENCING will define what codes to apply
will cut significant time on researching
Ultimately, the test question description will define what codes to apply. It may refer to “Code the diagnosis only,” discounting any references to procedures. A question may state, “What is the primary diagnosis for this patient?” This would be found in the subjective portion of the SOAP note.
This referencing will cut significant time spent on researching any given question and increase your chances for overall success.
“What is the primary diagnosis for this patient?”
“Code the diagnosis only.”
SUBJECTIVE

8. Presented by PMI Online