18 Diagnostic Coding.

18 Diagnostic Coding

Learning Outcomes (cont.)
18.1 Recall the six ways that ICD codes are used today. 18.2 Describe the conventions used by ICD-9-CM. 18.3 Outline the steps to code a diagnosis using ICD-9-CM. 18.4 Explain the purpose and usage of V codes and E codes.

Learning Outcomes (cont.)
18.5 Name the appendixes found in ICD-9-CM. 18.6 Compare ICD-9-CM and the ICD-10-CM. 18.7 Summarize the ICD-10-CM general coding guidelines. 18.8 Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes.

Introduction Diagnosis – translated into ICD codes
Reimbursement is based on codes entered so you must Understand what the codes mean Know how to chose correct codes Learning Outcome: Recall the six ways that ICD codes are used today. When submitting claims to insurance carriers, the diagnosis must be converted into numeric and alphanumeric codes, known as ICD (International Classification of Diseases) Codes. Insurance carriers pay claims, based on the codes assigned to describe the information within the medical record. It is vitally important to understand what the codes mean and how to choose the correct code based on the information found on the encounter forms and within the patient medical record.

The Reasons for Diagnostic Codes
Chief complaint (CC) Diagnosis (DX) Proves medical necessity of treatment Diagnostic code Coexisting conditions Learning Outcome: Recall the six ways that ICD codes are used today. Based on the patient’s chief complaint (CC), the physician establishes a diagnosis (Dx) that describes the primary condition for which a patient is receiving care. Additional conditions or symptoms that affect the patient’s management are called coexisting conditions. These conditions may be related or totally unrelated to the primary condition, but if they currently affect the patient’s condition or treatment, they must also be noted in the chart, coded, and reported to the insurance carrier. The diagnoses listed on a healthcare claim form should prove medical necessity for the treatment provided. The diagnosis is communicated to the third-party payer through a diagnosis code on the healthcare claim.

The Reasons for Diagnostic Codes
International Classification of Diseases 9th edition ~ ICD-9-CM 10th edition ~ ICD-10-CM Original purpose of ICD-9-CM Classification of morbidity and mortality statistics Medical research, education, and administration Learning Outcome: Recall the six ways that ICD codes are used today. Until October 1, 2013, use the International Classification of Diseases; more commonly referred to as the ICD-9-CM or simply ICD-9. Starting October 1, 2013, the 10th edition of the clinical modification of ICD should used. It is referred to as ICD-10-CM or simply ICD-10. The edition of diagnosis codes used is based on the date of service (DOS), not on the date the claim is submitted. HIPAA mandates ICD code use for reporting patients’ diseases, conditions, or their signs and symptoms if no actual diagnosis has been assigned.

The Reasons for Diagnostic Codes (cont.)
Current uses Facilitation of payment Evaluation of utilization patterns Study healthcare costs Research Prediction of trends Planning for future Learning Outcome: Recall the six ways that ICD codes are used today. Today, however, ICD-9 are used for: Facilitation of payment for medical services Evaluation of utilization patterns (patient use of healthcare facilities) Study of healthcare costs Research regarding quality of healthcare Prediction of healthcare trends Planning for future healthcare needs Codes assigned to the patient for receipt by the insurance carrier become part of their permanent record.

Apply Your Knowledge Correct! How are ICD codes used?
ANSWER: ICD codes are used for: Facilitation of payment for medical services Evaluation of utilization patterns Study of healthcare costs Research regarding quality of healthcare Prediction of healthcare trends Planning for future healthcare needs Learning Outcome: Recall the six ways that ICD codes are used today. Correct!

An Overview of the ICD-9-CM
Diseases and Injuries Tabular List (Volume 1) 17 chapters of disease descriptions and codes V codes E codes Alphabetic Index (Volume 2) Volume 3 ~ edition for hospitals Appendices Learning Outcomes: Describe the conventions used by ICD-9-CM. The ICD-9-CM consists of The Tabular List, known as Volume 1 The Alphabetic Index, known as Volume 2 Volume 3 – the tabular and alphabetic listings of procedures performed primarily in hospitals. The Tabular List for ICD-9 consists of 17 chapters of disease descriptions and codes. It also contains a chapter for services provided for patients who seek care but are not considered ill, known as V codes and, a chapter for causes of illnesses and injuries, known as E codes. The correct usage of the ICD reference is to look up the diagnosis description in the Alpha Index and then verify the code given by cross-referencing in the Tabular Index. Refer to Table 18-1 Tabular List of Chapters for ICD-9-CM.

Conventions NOS – not otherwise specified NEC – not elsewhere classified [ ] – brackets [ ] – slanted bracket Learning Outcomes: Describe the conventions used by ICD-9-CM. In order to use both indices easily, you must understand the conventions.. Conventions – a list of abbreviations, punctuation, symbols, typefaces, and instructional notes located at the beginning of the ICD-9. They provide guidelines for using the code set. NOS Used when a condition cannot be described more specifically. Use only if no other option is available. Ask the physician for more specific information to help select a more specific code Most of the NOS codes end with the number 9. NEC Used when the ICD-9 does not provide a code specific enough for the patient’s condition. Codes end with the number 8. [ ] Brackets – used around synonyms, alternative wordings, or explanations [ ] Slanted brackets appear in the Alphabetic Index Indicate that two codes will be required to completely code the diagnosis. The code in the slanted bracket is the secondary code.

Conventions (cont.) ( ) Parentheses : Colon } Brace
Includes Excludes Use additional code Learning Outcomes: Describe the conventions used by ICD-9-CM. ( ) Parentheses – used around descriptions in the Alphabetic Index that do not affect the code (nonessential or supplementary terms.) : Colon – used in the Tabular List after an incomplete term that needs one of the terms that follows the colon to make it assignable to a given category. } Brace – encloses a series of terms, each of which is modified by the statement that appears to the right of the brace. Includes – indicates that the entries following it further define the content of a preceding entry. Excludes These notes, which are boxed and italicized, indicate that an entry is not classified as part of the preceding code. The note may also give the correct location of the excluded condition to assist you in locating the correct code. Use additional code This note indicates that an additional code should be used, if available. The additional code is always listed after the primary code.

Conventions (cont.) Code first underlying disease
Code, if applicable, any causal condition first. Be aware of Boldface type Italicized typeface Learning Outcomes: Describe the conventions used by ICD-9-CM. Code first underlying disease – this instruction appears when the category is not to be used as the primary diagnosis. Code, if applicable, any causal condition first – this note means that the code may be used as a primary diagnosis if the underlying or “causal condition” is unknown or not applicable. Boldface – used for all codes and titles listed in the Tabular List. Italicization – used for all exclusion notes and to identify codes that are only used as secondary diagnoses.

Conventions (cont.) Alphabetic Index Read Coding Guidelines Omit Code
See Condition See Also Read Coding Guidelines Learning Outcomes: Describe the conventions used by ICD-9-CM. The Alphabetic Index includes two notations to be aware of. Omit Code – used to let you know that the medical term should not be coded as a diagnosis. See Condition When found in the Alphabetic Index, it refers you to a different “main term” for the condition. This is a directive; you must do so to locate the correct code See Also – a suggestion; you might find a better code for the diagnosis Follow all directions in the ICD-9 and read the Coding Guidelines in the beginning of the manual. These guidelines give very specific instructions on how to code each of the 17 chapters of the ICD-9 manual and the best use of E codes and V codes.

The Alphabetic Index Contains terms needed to locate codes
Organized by condition Main terms Subterms Nonessential terms Cross-references Learning Outcomes: Describe the conventions used by ICD-9-CM. The assignment of the correct code begins with looking up the medical term that describes the patient’s condition in the Alphabetic Index. It contains all the medical terms necessary to locate codes in the Tabular List and is organized by condition. Each main term is printed in boldface type and is followed by its code number. Subterms – any other terms needed to select correct codes. They are printed and indented after the main term. Subterms may show the cause or source of the disease, or describe a particular type or body site for the main term. Nonessential terms (in parentheses) – assist you in choosing the correct code, but do not need to be included within the code description. Cross-references of see or see also If the cross-reference see appears after a main term, you must look up the term that follows the word see in the index. The reference see also is a suggestion that you may find more information looking under a different term.

The Tabular List Organized by source or body system
Code structure - categories Rubrics ~ three digit Subcategories ~ four digit Subclassifications ~ five digit Code to highest level of specificity Learning Outcomes: Describe the conventions used by ICD-9-CM. The diseases, conditions, and injuries in the Tabular List are organized into chapters according to the source or body system. The Tabular List contains very specific information in numeric sequence, to back up, or expand on, the information found in the Alphabetic Index. Code Structure ICD-9-CM diagnosis codes are made up of three, four, or five digits Rubrics – three-digit categories, for diseases, injuries, and symptoms. Subcategories – divisions of categories; four-digit codes Subclassifications – further subdivisions of codes; five-digit codes You must code to the highest level of specificity. The minimum code contains 3 digits, but if a fourth digit is available, it must be used, and if a fifth digit is available, it also must be used. When placing diagnosis codes on the CMS-1500 form, the decimal points are omitted.

The Tabular List (cont.)
V codes Encounters not related to illness or injury Primary or supplemental codes May not be covered by insurance carrier Learning Outcomes: Describe the conventions used by ICD-9-CM. V codes Identify encounters for reasons other than illness or injury. Descriptions are found throughout the main portion of the alphabetic index. May be primary codes for an encounter or used as additional codes. Some insurance carriers, like Medicare, do not cover V codes, so the charges associated with them may become the patient’s responsibility.

The Tabular List (cont.)
E codes External causes of injuries and poisoning “How did that happen?” Only a supplemental code Learning Outcomes: Describe the conventions used by ICD-9-CM. E codes Identify the external causes of injuries and poisoning. Used in collecting public health information Never used alone; supplements the code that identifies the injury or condition itself. Found in the Alphabetic Index in two sections: Section 2 is the Alphabetic Table of Drugs and Chemicals Section 3, is the Alphabetic Index for all E codes V and E codes are alphanumeric The same rule for specificity applies to E and V codes regarding fourth and fifth digits; if a fourth or fifth digit is available, it must be utilized.

Yippee! Apply Your Knowledge Matching ANSWER:
___ contains synonyms or alternative wordings A. NOS ___ surround nonessential or supplementary terms B. NEC ___ used after an incomplete term C. [ ] ___ ICD-9 does not contain a code specific enough D. [ ] ___ used if condition cannot be better descriped E. ( ) ___ a directive; refers you to a different term F. : ___ indicates that 2 codes are needed G. See Also ___ a suggestion; you might find a better code H. See Condition C E F B A Learning Outcomes: Describe the conventions used by ICD-9-CM. . H D G

Coding with ICD-9 Steps to Locating an ICD-9-CM Code     
Record the code  Steps to Locating an ICD-9-CM Code Read to find the best code  Locate the code from the Alphabetic Index in the Tabular List  Find the diagnosis in the Alphabetic Index  Learning Outcome: Outline the steps to code a diagnosis using ICD-9-CM. Every diagnosis and procedure checked off on the encounter form must be verified in the medical record. EHR programs do not understand medical necessity. Locate the diagnosis Locate the code given for that description in the Alphabetic Index Verify the code in the Tabular Index and be sure to read all instructions which will help you find the right code or affirm that you have the correct code. Do not forget to look for instructions such as code also and code first underlying condition, as well as includes and excludes notes that assist you in deciding on the correct code or codes. Locate the patient’s diagnosis 

Coding with ICD-9 (cont.)
Acute vs. chronic conditions – list acute code first Combination codes – used in place of single codes Multiple coding – more than one code required to describe diagnosis Learning Outcome: Outline the steps to code a diagnosis using ICD-9-CM. Some further guidelines that will make your coding more specific and efficient. Acute versus Chronic Conditions An acute condition is defined as one that is of sudden onset or a more long-standing condition that has suddenly worsened. The acute code is always listed first, followed by the code for the chronic form of the condition. Combination Codes Two diagnoses are included in one code. This may be a diagnosis with an associated secondary process or a diagnosis with an associated complication. When a combination code is available, it must be used in place of the two single codes. Multiple Coding One code may not fully describe the diagnosis such as when a disease or condition is the result of another condition. No matter how you look up the code in the Alphabetic Index or check it in the Tabular List, you are directed which code to use first.

Coding with ICD-9 (cont.)
Coding unclear diagnoses Principal vs. primary diagnosis Principal diagnosis Primary diagnosis Secondary diagnosis Learning Outcome: Outline the steps to code a diagnosis using ICD-9-CM. Coding Unclear Diagnoses Outpatient coding rules require that an unclear diagnosis be coded using the symptoms that led the patient to seek care until an absolute diagnosis is made. A similar situation occurs with “impending” or “threatened” conditions. Check to see if a code exists for the threatened condition. If it does not exist, code the underlying conditions or symptoms as if the condition did not exist. Principal versus Primary Diagnosis Principal diagnosis – “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Primary diagnosis – the main reason for the patient’s visit and used for Outpatient coding. The secondary diagnoses – other conditions that are also affecting the patient at the time of the visit and are coded after the primary diagnosis. Refer to Procedure 18-1 Locating an ICD-9-CM Code

Apply Your Knowledge Good Answer!
What are the steps to code a diagnosis? ANSWER: Locate the diagnosis in the medical record Find the diagnosis in the Alphabetic Index Locate the correct code in Alphabetic Index and then in the Tabular Index Read all instructions to find the best code Record the code Learning Outcome: Outline the steps to code a diagnosis using ICD-9-CM. Good Answer!

V Codes and E Codes V codes – Supplementary Classification of Factors Influencing Health Status and Contact with Health Services E codes – Supplementary Classification of External Causes of Injury and Poisoning Learning Outcome: Explain the purpose and usage of V codes and E codes. V codes – describe patients who are not currently ill. E codes – “extra” codes that tell the insurance company how an illness or injury came about.

V Codes Outpatient use Examples: V04.81 Influenza vaccination
V58.11 (Encounter for) Chemotherapy treatment V14.0 History (personal) of allergy to penicillin Learning Outcome: Explain the purpose and usage of V codes and E codes. Because the patient is basically “healthy”, V codes are generally used in the outpatient setting. They are coded using the same Alphabetic Index as the other ICD-9 codes. Their Tabular List for verification is located directly after the injury and poisoning codes ( ). Refer to Procedure 18-2 Locating a V Code Examples: V04.81 Influenza vaccination Remember this is a diagnosis, not a procedure code V58.11 (Encounter for) Chemotherapy treatment The reason for the visit is the chemotherapy administration. This code is followed by the appropriate code for the neoplasm being treated.

E Codes General use Poisonings and Adverse Effects
Initial treatment only, except fractures Use as many codes as required Poisonings and Adverse Effects Refer to poisoning column then to how it occurred Must be documented in the medical record to code Learning Outcome: Explain the purpose and usage of V codes and E codes. The Table of Drugs and Chemicals and the Alphabetic Index for E codes are found at the end of the main Alphabetic Index for ICD-9 codes. General Use of E Codes CMS (Medicare), which does not require E codes on their claim forms. Only use for the initial treatment for the acute illness or injury, and not for subsequent visits with the exception of acute fractures. Use as many E codes as necessary to completely explain how the incident occurred.

E Codes are never the primary code
E Codes (cont.) Poisoning Accidental Therapeutic Suicide attempt Assault Burns Degree of burn Extent (% of body burned) How it occurred (E code) Learning Outcome: Explain the purpose and usage of V codes and E codes. Poisonings and Adverse Effects Accidental poisoning – used for accidental overdose, wrong substance given or taken, drug taken by mistake, accidental drug usage, and accidents in drug usage in a medical facility. Therapeutic use – used when the correct substance is properly administered in the correct dosage but caused a poisoning or other adverse effect. Suicide attempt – used when there is documentation of self-inflicted injury or poisoning. Assault – documentation indicates that the injury or poisoning was inflicted by another person with the intent to injure or kill the patient. Burns First use the key term Burn and then find the indented subterm for the burn location and, finally, the subclassification for the extent of the burn (1st, 2nd, or 3rd degree). Multiple burn degrees are coded to the highest extent of the burn. Locate the E code description from the Alphabetic Index for External Cause Codes and verify it in the Tabular List. Refer to Procedure 18-3 Locating an E Code E Codes are never the primary code

Excellent! Apply Your Knowledge
Determine whether a V code or E code should be used: ANSWER: patient required stitches to close a wound from a knife patient was exposed to a chemical that caused a rash patient was seen for a shingles vaccination patient had an annual physical patient presented with a fractured wrist child came to office for a sports exam patient is requesting birth control pills E code E code V code V code Learning Outcome: Explain the purpose and usage of V codes and E codes. E code V code Excellent! V code

Appendices of ICD-9 Morphology of Neoplasms Deleted
Classification of Drugs Classification of Industrial Accidents List of the Three Digit Categories Learning Outcomes: Name the appendices found in ICD-9-CM. The Appendices contain helpful research and technical information. Appendix A is the Morphology of Neoplasms. (M codes) Defines the development or changing nature of diagnosed neoplasms. These codes are not reported on insurance claim forms. They are used for tracking. Certified tumor registrars are responsible for assigning the M codes based on the diagnosis code assigned. They are noted in the Alphabetic Index in parentheses. Appendix B formerly contained the glossary of Mental Disorders. It was officially deleted on 10/1/04. Appendix C is the Classification of Drugs by American Hospital Formulary Service Number and the ICD-9 Equivalent. Appendix D Classification of Industrial Accidents According to Agency. Used by state and federal agencies to summarize industrial accidents. Appendix E consists of a listing of the Three Digit Categories used by ICD-9-CM, labeled for the chapter each represents.

Apply Your Knowledge Impressive! B C E A D
List the appropriate Appendix: deleted in 2004 Classification of Drugs Three Digit Categories Morphology of Neoplasms Classification of Industrial Accidents ANSWER: B C E A Learning Outcomes: Name the appendices found in ICD-9-CM. D Impressive!

Basic Comparison of ICD-9-CM and ICD-10-CM
Internal List of Causes of Death – 1893 ICD-9 ~ 1975 14,200 codes No expansion Volume 3 for hospital codes ICD-10-CM Over 68,000 diagnostic codes Greater specificity Provides for expansion ICD-10-PCS – hospital codes Learning Outcome: Compare ICD-9-CM and the ICD-10-CM. The ICD was originally introduced in 1893, as the first International List of Causes of Death, requiring physicians to better track a patient’s diagnosis and medical care. The greater specificity of the ICD-10-CM is particularly important relating to code linkage between ICD diagnosis codes and the CPT procedure codes to prove the medical necessity of a patient’s procedure or treatment The medical offices must not only learn the new system but also accommodate both systems during an overlap period. ICD-9 includes Volume 3, containing procedures performed primarily in the hospital- based setting. ICD-10 will have a totally separate volume for hospital procedure codes called ICD-10- PCS.

ICD-10 Information Alpha Index Tabular (numeric) List 21 chapters
Category ~ 3 characters Subcategory ~ 4-5 characters Final code ~ up to 7 characters Learning Outcome: Compare ICD-9-CM and the ICD-10-CM. Alphabetic and Numeric Indexes The Alphabetic (Alpha) Index of the diseases, conditions, and related terms directs the coder to the lists of appropriate codes in the Tabular (numeric) List. Refer to Table 18-3 Chapter, Description, and Code Ranges for ICD-10-CM. A category has 3 characters and a subcategory has 4–5 characters, with the final code consisting of up to 7 characters.

Characters and Specificity
Codes begin with an Alpha character Possible characters ~ 3-7 More precise clinical picture Enhances trending analysis ICD-9 (limited specificity) ICD-10 (expanded specificity) Code: Carcinoma in situ breast (vague as to cancer type) Code: D05.01 Lobular carcinoma in situ of right breast OR Code: D05.11 Intraductal carcinoma in site of right breast Learning Outcome: Compare ICD-9-CM and the ICD-10-CM. The most striking difference is the way the ICD-10 code looks in comparison to an ICD-9 code. This change is directly related to the need to expand the specificity of many of the diagnosis codes and so a new format was required. All ICD-10 codes begin with an alpha character. The number of possible characters has increased from 3-5 in the ICD-9 to 3-7 in the ICD-10 edition. This provides a more precise clinical picture of the patient and enhances trending analysis. Refer to Table 18-4 Example of Greater Specificity available with ICD-10 vs. ICD-9.

Placeholders “x” – placeholder for future expansion of code’s specificity Do not drop placeholder when adding characters ICD-9-CM ICD-10-CM 910.0 Face, neck, and scalp; abrasion or friction burn without mention of infection S00.01 Abrasion of scalp (code noted to √x7th) 910.1 Face, neck, and scalp; abrasion or friction burn, infected S00.01xA Abrasion of scalp, initial encounter S00.01xD Abrasion of scalp, subsequent encounter S00.01xS Abrasion of scalp, sequela Learning Outcome: Compare ICD-9-CM and the ICD-10-CM. The ICD-9 did not incorporate a placeholder in anticipation of new codes. The ICD-10 uses an “x” to hold a place for future expansion of the code’s specificity. Refer to Table 18-5 Example of ICD-10 placeholder, which is not available in ICD-9. Note the instruction of √x7th – the base code (only contains 5 characters). it is clear that ICD-10 Chapter 19 “S” (injury) codes require a 7th digit encounter determination: “A” designates an initial encounter “D” designates a subsequent encounter “S” designates sequel If the “x” placeholder and 7th digit are not listed, the code will not be accepted. You must be careful when adding characters that you do not drop the “x” placeholder.

Combination Codes More combination codes available
Decreased need for multiple codes ICD-9-CM ICD-10-CM Severe sepsis and Septic shock R65.21 Severe sepsis with septic shock Learning Outcome: Compare ICD-9-CM and the ICD-10-CM. The ICD-9-CM accommodates only a relatively small number of combination codes. It often requires the use of multiple codes to completely code a condition, illness, or injury. The ICD-10-CM contains many more combination codes, greatly cutting down on the need for multiple codes for a single diagnosis. Multiple codes are used with ICD-10 coding when appropriate. Refer to Table 18-6 Example of an ICD-10 Combination Code.

Apply Your Knowledge Good Answer!
List at least two ways that the ICD-10 is an improvement over the ICD-9. ANSWER: The ICD-10 contains many more codes, allows for expansion; has more combination codes, and incorporates placeholders all of which enables more precise coding. Learning Outcome: Compare ICD-9-CM and the ICD-10-CM. Good Answer!

Basic Coding Guidelines for ICD-10
Locate term in Alphabetic Index Refer to notes Read and follow terms in ( ) and [ ] Go to Tabular list Follow instructional terms to appropriate code Learning Outcome: Summarize the ICD-10-CM general coding guidelines. . The basic rules for coding with ICD-10 remain similar to that of ICD-9. Locate the term in the Alphabetic Index. Refer to the notes under the appropriate heading. Read and follow the terms in the parentheses and brackets. Proceed to the Tabular List number(s) as directed by the Alphabetic Index. Follow instructional terms to direct you to the appropriate code. Use caution with chapter categories that have an alphabetical character that may be mistaken for a numerical character, like the letter “O” for Chapter 15, Pregnancy, Childbirth, and the Puerperium (may be mistaken for the number “0”). Assign the appropriate code using the highest degree of specificity. Assign an additional appropriate code for other signs and symptoms that may not be routinely associated with the condition or disease process Assign the appropriate code with highest degree of specificity Assign additional code for s/s not associated with disease

Basic Coding Guidelines for ICD-10 (cont.)
Conventions are similar to ICD-9 ICD-10 More detailed documentation by physician Never code from the Alpha Index Verify codes in Tabular list Learning Outcome: Summarize the ICD-10-CM general coding guidelines. Many of the same conventions are used in ICD-10 to assist the coder in finding and choosing the correct code. Table 18-7 Common Conventions found in ICD-10-CM. The ICD-10 requires more detailed physician documentation to attain the level of description required by the new system. All codes must be verified in the Tabular List to be sure descriptions are correct and all notes are followed.

Apply Your Knowledge Good Job!
What are the general coding guidelines for the ICD-10? ANSWER: Locate the diagnosis in the Alphabetic Index Read and follow all notes and conventions. Locate in Tabular list. Follow instructions to the appropriate code. Assign the code with highest degree of specificity. Learning Outcome: Summarize the ICD-10-CM general coding guidelines. Good Job!

Synopsis of ICD-10 Coding Guidelines by Chapter
Chapter 1 – HIV coding R75 ~ inconclusive laboratory evidence B20 ~ positive serology Z21 ~ HIV positive, asymptomatic Z71.7 ~ counseling provided Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 1: Certain Infectious and Parasitic Diseases (A00–B99) To code HIV positivity the physician must state “known HIV” or “positive HIV” R75 – no definitive diagnosis or manifestation of HIV is present and inconclusive serology. B20 – a positive serology or culture and has developed an HIV-related illness Z21 – HIV positive but asymptomatic Z71.1 – additional code used if counseling is provided during the same encounter When a patient presents with any signs or symptoms while being seen for HIV testing, code only the signs and symptoms.

Synopsis of ICD-10 Coding Guidelines by Chapter
Chapter 2 – Neoplasms Type of neoplasm Location Additional codes Primary vs. secondary neoplasms Treatments Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 2: Neoplasms (C00–D48) Documentation must state whether it is benign, malignant, in-situ, or of uncertain behavior. Once the site is identified, any additional instructions for coding must be observed. The correct coding and sequencing of neoplasms is critical. If treatment is directed at the primary neoplasm, that code is the primary diagnosis. If treatment is for the secondary site, then the secondary neoplasm is the primary diagnosis. If chemotherapy, radiation therapy, or immunotherapy is the primary reason for medical care, it is coded first, followed by the code for the malignancy being treated.

Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)
Chapter 4 – Diabetes mellitus Type Body system affected Complications Use of insulin Chapter 5 – Pain Psychological F45.41 Appropriate code from G89 category Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00–E90) Codes for diabetes mellitus are combination codes that include the type of diabetes: The body system affected by diabetes and the condition affecting the anatomical structure are included. When the type of diabetes is not documented in the medical record, assign a code for type 2 diabetes mellitus. Any underlying condition must be sequenced first so if diabetes causes a complication, code the diabetes first and the complication second. If the patient uses of insulin, use code Z79.4 after the diabetes diagnosis is coded completely. Chapter 5: Mental and Behavioral Disorders (F01–F99) Pain that is associated with and is exclusively psychological should be assigned code F45.41: pain disorder with related psychological factors. It is then followed by the appropriate code from the category G89.

Eye and ear not included G89 ~ pain diagnoses If present, list underlying cause first then the pain code Chapter 9 – Hypertension I10 ~ essential hypertension Code underlying etiology then code hypertension R030.3 ~ transient hypertension Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 6: Diseases of the Nervous System (G00-G99) The nervous system chapter in ICD-10 no longer includes the eye and ear. Specific instructions for coding the eye and adnexa (Chapter 7) and ear and mastoid process (Chapter 8) are not yet available. Code G89 is used for pain diagnoses and is used as a first listed diagnosis when the reason for the encounter is the treatment of the pain. If there is a definitive diagnosis and pain is also noted, then the definitive diagnosis should be listed first, followed by the most specific pain code possible. Chapter 9: Diseases of the Circulatory System (I00-I99) The rules for coding hypertension have not changed. I10 – primary hypertension, also known as essential hypertension If hypertension is caused by an underlying condition (secondary hypertension), code the underlying etiology (cause) first and then code the hypertension. R03.0 – transient hypertension

Avian or H1N1 influenza Other types of influenza Chapter 13 – Fractures Laterality Unilateral – 4th digit “1” Designated by 5th digit Required 7th character Initial Subsequent Sequela Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 10: Diseases of the Respiratory System (J00-J99) A positive laboratory documentation is not required to code either avian or H1N1 influenza as a diagnosis. Only the physician’s documentation of “suspected or probable” avian influenza or H1N1 influenza is required. Note the difference in the Tabular List between Avian influenza codes and descriptions and those for Influenza due to other influenza viruses. Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue (M00–99) Categories for fractures are coded quite differently in the ICD-10 Laterality for fractures is new 0 = unspecified 1 = right 2 = left Fracture codes require a 7th character designating the type of encounter for which the patient is being seen. Initial means an active fracture that is still healing Subsequent defines follow-up after the active fracture care Sequela refers to care after the injury has healed

Four stages of chronic kidney disease ESRD Chapter 15 7th digit Read instructions carefully Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 14: Diseases of the Genitourinary System (N00-N99) ICD-10 provides for four stages of chronic kidney disease (CKD) Code N18.1 is the beginning stage N18.2 mild CKD N18.3 moderate CKD N18.4 severe CDK End-stage renal disease (ESRD), code N18.6; this code is used alone Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00–O99) The ICD-10 often requires a 7th digit Read these descriptions carefully

Congenital or chromosomal Primary or secondary diagnosis Chapter 18 (NEC) R codes No definitive diagnosis Multiple combination codes Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 17: Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00–Q99) The diagnosis or condition is congenital or chromosomal in nature. May be either primary or secondary diagnoses, dependent on the instructions given within the coding instructions Chapter 18: Signs, Symptoms, and Abnormal Clinical and Laboratory Findings (NEC) (R00–R99) No definitive diagnosis available There are multiple combination codes – follow guidelines for their use.

Poisoning 5th digit – placeholder “x” 6th digit – how occurred 7th digit – type of encounter Burns and Corrosions Depth, extent, agent Corrosive material sequenced first Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 19: Injury, Poisoning, and Certain Other Consequences of External Causes, (S00–T98) Poisoning – requires very specific codes 5th digit – “x” placeholder 7th digit of A (initial), D (subsequent), or S (sequelae) is used to describe the type of encounter. Burns and Corrosions Burns are classified by three factors Depth of the burn (first-degree, second-degree, or third-degree) Extent (total body area based on the rule of nines) Agent Burns that are caused by a corrosive material are coded the same as any burn with the additional code for the corrosive material being sequenced first.

Replaces E codes Accidents or injuries Research and prevention Abuse codes take priority Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 20: External Causes of Morbidity and Mortality (V00–Y99) Secondary codes, previously referred to as E codes in ICD-9. Identify who, what, when, and where an accident or injury occurred. Used in determining research and prevention strategies for injuries. May be used as secondary codes to describe health conditions. List the code indicating the cause or intent, or medical misadventure first. Codes for child and adult abuse take priority over all other external cause codes. Read the guidelines carefully.

Z codes replace V codes Expanded to include Chemo, radiation, and immunotherapy After care Administrative exams Family history Personal history Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Chapter 21: Factors Influencing Health Status and Contact with Health Services (Z00–Z99) The unique ICD-9 V codes were replaced by Chapter 21 This category is greatly expanded to include, but is not limited to, the following reasons for healthcare encounters: Chemo, radiation, and immunotherapy After care Administrative exams (such as a sports physical) Family history if the patient may be at risk for like illness Personal history if the patient’s habits or past illnesses or condition place him at risk

Practice Read guidelines carefully Ask questions Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Diagnosis coding can be intimidating and takes practice. Read all guidelines carefully. Ask questions, particularly if you do not understand terminology, so that you are capable of choosing the most appropriate code. Refer to Procedure 18-4 Locating an ICD-10-CM Code Refer to CONNECT to see a video about Locating an ICD-10-CM Code

Apply Your Knowledge Right!
When a code requires a 7th code, what does it indicate? ANSWER: The 7th character of a code indicates the type of encounter: initial, subsequent, or sequela. Learning Outcome: Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes. Right!

In Summary 18.1 ICD codes are used to facilitate payment for medical services; evaluate utilization patterns; study healthcare costs; research quality of healthcare; predict healthcare trends; and plan for future healthcare needs There are conventions used in the ICD. Bold and italics are used in both the Alphabetic Index and Tabular List. Instructions to omit code, see condition, and see also are found exclusively in the Alphabetic Index. 18.1 ICD codes are used to facilitate payment for medical services; evaluate utilization patterns (patient use of healthcare facilities); study healthcare costs; research quality of healthcare; predict healthcare trends; and plan for future healthcare needs. 18.2 The conventions used in ICD include: NOS; NEC; brackets; slanted brackets; parentheses; colon; brace; includes and excludes notes; instructions to use additional code, code first underlying disease, and code, if applicable, any causal condition first. Additionally, bold and italics are used in both the Alphabetic Index and Tabular List. Instructions to omit code, see condition, and see also are found exclusively in the Alphabetic Index.

In Summary (cont.) 18.3 To choose an ICD code, locate all applicable diagnoses. Find the key term in the Alphabetic Index and any applicable subterms. Verify the code’s description in the Tabular List, reading all applicable notations for other coding options and instructions. Document each code carefully using instructions as to code sequencing on the CMS-1500 claim form. 18.3 To choose an ICD code, check the encounter form (superbill) and/or patient medical record for all applicable diagnoses. Find the key term in the Alphabetic Index and then search for any applicable subterms. Once the code has been located, verify its description in the Tabular List, again reading all applicable notations for other coding options and instructions. Document each code carefully using instructions as to code sequencing on the CMS-1500 claim form.

In Summary (cont.) 18.4 V codes are used for patients who, though not ill, are seeking healthcare. E codes are used to explain how an illness or injury came about. 18.5 The following appendices are found in ICD-9-CM: Appendix A Appendix B Appendix C Appendix D Appendix E 18.4 V codes are defined as Supplementary Classification of Factors Influencing Health Status and Contact with Health Services. They are used for patients who, though not ill, are seeking healthcare. They are used for exams (V70.0), counseling (V61.10), donors (V59.01), and so on. E codes are defined as Supplementary Classification of External Causes of Injury and Poisoning. They are used to explain how an illness or injury came about. Examples of E codes include cyclist accident (E826.1), accidental poisoning by antibiotics (E856), and exposure to laser radiation (E926.4). 18.5 The following appendices are found in ICD-9-CM: Appendix A is the Morphology of Neoplasms; Appendix B formerly contained the glossary of Mental Disorders. It was officially deleted on 10/1/04; Appendix C is the Classification of Drugs by American Hospital Formulary Service Number and the ICD-9 Equivalent; Appendix D is the Classification of Industrial Accidents According to Agency; Appendix E consists of a listing of the Three Digit Categories used by ICD-9-CM.

In Summary (cont.) 18.6 ICD-10-CM is intended to provide a more precise clinical picture of the patient and enhanced trending analysis for data reporting. The number of codes increases in the ICD-10 and the characters change from 3–5 numerical to 3–7 alphanumeric. Both contain the Alphabetic Index of the diseases, conditions, and related terms. The I-10 Tabular List incorporates 21 chapters Many codes use an “x” as a placeholder for future expansion; which was not possible with ICD-9. 18.6 ICD-10-CM is intended to provide a more precise clinical picture of the patient and enhanced trending analysis for data reporting. The number of codes increases from under 15,000 in the ICD-9 to 68,000 in the ICD-10 and the characters change from 3–5 numerical (with the exception of the E and V codes) to 3–7 alphanumeric. Both the 9th and 10th revisions contain the Alphabetic Index of the diseases, conditions, and related terms. The I-10 Tabular List incorporates 21 chapters (vs. ICD-9 with 17 chapters) with a corresponding range of codes. Many codes use an “x” as a placeholder for future expansion; which was not possible with ICD-9.

In Summary (cont.) 18.7 The technique of coding with ICD-10 is very similar to that of coding with ICD-9-CM. Locate the diagnosis or symptom in the Alphabetic Index and consider all notes. You then move to the Tabular List as instructed in the Alpha Index. After following terms, abbreviations and symbols, the appropriate code with the highest specificity supported by medical record documentation is selected. 18.7 The technique of coding with ICD-10 is very similar to that of coding with ICD-9-CM. The diagnosis or symptom is located first in the Alphabetic Index and all notes considered. You then move to the Tabular List as instructed in the Alpha Index. After following terms, abbreviations and symbols, the appropriate code with the highest specificity supported by medical record documentation is selected.

In Summary (cont.) 18.8 The majority of ICD-10 CM codes follow the general guidelines. However, unique coding applications do exist and chapter guidelines must be followed. These include but are not limited to the chapters on neoplasms, diabetes mellitus, fractures, R codes, poisonings, and the new Z codes. Refer to CONNECT to see EHR activities on Activating an ICD-9 Code and Using an ICD-9 Code

Fraud and falsehood only dread examination. Truth invites it.
End of Chapter 18 Fraud and falsehood only dread examination. Truth invites it. ~ Samuel Johnson

18 Diagnostic Coding.

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