1. CHAPTER 7 CODING MEDICAL CONDITIONS (DIAGNOSIS CODING) UNDERSTANDING HOSPITAL BILLING AND CODING Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc.

2. 2 CODINIG MEDICAL CONDITIONS DIAGNOSIS CODING  Hospital coding professionals Must master coding principles and applications to accurately describe patient conditions, ensure compliance with coding guidelines, and obtain proper reimbursement  Hospital billing professionals Understanding of coding is critical to ensure compliance with billing guidelines and to obtain accurate reimbursement HOSPITAL CODING AND BILLING PROFESSIONALS

3. 3 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING Evolution of diagnosis coding systems dates back to the 17th century, when systems were originally developed to track the number of deaths in children.

4. 4 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING Evolution of ICD to ICD-9-CM  International List of the Causes of Death Revisions 1-5, 1938-1958  International Classification of Diseases Revisions 6-9, 1958-1978  International Classification of Diseases, 9th Revision, Clinical Modification, 1979 to today

5. 5 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) was “clinically” modified to enhance the classification and collection of morbidity data and for indexing medical records.

6. 6 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING ICD-9-CM DATA CLASSIFICATIONS ICD-9-CM allows the collection of data regarding:  Morbidity (patient illness or disease)  Mortality (factors that contribute to death)  Hospital procedures (significant procedures performed in the hospital, such as surgery)

7. 7 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING ICD-9-CM Coordination and Maintenance Committee (Cooperating Parties)  Maintenance and update of the ICD-9-CM is the result of a collaborative effort of members of the ICD-9-CM Coordination and Maintenance Committee that consists of representatives from four organizations:  National Center for Health Statistics (NCHS)  Centers for Medicare and Medicaid Services (CMS)  American Hospital Association (AHA) and  American Health Information Management Association (AHIMA)

8. 8 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OFDIAGNOSIS CODING International Classification of Diseases, 10 th Revision (ICD-10)  In 1993 the World Health Organization published the newest version of the International Classification of Diseases, Tenth Revision (ICD-10). The ICD-10 is being used in some European countries and implementation, in the U.S., is set for 2013.

9. 9 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. PURPOSE OF DIAGNOSIS CODING  Coding systems are designed to provide a standardized system for describing and classifying data  Coding classification systems provide an efficient method to collect, track, research, and analyze specified data  Coding medical conditions (diagnosis) involves assigning codes to written descriptions of the patient’s signs, symptoms, illness, injury, disease, condition, or other reason for patient care services

10. 10 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING Utilization of Diagnosis Code Data Data collected through the ICD-9-CM coding system are utilized in a number of ways. Various organizations and other entities such as government agencies, research organizations, medical associations, and insurance companies use data collected for:  Research  Education  Administration

11. 11 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING ORGANIZATIONS UTILIZING DIAGNOSIS CODE DATA  Centers for Disease Control and Prevention (CDC)  Centers for Medicare and Medicaid Services (CMS)

12. 12 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. HISTORY AND PURPOSE OF DIAGNOSIS CODING DIAGNOSIS CODING DEFINED  The definition of coding is the process of translating written descriptions of signs, symptoms, illness injury, disease, and other reasons for healthcare services from the patient’s record into numeric or alphanumeric codes

13. 13 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. DIAGNOSIS CODING RELATIONSHIPS  DOCUMENTATION  MEDICAL NECESSITY  CLAIM FORMS  REIMBURSEMENT

14. 14 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. DIAGNOSIS CODING RELATIONSHIPS DOCUMENTATION  Documentation is the term used to describe information regarding the patient’s condition, treatment, and response to treatment  It is the coder’s responsibility assign code(s) for conditions that are recorded in the patient’s medical record

15. 15 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. DIAGNOSIS CODING RELATIONSHIPS DOCUMENTATION GOLDEN RULE IN CODING “IF IT IS NOT DOCUMENTED, DO NOT CODE IT”

16. 16 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. GOOD CODING HABITS Develop good coding habits to ensure accurate and effective coding  DO NOT ASSUME  Identify all possible codes in the Index (Volume II)  NEVER EVER code from the Index (Volume II)  Review each code in the Tabular List (Volume I)  Review all codes in the range  WHEN IN DOUBT, ask  Never use an E code as the first listed condition

17. 17 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. DIAGNOSIS CODING RELATIONSHIPS MEDICAL NECESSITY Medical necessity is the term used to describe services that are reasonable and medically necessary to address the patient’s medical condition.  Diagnosis codes explain the medical necessity for services or items provided.  Medical necessity is generally determined based on standards of medical practice.  Payer guidelines will vary by payer.

18. 18 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. DIAGNOSIS CODING RELATIONSHIPS CLAIM FORMS Two claim forms used to submit charges for services rendered to payers for reimbursement.  CMS-1500 is used for submission of physician and outpatient services. ICD-9-CM codes describing the first listed condition and other conditions are reported in block 21. Note: the first listed condition is the major most significant reason for why the patient is seeking healthcare services.  CMS-1450 (UB-04) is used for submission of facility charges for services provided by a hospital or other facility. ICD-9-CM codes describing the principal, admitting and other diagnoses are reported in FL 67a-q 69, 70 and 72.

19. 19 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. DIAGNOSIS CODING RELATIONSHIPS REIMBURSEMENT Reimbursement is the term used to describe payment from payers for services rendered.  Claim forms are submitted to third-party payers such as insurance companies, Medicare, and other government payers to obtain reimbursement for services provided.  Diagnosis codes are utilized on the claim form to explain why the services were provided.

20. 20 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT ICD-9-CM CONTAINS THREE VOLUMES:  Volume I includes the tabular list of diseases, two supplemental classifications, and appendices.  Volume II consists of an alphabetic Index to diseases, three tables, and an alphabetic index to external causes of injury as outlined  Volume III contains an alphabetic and tabular listing of procedures

21. 21 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME I—THE TABULAR LIST  Tabular List of Diseases  Supplemental classification  Classification of Factors Influencing Heath Status and Contact with Health Services (V01-V84)  Classification of External Causes of Injury and Poisoning (E800-E999)  Appendices  Morphology of Neoplasms  Glossary of Mental Disorders  Classification of Drugs by American Hospital Formulary  Classification of Industrial Accidents According to Agency  List of Three-Digit Categories

22. 22 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME I—THE TABULAR LIST  Tabular List of Diseases The tabular list is a numerical listing of diseases, and it includes signs, symptoms, injury, illness, disease, or other reasons why the patient seeks health care. The tabular list consists of 17 chapters that categorize conditions by body system or type of condition. Examples:  Chapter 1: Infectious and Parasitic Diseases, which are coded utilizing code range of 001-149  Chapter 2: Neoplasms code range 140-239

23. 23 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME I—THE TABULAR LIST SUPPLEMENTAL CLASSIFICATIONS  Classification of Factors Influencing Heath Status and Contact with Health Services (V01-V84) These codes are used to describe reasons patients seeks healthcare services that are other than a condition, sign, symptom, injury, illness, or disease. These codes are used to describe reasons patients seeks healthcare services that are other than a condition, sign, symptom, injury, illness, or disease.  Classification of External Causes of Injury and Poisoning (E800-E999) These codes are used to describe external causes of injury, such as auto accident, explosion, or a fall. These codes are used to describe external causes of injury, such as auto accident, explosion, or a fall.

24. 24 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX  Alphabetic Index to Diseases  Tables  Alphabetic Index to External Causes of Injury

25. 25 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX  Alphabetic Index to Diseases Contains an alphabetical listing of signs, symptoms, conditions, injuries, illnesses, diseases and other reasons that patients seek healthcare services.  Main terms are in bold print and subterms that further define the condition are indented below the main term

26. 26 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX  Tables There are three tables in the index that are utilized to identify possible codes for review in the tabular section. 1. Hypertension Table 2. Neoplasm Table 3. Table of Drugs and Chemicals

27. 27 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX TABLES 1. Hypertension Table Lists codes for malignant, benign, and unspecified hypertension and related conditions 2. Neoplasm Table Lists codes for Neoplasm according to behavior: malignant, benign, or uncertain behavior, or non-specified 3. Table of Drugs and Chemicals Lists codes for poisoning caused by ingestion of a substance or chemical that is toxic and adverse reactions from chemicals and substances

28. 28 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX HYPERTENSION TERMS  Hypertension  Essential hypertension  Benign hypertension  Malignant hypertension  Unspecified hypertension

29. 29 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX NEOPLASM TERMS  Neoplasm  Benign neoplasm  Malignant neoplasm  Primary, Secondary, Carcinoma in situ  Metastasis, Metastasize, Metastatic  Uncertain behavior  Unspecified

30. 30 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX TABLE OF DRUGS AND CHEMICALS POISONING versus ADVERSE EFFECT  Poisoning is a condition caused by the ingestion of a substance or chemical that is toxic or when a medication is taken that is not properly prescribed or administered.  Adverse effect is an unexpected condition that occurs in reaction to a medication that is properly prescribed and administered.

31. 31 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX TABLE OF DRUGS AND CHEMICALS CODING POISONING versus ADVERSE EFFECT  Poisoning 1. Select a code from the poisoning column of the table of drug for each chemical or substance 2. Select code(s) that describe the patient’s condition 3. Select a code from one of the External Cause Columns for each chemical or substance

32. 32 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX TABLE OF DRUGS AND CHEMICALS CODING POISONING versus ADVERSE EFFECT  Adverse Affect 1. Select code(s) that describe the patient’s condition 2. Select a code from the “Therapeutic Use” for each chemical or substance to describe the external cause

33. 33 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONTENT VOLUME III—PROCEDURES  Alphabetic Index to Procedures Contains an alphabetical listing of procedures and services. Main terms are in bold print and subterms that further define procedure or service are indented below.  Tabular List of Procedures Contains a numerical listing of procedures and services.

34. 34 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONVENTIONS Convention is a term used to describe the special terms, punctuation marks, abbreviations, or symbols used as shorthand in a coding system to efficiently communicate special instructions to the coder

35. 35 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM OFFICIAL CONVENTIONS  ICD-9-CM Official Abbreviations and Symbols  ICD-9-CM Official Instructional Notes  ICD-9-CM Official Other Conventions  ICD-9-CM Convention Variations

36. 36 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM OFFICIAL ABBREVIATIONS AND SYMBOLS  NECNot elsewhere classifiable  NOSNot otherwise specified  Brackets[ ]  Slanted brackets[ ]  Parentheses( )  Colon:  Brace }  Section mark §

37. 37 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM OFFICIAL INSTRUCTIONAL NOTES  Includes  Excludes  Use additional code  Code first underlying disease  Code, if applicable, any causal condition first  And  With  See, See also, See category, See condition

38. 38 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM OFFICIAL OTHER CONVENTIONS  Boldface type Used in the alphabetic index to highlight main terms to help the coder find main conditions identified in the patient record  Italicized type Used in the tabular list to indicate conditions that are excluded in a range and to indicate codes that should not be used as a primary diagnosis

39. 39 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM CONVENTION VARIATIONS  Age-specific  American Hospital Association (AHA) coding clinic  Complication  Definitions  Gender-specific  Medicare code edits (MCEs)  Medicare secondary payer (MSP)  New code  Nonspecific diagnosis  Primary/secondary diagnosis  Revised code  Use additional code

40. 40 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. STEPS TO CODING DIAGNOSIS UTILIZING ICD-9-CM VOLUMES I AND II STEPS TO CODING DIAGNOSIS UTILIZING ICD-9-CM VOLUMES I AND II  Step 1: Read the Record. Identify the main term for each condition treated and those that affect treatment.  Step 2: Refer to ICD-9-CM Volume II Alphabetic Index. Look up main term and identify all possible codes.  Step 3: Refer to ICD-9-CM Volume I Tabular List. Review each code and select the code that most adequately describes the condition recorded in the record.

41. 41 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. STEPS TO CODING DIAGNOSIS UTILIZING ICD-9-CM VOLUMES I AND II STEPS TO CODING DIAGNOSIS UTILIZING ICD-9-CM VOLUMES I AND II  Step 4: Sequence ICD-9-CM Codes Sequencing is a term used to describe the process of listing codes in an order that accurately describes the conditions treated and those that affect treatment. The UB-04 requires a combination the following based on the type of service (Outpatient or Inpatient):  Principal Diagnosis  Other Diagnosis  Admitting Diagnosis  Patient Reason Diagnosis  External Cause of Injury

42. 42 Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc. ICD-9-CM OFFICIAL GUIDELINES The ICD-9-CM Official Guidelines for Coding and Reporting provides coders with critical information on how to code and report various clinical circumstances. The guidelines are broken down into the following sections:  Section I - ICD-9-CM Conventions, General Coding Guidelines, and Chapter Specific Guidelines  Section II - Selection of Principal Diagnosis for Inpatient, Short-Term, Acute Care Hospital Records  Section III - Reporting Additional Diagnoses for Inpatient, Short-Term, Acute Care Hospital Records  Section IV - Diagnostic Coding and Report Guidelines for Outpatient Services