1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. THE COMPLETE DIAGNOSIS CODING SOLUTION THIRD EDITION Chapter 3 General Guidelines and Notations 3-1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes 3.1 Identify the manner in which to report codes with the greatest specificity. 3.2 Apply the guidelines for properly using placeholder characters. 3.3 Identify when a seventh character is required. 3-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes (cont.) 3.4 Use the punctuation presented to clarify code choices. 3.5 Abstract physicians’ notes to pinpoint key terms related to the diagnoses. 3.6 Determine the most accurate diagnosis code. 3-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Acute Chronic Manifestation Nonessential modifier Not elsewhere classifiable (NEC) 3-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Other specified Principal diagnosis Underlying condition Unspecified 3-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction ICD-10-CM codes are THREE to SEVEN characters in length. Diagnoses, signs, and symptoms each need various levels of detail to completely explain them. Learning Outcome: 3.1 3-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Three-Character Codes Categories Sometimes the three-character code is all that is needed to report the whole story about the patient’s condition. –J14 Pneumonia due to Hemophilus influenzae Learning Outcome: 3.1 3-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Four-Character, Five-Character, and Six-Character Codes (Subcategories) In some cases, additional characters are required to report a more specific description. - This is not optional! Learning Outcome: 3.1 3-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Four-Character, Five-Character, and Six-Character Codes (cont.) Example: L02 Cutaneous abscess, furuncle and carbuncle L02.2 Cutaneous abscess, furuncle and carbuncle of trunk L02.21 Cutaneous abscess of trunk L02.214 Cutaneous abscess of groin Learning Outcome: 3.1 3-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Placeholder Character Sometimes a fourth, fifth, sixth, or seventh character is required, yet there are no previous characters. In these cases, ICD-10-CM uses a placeholder character, the letter “X”, so the following characters will fall into their correct locations. - T15.01XA Foreign body in cornea, right eye, initial encounter Learning Outcome: 3.2 3-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Seventh Characters Some ICD-10-CM codes require a seventh character. Different subsections use this position to add different types of information. Learning Outcome: 3.3 3-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Seventh Characters (cont.) Example: In the Diseases of the musculoskeletal system and connective tissue chapter: The appropriate 7th character is to be added to each code: A initial encounter for fracture D subsequent encounter for fracture with routine healing G subsequent encounter for fracture with delayed healing K subsequent encounter for fracture with nonunion P subsequent encounter for fracture with malunion S sequela Learning Outcome: 3.3 3-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations INCLUDES Lists additional terms and diagnoses that are also reported with the above code or included in this code’s description. –F31 Bipolar disorder Includes: Manic-depressive illness Manic-depressive psychosis Manic-depressive reaction Learning Outcome: 3.3 3-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) EXCLUDES1 Identifies codes that cannot be used on the same health claim form with the originally listed code. –F32 Major-depressive disorder, single episode Excludes1: F31.- Bipolar disorder F30.- Manic episode F33.- Recurrent depressive disorder Learning Outcome: 3.3 3-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) EXCLUDES2 Is a warning not to mistakenly use the code above when the code below is more accurate. –F34.1 Persistent mood [affective] disorder Excludes2: F41.8 anxiety depression Learning Outcome: 3.3 3-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) CODE FIRST Instructs you to list the code for the underlying disease before this code on the claim form. –D63.1 Anemia in chronic kidney disease Code first underlying chronic kidney disease (CKD) N18.- Learning Outcome: 3.3 3-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) USE ADDITIONAL CODE Instructs you to include another code on the claim form to specifically identify the manifestation of this diagnosis. - D57 Sickle-cell disorders Use additional code for any associated fever (R50.81) Learning Outcome: 3.3 3-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) CODE ALSO If the documentation notes another condition, this notation instructs you to include an additional code on the claim. –D70.1 Agranulocytosis secondary to cancer chemotherapy Code also underlying neoplasm Learning Outcome: 3.3 3-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) Category Notes Additional information and direction that will help you code correctly and accurately. - Bacterial and viral infectious agents (B95-B97) Note: These categories are provided for use as supplementary or additional codes to identify the infectious agent(s) in diseases classified elsewhere Learning Outcome: 3.3 3-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) AND The guidelines for the accurate use of ICD-10- CM instruct you to interpret the use of the word and in a code description as “and/or.” - D14.31 Benign neoplasm of right bronchus and lung - bronchus and lung - bronchus - lung Learning Outcome: 3.4 3-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) NEC = Not Elsewhere Classified The physician documented additional details - C46.1 Kaposi’s sarcoma of lymphatic(s) NEC Other Specified Means the same thing as NEC Learning Outcome: 3.3 3-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Notations (cont.) NOS = Not Otherwise Specified The physician did not document additional details - A48.52 Wound botulism Non-foodborne botulism NOS Unspecified Means the same thing as NOS Learning Outcome: 3.3 3-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Punctuation Brackets [ ] show alternate terms. Italicized brackets [ ] show additional codes that must be included with the first code. Parentheses ( ) show alternate terms called nonessential modifiers. Learning Outcome: 3.4 3-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Punctuation (cont.) Colon : indicates one of the following descriptors are required to make the code valid. Brace } indicates a list of descriptors all relate to one term. Learning Outcome: 3.4 3-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Combination Codes One code that reports two or more diagnoses or multiple versions of one diagnosis. - J96.2 Acute and chronic respiratory failure Learning Outcome: 3.4 3-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Which Conditions to Code Only those diagnoses, signs, symptoms, conditions, problems, or complaints directly addressed by the provider during this encounter. Learning Outcome: 3.5 3-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Multiple and Additional Codes If the patient has several conditions or concerns, the physician might possibly indicate more than one diagnosis. Only tell the whole story about the encounter between the health care provider and the patient. Learning Outcome: 3.6 3-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Multiple and Additional Codes (cont.) Code Sequencing The code reporting the most important reason for the encounter is called the principal diagnosis or first-listed diagnosis. Learning Outcome: 3.6 3-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Multiple and Additional Codes (cont.) Code Sequencing (cont.) When there are multiple confirmed diagnoses identified – code in order of severity from the most severe to the least severe. Learning Outcome: 3.6 3-29

30. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Multiple and Additional Codes (cont.) For every case, every encounter, every scenario, you are responsible for telling the WHOLE STORY about the encounter. Learning Outcome: 3.6 3-30

31. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary ICD-10-CM is formatted to guide you toward the best, most accurate code. All guidelines and notations must be followed to ensure that codes are complete. 3-31