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 1 Introduction to Diagnosis Coding 1-1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes 1.1 Explain the purpose of health care coding. 1.2 Apply correctly the appropriate steps to coding. 1.3 Apply the official guidelines provided to find the best, most accurate code. 1-2

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.) 1.4 Detect the ethical danger zones that might exist in the workplace. 1.5 Know the AHIMA Code of Ethics and AHIMA’s Standards of Ethical Coding. 1.6 Know the AAPC Code of Ethics. 1-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Adverse effect Anatomical cavity Anatomical direction Anatomical position Anatomical site Body area 1-4

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.) Coding for coverage Diagnosis Double billing Etiology ICD-9-CM ICD-10-CM 1-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Medical Necessity Organ system Pathology Pathophysiology Pharmaceuticals Risk Factor 1-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Sign Supporting documentation Symptom Unbundling Upcoding 1-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction The purpose of coding is to make every effort to ensure clear and concise communication between all parties involved with the health and well-being of the population. Learning Outcome: 1.1 1-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction (cont.) Diagnosis is a physician’s determination of a patient’s condition, illness, or injury. WHY the patient came to see the health care provider is translated into diagnosis codes. Learning Outcome: 1.1 1-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction (cont.) A SIGN is objective evidence of a disease or condition. –Example: Fever A SYMPTOM is subjective, as related by the patient. –Example: Feeling tired Learning Outcome: 1.1 1-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction (cont.) Signs and symptoms are only coded when there is no definite diagnosis. Learning Outcome: 1.3 1-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Medical Necessity Diagnosis codes explain WHY the insurance carrier should pay for the provision of procedures, treatments, and services. Medical necessity identifies that the physician was acting within the bounds of good medicine. Learning Outcome: 1.1 1-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Medical Necessity (cont.) Procedure codes explain WHAT the health care professional did for the patient during this encounter. Procedure codes are reported from CPT and ICD-10-PCS. Learning Outcome: 1.2 1-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Steps to Accurate Coding Read the notes and superbill completely. Highlight key words regarding the diagnoses (WHY) and the procedures (WHAT) occurred during this encounter. Learning Outcome: 1.2 1-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Steps to Accurate Coding (cont.) Query the physician if there is any unclear, conflicting, or missing information. Code each diagnosis and/or appropriate signs or symptoms. Learning Outcome: 1.2 1-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Steps to Accurate Coding (cont.) Assign codes to the greatest specificity. Code only those documented conditions that require or influence treatment at this encounter. Learning Outcome: 1.3 1-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Steps to Accurate Coding (cont.) Use as many codes as are necessary to tell the whole story of this encounter. Code each procedure, service, and/or treatment provided to the patient during this encounter. Learning Outcome: 1.2 1-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Steps to Accurate Coding (cont.) Link each and every procedure code to at least one diagnosis code. Double-check your codes! Learning Outcome: 1.2 1-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Superbills vs. Notes Coding from superbills is faster but often is NOT more ACCURATE. The Official Guidelines state that the entire record should be reviewed. Learning Outcome: 1.3 1-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Official Guidelines Official Guidelines can be found in your ICD-10-CM book for quick reference and reminders. Guidelines instruct you how to code accurately. Learning Outcome: 1.3 1-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Ethical & Legal Coding Don’t report a code without the supporting documentation. Coding for coverage is illegal. It is fraud to upcode (use a code that claims a higher level of service or a more severe condition than is true). Learning Outcome: 1.4 1-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Ethical & Legal Coding (cont.) It is illegal to unbundle combination codes. You must code ALL conditions relevant to the current encounter. Codes for one encounter must be shown on one claim form. Learning Outcome: 1.4 1-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Ethical & Legal Coding (cont.) It is not worth breaking the law, and chancing getting hit with fines, penalties, and possibly prison, just to hang on to a job. Learning Outcome: 1.4 1-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Resources Medical dictionary Merck Manual Physician’s Desk Reference (PDR) Coding Clinic Correct Coding Initiative Learning Outcome: 1.2 1-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Organ Systems Integumentary system Musculoskeletal system Respiratory system Cardiovascular system Digestive system Urinary system Learning Outcome: 1.6 1-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Organ Systems (cont.) Genital system Nervous system Sensory systems Endocrine system Lymphatic system Hematologic system Learning Outcome: 1.6 1-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Body Areas Head, eyes, ears, nose, and throat Neck Torso Breasts Skin Abdomen Learning Outcome: 1.6 1-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Body Areas (cont.) Groin Buttocks Arm(s) Leg(s) Feet Learning Outcome: 1.6 1-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Positions Learning Outcome: 1.6 1-29

30. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Body Planes Learning Outcome: 1.6 1-30

31. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions 1-31

32. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions Top to Bottom –Superior –Cephalad –Inferior –Caudal –Palmar –Plantar Learning Outcome: 1.6 1-32

33. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions (cont.) Side and Side –Left –Right –Lateral –Bilateral Learning Outcome: 1.6 1-33

34. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions (cont.) Side and Side (cont.) –Medial –Proximal –Distal –Transverse Learning Outcome: 1.6 1-34

35. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions (cont.) Front to Back –Anterior –Ventral –Posterior –Dorsal Learning Outcome: 1.6 1-35

36. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions (cont.) Inside and Outside –Visceral –Deep –Medullary –Parietal –Superficial –Cortical Learning Outcome: 1.6 1-36

37. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions (cont.) Direction for Imaging –Anteroposterior (AP) –Lateral (lat) –Left anterior oblique (LAO) –Left posterior oblique (LPO) Learning Outcome: 1.6 1-37

38. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Directions (cont.) Direction for Imaging (cont.) –Oblique (O) –Posteroanterior (PA). –Right anterior oblique (RAO) –Right posterior oblique (RPO) Learning Outcome: 1.6 1-38

39. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Anatomical Cavities Learning Outcome: 1.6 1-39

40. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Abdominopelvic Cavity Learning Outcome: 1.6 1-40 The Nine Regions

41. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Abdominopelvic Cavity (cont.) Learning Outcome: 1.6 1-41 The Quadrants

42. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Codes of Ethics American Health Information Management Association (AHIMA) –Code of Ethics –Standards of Ethical Coding Learning Outcome: 1.5 1-42

43. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Codes of Ethics (cont.) American Academy of Professional Coders (AAPC) –Code of Ethical Standards Learning Outcome: 1.6 1-43

44. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary Once you assign a diagnosis or procedure code to a patient’s claim form, it becomes a legal document. Coding is very important to the health care industry. 1-44