chapter 4 icd-9-cm medical coding
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Comprehensive Health Insurance
Billing, Coding, and Reimbursement
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Chapter 4ICD-9-CM Medical Coding
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Definition of Diagnosis Coding
Describes services and procedures diagnoses
ICD-9-CM:– Volumes are now used for coding the
appropriate medical conditions
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Coding History
Bills of mortality 1665: some of the earliest uses of coding
Warnings of plague epidemics Diagnoses were often wrong or vague 18th century: Cause of death was noted
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Purpose of the ICD-9-CM
Establishes medical necessity Translates written terminology into
common language Provides data for statistical analysis
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
The Yearly Addenda
Includes the addition of new codes Deletes old codes Includes descriptor revisions
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
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Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
The Three Volumes of the ICD-9-CM
Volume 1: Tabular/numerical list of diseases
Volume 2: Alphabetic index of disease Volume 3: Tabular and alphabetic index of
procedures
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
ICD-10-CM
Replaces volumes 1 and 2 of the ICD-9-CM
Uses alphanumeric codes Is much more detailed than ICD-9-CM Includes ambulatory and managed care
encounters Contains injury codes
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
ICD-10-CM
Combines many codes to give a more detailed description of the injury or illness
No implementation date has been set yet for the ICD-10-CM. Implementation will be based on the process for adoption of standards under HIPAA.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Common Terminology
Encounter: Refers to all healthcare settings
Provider: Physician or qualified healthcare provider
Diagnostic statement: The main reason for encounter
Primary diagnosis: The main reason for visit or encounter
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Common Terminology
Principal diagnosis: The final diagnosis Manifestation: The sign or symptom of a
disease NEC: Not elsewhere classified NOS: Not otherwise specified
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Symbols and Typeface and Terms
Boldface: Main term Subterms: Indented two spaces to the
right Supplementary term: Assists coder in
finding correct term ( ): Parentheses enclose supplementary
words
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Symbols and Typeface and Terms
Colon (:) is used after incomplete phrase or term requiring indented term(s)
[ ]: used to enclose synonyms, alternate wordings, or explanatory phrases
Instructional terms: Assists coder in finding most specific term
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Volume 2, The Alphabetical Index
Use this volume first to search for the correct code or condition.
After you find the code, use Volume 1 (tabular list) to research the specific code.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Volume 1, The Tabular List
Used to research the specific code Punctuation has various meanings.
– A colon : is used after an incomplete phrase or when a modifier is needed.
– Square brackets, [ ], are used to enclose synonyms, alternate wordings, or explanations.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Volume 1, The Tabular List
Punctuation has various meanings.– Parentheses () are used to enclose
supplementary words that may be present or absent in a statement of disease without affecting the code assignment
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Three Steps for Accurate Coding
1. Determine the reason for the encounter.
2. Locate the term in alphabetic index Volume 2.
3. Verify the code in the tabular list (Volume 1).
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Key Coding Guidelines
Code the primary diagnosis first, followed by current coexisting conditions.
Code to the highest level of certainty. Code to the highest level of specificity.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Code to the Highest Level of Certainty
Code condition of encounter. Sign: Objective Symptom: Subjective Signs, symptoms, ill-defined conditions Use Volume 2, alphabetic index, for sign
or symptom Use Volume 1, Chapter 16, to verify
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Code to Highest Degree of Specificity
Assign three-digit codes if there are no four-digit codes in the category.
Assign four-digit codes if there are no five-digit codes in the category.
Claims submitted with three- or four-digit codes will be returned if four- to five-digit codes are available.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Proper Order for Coding
Main reason for encounter Any current coexisting condition Do not code conditions that were
previously treated and no longer exist.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Subsequent Coding
Surgical coding: Diagnosis for which surgery is performed
Late effects/residual effects: Condition that remains after an acute illness or injury
Acute and chronic conditions Combination codes
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Subsequent Coding
V codes: Supplemental code that describes problems, services, or facts
E codes: Supplemental classifications of external causes of injuries and poisonings
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Nine Steps of Accurate ICD-9-CM Coding
Locate main term in the diagnostic statement.
Locate the main term in Volume 2, the alphabetic index.
Refer to all notes under the main term. Use instructions in any notes appearing in a box after the main term.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Nine Steps of Accurate ICD-9-CM Coding
Examine any modifiers. Note any subterms that provide greater
specificity.
Copyright ©2009 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458
All rights reserved.
Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes
Nine Steps of Accurate ICD-9-CM Coding
Follow any cross-reference instructions. Confirm the code selection in the tabular
list (Volume 1). Follow the instructional terms in Volume 1. Assign the correct code number.
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