chapter 5 diagnostic coding elsevier items and derived items © 2010, 2008 by saunders, an imprint...

Chapter 5Chapter 5

Diagnostic Coding Diagnostic Coding

Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

22Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

Importance of Correct Diagnostic Importance of Correct Diagnostic CodingCoding

Diagnostic coding must be accurate because Diagnostic coding must be accurate because payment for inpatient services rendered to a payment for inpatient services rendered to a patient may be based on the diagnosis.patient may be based on the diagnosis.

In the outpatient setting, the diagnosis code In the outpatient setting, the diagnosis code must correspond to the treatment or services must correspond to the treatment or services rendered to the patient or payment may be rendered to the patient or payment may be denied.denied.


The Diagnostic Coding SystemThe Diagnostic Coding System

Guidelines for diagnostic coding must be Guidelines for diagnostic coding must be followed when assigning codesfollowed when assigning codes

Only diagnoses that currently relate to patient Only diagnoses that currently relate to patient state should be codedstate should be coded

Payment for services may be tied into Payment for services may be tied into diagnostic coding, due to medical necessity diagnostic coding, due to medical necessity requirementsrequirements


Sequencing of Diagnostic CodesSequencing of Diagnostic Codes

Primary diagnosis (first-listed)Primary diagnosis (first-listed) Related to the chief complaintRelated to the chief complaint Main reason for the encounterMain reason for the encounter

Secondary diagnosisSecondary diagnosis May contribute to the primary diagnosisMay contribute to the primary diagnosis Not the underlying cause (etiology)Not the underlying cause (etiology)

Principal diagnosisPrincipal diagnosis Only applicable to inpatient cases/claimsOnly applicable to inpatient cases/claims Similar to primary diagnosis for outpatientSimilar to primary diagnosis for outpatient


Reasons for the Development Reasons for the Development and Use of Diagnostic Codesand Use of Diagnostic Codes

Tracking of disease processesTracking of disease processes Classification of causes of mortalityClassification of causes of mortality Medical researchMedical research Evaluation of hospital service utilizationEvaluation of hospital service utilization


Use of Standard Transaction Use of Standard Transaction Code SetsCode Sets

Each transaction must include the use of Each transaction must include the use of medical and other code setsmedical and other code sets

ICD-9-CM must be used for when assigning ICD-9-CM must be used for when assigning diagnostic codesdiagnostic codes Required, per HIPAA standardsRequired, per HIPAA standards

Diagnostic codes should tie into the services Diagnostic codes should tie into the services rendered to the patientrendered to the patient Indicated by procedure codes (in Ch. 6)Indicated by procedure codes (in Ch. 6)

Physician’s fee profilePhysician’s fee profile


History of Coding DiseasesHistory of Coding Diseases

1869: 1869: American Nomenclature of DiseasesAmerican Nomenclature of Diseases (AMA)(AMA)

1903: 1903: Bellevue Hospital Nomenclature of Bellevue Hospital Nomenclature of Diseases Diseases Standard Nomenclature of Standard Nomenclature of Diseases and OperationsDiseases and Operations

1960s-1991: 1960s-1991: Current Medical Information and Current Medical Information and Terminology (CMIT) Terminology (CMIT) (AMA)(AMA)

Current: Current: Systemized Nomenclature of Systemized Nomenclature of Medicine, Clinical Terms (SNOMED-CT)Medicine, Clinical Terms (SNOMED-CT)


International Classification of International Classification of DiseasesDiseases

1717thth century: ICD developed in England century: ICD developed in England 1818thth century: ICD use began in U.S. century: ICD use began in U.S. 1950s: ICD used in hospitals to classify and 1950s: ICD used in hospitals to classify and

index diseaseindex disease Current: ICD-9 (9Current: ICD-9 (9thth revision) in use revision) in use


Organization and FormatOrganization and Format

Three volumesThree volumes Volume 1: Tabular List of DiseasesVolume 1: Tabular List of Diseases Volume 2: Alphabetic Index of DiseasesVolume 2: Alphabetic Index of Diseases Volume 3: Tabular List and Alphabetic Index of Volume 3: Tabular List and Alphabetic Index of

ProceduresProcedures Volumes 1 and 2 are used in physician Volumes 1 and 2 are used in physician

offices and hospitals for diagnosesoffices and hospitals for diagnoses Volume 3 is used in hospitals for proceduresVolume 3 is used in hospitals for procedures


Outline of Volumes 1 and 2 Outline of Volumes 1 and 2 of ICD-9-CM of ICD-9-CM


ICD-9-CM ConventionsICD-9-CM Conventions


General Coding GuidelinesGeneral Coding Guidelines

Code only conditions or problems that are Code only conditions or problems that are actively managed at the visitactively managed at the visit

First, look up condition in Volume 2First, look up condition in Volume 2 Main term is the conditionMain term is the condition

Second, go to Volume 1 to assign the codeSecond, go to Volume 1 to assign the code Follow instructions from Volume 2 and Follow instructions from Volume 2 and

conventions in Volume 1conventions in Volume 1


Illustration of Main Terms, Illustration of Main Terms, Subterms, and Nonessential Subterms, and Nonessential

ModifiersModifiers


Code DigitsCode Digits

ICD-9-CM contains at least three digitsICD-9-CM contains at least three digits Fourth or fifth digits can also be appendedFourth or fifth digits can also be appended

Provides greater specificityProvides greater specificity Must be used if availableMust be used if available

Fifth digit codes can appear:Fifth digit codes can appear: At the beginning of the chapterAt the beginning of the chapter At the beginning of a sectionAt the beginning of a section At the beginning of a three-digit categoryAt the beginning of a three-digit category In a fourth-digit subcategoryIn a fourth-digit subcategory


V Codes & E CodesV Codes & E Codes

V Codes are used when a person who is not V Codes are used when a person who is not currently sick encounters health services for currently sick encounters health services for some specific purpose.some specific purpose.

E Codes are used when some circumstance E Codes are used when some circumstance or problem is present that influences the or problem is present that influences the person’s health status but is not in itself a person’s health status but is not in itself a current illness or injury.current illness or injury.


V Code UseV Code Use

V codes are used in four circumstancesV codes are used in four circumstances When a person who is not currently sick When a person who is not currently sick

encounters health services for a specific purpose encounters health services for a specific purpose (vaccination, etc.)(vaccination, etc.)

When a person with a resolving disease or injury When a person with a resolving disease or injury seeks aftercareseeks aftercare

When a circumstance influences an individual’s When a circumstance influences an individual’s health status but the illness is not currenthealth status but the illness is not current

When it is necessary to indicate the birth status of When it is necessary to indicate the birth status of a newborna newborn


V Code ExamplesV Code Examples


V Code Examples (cont’d.)V Code Examples (cont’d.)


E CodesE Codes

Used to explain the mechanism for the injuryUsed to explain the mechanism for the injury Used to gather data about injury causesUsed to gather data about injury causes Should be reported in addition to the Should be reported in addition to the

appropriate procedural/diagnostic codesappropriate procedural/diagnostic codes E codes are NEVER the primary diagnosisE codes are NEVER the primary diagnosis


E Codes (cont’d.)E Codes (cont’d.)


Table of Drugs and ChemicalsTable of Drugs and Chemicals


E Coding ExamplesE Coding Examples


E Coding Examples (cont’d.)E Coding Examples (cont’d.)


Signs, Symptoms, and Ill-Defined Signs, Symptoms, and Ill-Defined ConditionsConditions

Signs and symptoms codes can be used: Signs and symptoms codes can be used: No precise diagnosis can be madeNo precise diagnosis can be made Signs and symptoms are transient, and a specific Signs and symptoms are transient, and a specific

diagnosis was not madediagnosis was not made Provisional diagnosis for a patient who does not Provisional diagnosis for a patient who does not

return for further carereturn for further care A patient is referred for treatment before a definite A patient is referred for treatment before a definite

diagnosis is madediagnosis is made


SterilizationSterilization

V25.2 should be used for sterilization for V25.2 should be used for sterilization for contraceptive purposescontraceptive purposes Elective sterilization: only V25.2Elective sterilization: only V25.2 Elective sterilization after obstetric delivery: V25.2 Elective sterilization after obstetric delivery: V25.2

as secondaryas secondary Sterilization for other reasons does not Sterilization for other reasons does not

require a V coderequire a V code


Neoplasm TerminologyNeoplasm Terminology

Benign tumor:Benign tumor: one that does not have one that does not have properties of invasion and metastasis and is properties of invasion and metastasis and is usually surrounded by a fibrous capsuleusually surrounded by a fibrous capsule

Malignant tumor:Malignant tumor: has the properties of has the properties of invasion and metastasisinvasion and metastasis

Carcinoma:Carcinoma: refers to a cancerous or refers to a cancerous or malignant tumormalignant tumor

Carcinoma in situ:Carcinoma in situ: cancer confined to the cancer confined to the site of origin without invasion of neighboring site of origin without invasion of neighboring tissuestissues


Coding for NeoplasmsCoding for Neoplasms


Neoplasm Coding ExamplesNeoplasm Coding Examples


Neoplasm Coding Examples Neoplasm Coding Examples (cont’d.)(cont’d.)


Cardiovascular System Cardiovascular System ConditionsConditions

HypertensionHypertension Malignant vs. benignMalignant vs. benign Cause should be coded when specifiedCause should be coded when specified

Myocardial infarctionsMyocardial infarctions Chronic rheumatic heart diseaseChronic rheumatic heart disease

Conditions presumed to be caused by rheumatic Conditions presumed to be caused by rheumatic feverfever

Arteriosclerotic cardiovascular/heart diseaseArteriosclerotic cardiovascular/heart disease Cardiovascular vs. heartCardiovascular vs. heart


Classification of Diabetes MellitusClassification of Diabetes Mellitus


Pregnancy, Delivery, and Pregnancy, Delivery, and AbortionAbortion

Many codes in this category require five-digit Many codes in this category require five-digit subclassificationssubclassifications

Follow guidelines for coding deliveries and Follow guidelines for coding deliveries and complicationscomplications


Admitting DiagnosisAdmitting Diagnosis

Criteria for admitting inpatient diagnosisCriteria for admitting inpatient diagnosis One or more significant findings representing One or more significant findings representing

patient distress or abnormal findings on patient distress or abnormal findings on examinationexamination

A diagnosis established on an ambulatory care A diagnosis established on an ambulatory care basis or previous hospital admissionbasis or previous hospital admission

An injury or poisoningAn injury or poisoning A reason or condition not classifiable as an illness A reason or condition not classifiable as an illness

or injuryor injury


BurnsBurns

Percentage of body area for code assignmentPercentage of body area for code assignment The Rule of NinesThe Rule of Nines

Severity of burnSeverity of burn First degreeFirst degree Second degreeSecond degree Third degreeThird degree


Injuries and Late EffectsInjuries and Late Effects

Multiple injuriesMultiple injuries List diagnosis in order of importanceList diagnosis in order of importance Most severe problem listed firstMost severe problem listed first

Guidelines for coding injuriesGuidelines for coding injuries Decide whether a diagnosis represents a current Decide whether a diagnosis represents a current

injury or late effectinjury or late effect Fractures are coded as closed if there is no Fractures are coded as closed if there is no

indication of “open” or “closed”indication of “open” or “closed” The word “with” indicates involvement of both The word “with” indicates involvement of both

sites, and the word “and” indicates involvement of sites, and the word “and” indicates involvement of one or two sites when multiple injury sites are one or two sites when multiple injury sites are givengiven


Common Injury Medical TermsCommon Injury Medical Terms


ICD-10-CM and ICD-10-PCSICD-10-CM and ICD-10-PCS

ICD-10-CM will replace ICD-9-CM Volumes 1 ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 (diagnosis codes)and 2 (diagnosis codes)

ICD-10-PCS will replace ICD-9-CM Volume 3 ICD-10-PCS will replace ICD-9-CM Volume 3 (procedure codes)(procedure codes)

Reasons for developmentReasons for development ICD-9-CM was not expandable, comprehensive, or ICD-9-CM was not expandable, comprehensive, or

multiaxialmultiaxial ICD-9-CM did not have standardized terminology ICD-9-CM did not have standardized terminology

and included diagnostic informationand included diagnostic information


ICD-10-CM vs. ICD-9-CMICD-10-CM vs. ICD-9-CM Change in code book organizationChange in code book organization New categories and chaptersNew categories and chapters New six- to seven-digit alphanumeric codesNew six- to seven-digit alphanumeric codes Old injuries are to use S and T codes, by siteOld injuries are to use S and T codes, by site Expanded explanatory notes and instructionsExpanded explanatory notes and instructions Expanded dual classification systemExpanded dual classification system E and V codes are now separate chaptersE and V codes are now separate chapters New procedures get unique codesNew procedures get unique codes Combination diagnosis/symptom codes addedCombination diagnosis/symptom codes added Postoperative complication codes describe type and site or complicationPostoperative complication codes describe type and site or complication

misadventuremisadventure early complicationearly complication late complicationlate complication sequelasequela transient postoperative conditiontransient postoperative condition

New activity code categoryNew activity code category ICD-10-PCS is more specific than CPTICD-10-PCS is more specific than CPT


ICD-10-CM Coding ConventionsICD-10-CM Coding Conventions Braces and brackets are not applicableBraces and brackets are not applicable Added conventionsAdded conventions

““and” and” Excludes 1Excludes 1 Excludes 2Excludes 2

Acute and chronic conditions can be assigned togetherAcute and chronic conditions can be assigned together Acute should be sequenced firstAcute should be sequenced first

Bilateral sitesBilateral sites Right side is character 1; Left side is character 2Right side is character 1; Left side is character 2 Bilateral is character 3Bilateral is character 3 Unidentified side requires unspecified codeUnidentified side requires unspecified code


Transition to ICD-10-CMTransition to ICD-10-CM

Implementation could be October 2010Implementation could be October 2010 Requires higher level of clinical knowledgeRequires higher level of clinical knowledge Training is necessaryTraining is necessary Different ICD-10-CM books will be offeredDifferent ICD-10-CM books will be offered


Basic Steps in CodingBasic Steps in Coding

Locate the main term in the Alphabetic Index Locate the main term in the Alphabetic Index in Volume 2.in Volume 2. Refer to any notes under the main term.Refer to any notes under the main term. Read any terms enclosed in parentheses after the Read any terms enclosed in parentheses after the

main term.main term. Look for appropriate subterm.Look for appropriate subterm. Look for appropriate sub-subterm.Look for appropriate sub-subterm. Follow any cross-reference instructions.Follow any cross-reference instructions. Write down the code.Write down the code.


Basic Steps in Coding (cont’d.)Basic Steps in Coding (cont’d.)

Verify the code number in the Tabular List in Verify the code number in the Tabular List in Volume 1.Volume 1. Read and be guided by any instructional terms in Read and be guided by any instructional terms in

the Tabular List.the Tabular List. Read complete description and assign the code to Read complete description and assign the code to

the highest specificity.the highest specificity.


Coding Chronic Alcoholic Liver Coding Chronic Alcoholic Liver DiseaseDisease


Tabular List Coding ExamplesTabular List Coding Examples


Tabular List Coding Examples Tabular List Coding Examples (cont’d.)(cont’d.)


Coding by EtiologyCoding by Etiology


Four-Digit Residual Four-Digit Residual SubcategoriesSubcategories


Combination CodingCombination Coding


Special Points to Remember in Special Points to Remember in Volume 1Volume 1

Use two or more codes if necessary to Use two or more codes if necessary to completely describe a diagnosis.completely describe a diagnosis.

Search for one code when two diagnoses or Search for one code when two diagnoses or a diagnosis with an associated secondary a diagnosis with an associated secondary process or complication is present. See process or complication is present. See Figure 5-8.Figure 5-8.

Use category codes only if there are no Use category codes only if there are no subcategory codes.subcategory codes.


Special Points to Remember in Special Points to Remember in Volume 2Volume 2

Notice that appropriate sites or modifiers are Notice that appropriate sites or modifiers are listed in alphabetic order under the main listed in alphabetic order under the main terms, with further subterm listings as terms, with further subterm listings as needed.needed.

Examine all modifiers that appear in Examine all modifiers that appear in parentheses next to the main term.parentheses next to the main term.

Check for nonessential modifiers that apply to Check for nonessential modifiers that apply to any of the qualifying terms used in the any of the qualifying terms used in the statement of the diagnosis found in the statement of the diagnosis found in the patient’s medical recordpatient’s medical record


Special Points to Remember in Special Points to Remember in Volume 2 (cont’d)Volume 2 (cont’d)

Notice that eponyms appear as both main Notice that eponyms appear as both main term entries and modifiers under main terms term entries and modifiers under main terms such as “disease” or “syndrome” and such as “disease” or “syndrome” and “operation.”“operation.”

Look for sublisted terms in parentheses that Look for sublisted terms in parentheses that are associated with the eponym.are associated with the eponym.

Locate closely related terms, code Locate closely related terms, code categories, and cross-referenced synonyms categories, and cross-referenced synonyms indicated by indicated by seesee and and see alsosee also..


Excerpt from Alphabetic Index Excerpt from Alphabetic Index of ICD-9-CM Volume 2of ICD-9-CM Volume 2


Excerpt from Tabular List Excerpt from Tabular List of ICD-9-CM Volume 1of ICD-9-CM Volume 1

chapter 5 diagnostic coding elsevier items and derived items © 2010, 2008 by saunders, an imprint...

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