HS225 Medical Coding I

Unit 9 Seminar

Chapters 3 & 4

Index to Diseases, Tabular List of Diseases, and Index to Procedures

Format Spacing

Eponyms

Diseases or syndromes that are named for persons For example, Meniere’s disease Colle’s Fracture Grave’s Disease

Abbreviations

NEC (not elsewhere classifiable) “Other specified” For example, 250.8

Diabetes with other specified manifestations

NOS (not otherwise specified) Equivalent to unspecified For example, 250.9

Diabetes with unspecified complication

Punctuation

Slanted brackets [ ]

Square brackets [ ]

Parentheses ( )

Colon :

Slanted Brackets [ ]

Located in Index to Diseases Identify manifestation codes For example, 277.3 [357.4]

Square Brackets [ ]

Located in Tabular List of Diseases and Tabular List of Procedures

Enclose synonyms, alternative wording, or explanatory phrases

For example:253.3 Pituitary dwarfism Isolated deficiency of (human) growth Hormones [HGH]

Parentheses ( )

May be present or absent in the doctor’s diagnostic statement

Enclose nonessential modifiers For example, (acute) (chronic)

Diverticulitis (acute) Hypertension (essential, vascular, crisis)

Colon :

Used after an incomplete term in Tabular List of Diseases and Tabular List of Procedures

Indicates when one or more additional terms (modifiers) located after the colon are to be included in diagnostic statement

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Colon :

For example:380.22 Other acute otitis externa Acute otitis externa: actinic chemical contact eczematoid reactive

Boxed Notes

Define terms Provide coding instruction List fifth-digit subclassifications

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Boxed Notes

For example:249 Secondary diabetes melltusThe following fifth digit sub-classification is for use with 249: 0 not stated as uncontrolled or unspecified 1 uncontrolled

Tables

Organize sub-terms, second qualifiers, third qualifiers, and their codes in columns and rows to make it easier to select proper code

Examples of tables: Hypertension, hypertensive Neoplasms Table of Drugs and Chemicals

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Includes Notes

Located immediately below ICD-9-CM Tabular List of Diseases and Tabular List of Procedures Codes

Further defines or provides examples

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Includes Notes

For example:023 Brucellosis

Fever: Malta Mediterranean undulant

INCLUDES

Excludes Notes

Located in ICD-9-CM Tabular List of Diseases and Tabular List of Procedures

Directs coder to another location in the tabular list to classify conditions

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Excludes Notes

For example:010.8 Other primary progressive tuberculosis

tuberculous erythema nodosum (017.1)

Excludes

Inclusion Terms

Listed below certain four- and five-digit ICD-9-CM codes

Include conditions or procedures for which that code number is to be assigned

May be synonyms for code title Include terms that do not appear in

tabular list

Other and Other Specified Codes

Assigned when documentation provides detail for a code that does not exist in ICD-9-CM

Usually represented by a fourth and/or fifth digit of 8 and/or 9

Unspecified Codes

Assigned because documentation is insufficient to assign a more specific code

Usually represented by a fourth digit of 9 and/or a fifth digit of 0

Etiology and Manifestation Rules

Include the following notes in the Tabular List of Diseases: Code first underlying disease If applicable, code any causal condition

first Use additional code In diseases classified elsewhere

And

Located in category titles and code descriptions in Tabular List of Diseases and Tabular List of Procedures

Interpreted as meaning “and/or” 464 Acute laryngitis and tracheitis

Means Acute laryngitis and/or tracheitis

Due To

Located in Index to Diseases as sub-term

Alphabetic order Causal relationship For example, meningitis due to

adenovirus

In

Located in Index to Diseases in alphabetic order below main term

For example, pneumonia in candidiasis

With

Located in Index to Diseases or Index to Procedures immediately below main term

Physician must document both conditions or procedures for code to be assigned

Cross-References

See See also See category See condition

Chapter 4 Coding Guidelines

Guidelines

Signs and symptoms that are integral to the disease should not be assigned as additional codes.

The etiology and manifestation convention requires two codes to be reported to completely describe a single condition.

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Guidelines

Multiple coding for a single condition Use additional code Code first If applicable, code any causal condition

first

Acute (or subacute) and chronic conditions

Combination code versus multiple code

Late Effect

Residual condition that develops after acute phase of illness or injury has ended No time limit on reporting these codes

Combination code assigned For example, painful cicatrix following

severe burn to the elbow or left-sided paralysis due to previous cerebrovascular accident (CVA)

General Procedure Guidelines

Based on anatomy rather than surgical specialty

Numeric codes Use both Index to Procedures and

Tabular List of Procedures

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General Procedure Guidelines

Index to Procedures main terms organized in alphabetic order according to type of procedure

Report codes using highest number of digits available

— omit code

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General Procedure Guidelines

Common key terms: Application Closure Correction Destruction Division Incision

Insertion Operation Procedure Release Removal Repair

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General Procedure Guidelines

Common key terms: Resection Revision Suture Test Therapy Transfer

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General Procedure Guidelines

Combination codes Multiple codes And/Or Open procedure versus closed

procedure Endoscopic procedures Biopsies Canceled surgery

Questions