Step by step medical coding

Chronic diseases

Chronic diseases treated on an ongoing basis may b coded and reported as many times as the patient receive treatment and care for the conditions

Innoculations and vaccinations

Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive prophylactic inoculations against a disease. Procedure codes are required to identify the actual administration of the injection and the types of immunizations given. Code Z23 may be sued as secondary code if the inoculation is given a routine part of preventive health care, such as a well-baby visit.

Code all documented conditions that coexist

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and not longer exist. However, history codes categories Z80 Z87 may be used as secondary codes if the historical condition or family history has an impact on current care of influences treatment.

supervision of high-risk pregnancy

Codes from 009, Supervision of high risk pregnancy, are intended for use only during the prenatal period. For complications during the labor or delivery episode as a result of a high risk pregnancy assign the applicable complication code from Chapter 15. If there are not complications during the labor or delivery episode, assign code 080, Encounter for full term uncomplicated delivery.

Codes that describe symptomes and signs

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. chapter 18 of ICD 10 CM, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified (Codes R00-R99) contain many, but not all codes for symptoms

Contact/efirst listed codexposure

Contact exposure codes may be used as a code to explain an encounter for testing, or, more commonly, as a secondary codes to identify a potential risk.

Uncertain diagnosis

Do not code diagnoses documented as "probable" "suspected," "questionable," "rule out," "compatible with," "consistent with,," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the conditions to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results, or other reason for the visit.

Accurate reporting of ICD 10 CM diagnosis codes

For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient's condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these.

Ambulatory surgery

For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is know to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since is it the most definitive

Patients receiving diagnostic services only

For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routing testing is performed during the same encounter as a test to evaluate a sign, symptoms, or diagnosis, it is appropriate to assign both the Z code and the describing the reason for the non-routine test.

Status codes

For encounters for weaning from a mechanical ventilator, assign a code from subcategory J96.1, chronic respiratory failure, followed by code Z99.11, dependence on reparatory ventilator status

Patients receiving diagnostic services only

For outpatient encounters for diagnostic test that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnoses documented in the interpretation. Don not code related signs and symptoms as additional diagnoses

Patients receiving diagnostic servies only

For patients receiving diagnostic services only during and encounter/visit, sequence first the diagnosis, condition problem, or other reason for encounter/visit should in the medical record to be chiefly responsible for the outpatient service provided during the encounter/visit. Codes for other diagnoses e.g. chronic conditions may be sequenced as additional diagnoses.

Patients receiving preoperative evaluations only

For patients receiving preoperative evaluations only, sequence first a code from subcategory Z01.81, Encounter for pre-procedural examination, to describe the pre-op consultations,. Assign a code for the condition to describe the reason for the surgery as an additional diagnosis. Code also any finding related to the pre-op evaluation

Patients receiving therapeutic services only

For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses e.g. chronic conditions may be sequenced as additional diagnoses.

Routine outpatient prenatal visits

For routine outpatient prenatal visits when no complications are present, a code from category Z34, Encounter for supervision of normal pregnancy, should be used as the first-listed diagnosis. These codes should not be used in conjunction with chapter 15 codes.

Encounters foer circumstances for other than a disease or injury

ICD 10 CM provides codes to deal with encounters for circumstances other than a disease or injury. The Factors Influencing Health Status and Contact with Health Service codes Z00 - Z99 are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems

Supervision of High Risk Pregnancy

For routing prenatal outpatient visits for patients with high risk pregnancies, a code from category 009, Supervision of high risk pregnancy, should be used as the first listed diagnosis. Secondary chapter 15 codes may be used in conjunction with these codes if appropriate

Observation stay

when a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first listed diagnosis

Status Codes

A status code should not be used with a diagnosis code from one of the body system chapters, if the diagnosis code includes the information provided by the status code. For example, code Z94.1, Heart transplant status, should not be used with a code from subcategory T86.2, Complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart transplant patient

Contact/exposure

Category Z20 indicates contact with and suspected exposure to communicable diseases. These codes are for patients who are suspected to have been exposed to a diseCase by close personal contact with an infected infividual or are in an area where a disease is epidemic

Contact/exposure

Category Z77, Other contact with and suspected exposure hazardous to health, indicates contact with and suspected exposures hazadous to health

ICD 10 CM code for eh diagnosism, condition, problem, or other reason for encounter/visit

List first the ICD 10 CM code for the diagnosis, condition, problem, or other reason for encounter/visit should on the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first listed diagnosis ay be a symptom when a diagnosis has not be established confirmed by the provider

ICD 10 CM code for the diagnosis, condition, problem, or other reason for encounter/visit

List first the ICD 10 CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first listed diagnosis may be a symptom when a diagnosis has not been established confirmed by the provider

Observation stay

When a patient present for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis reason for the encounter, followed by codes for the compilations as secondary diagnoses

Outpatient surgery

When a patient presents for outpatient surgery (same-day surgery), code the reason for the surgery as the first-listed diagnosis (reason for the encounter), even if the surgery is not performed due to a contraindication.

First listed diagnosis and coexisting conditions

You have already had practice at selecting the first listed diagnosis, and you know that it is possible for the first listed diagnosis to be a symptom. The important information in this Guideline is that additional codes should be assigned for any coexisting conditions that are present or treated during the visit or encounter. Sometimes there is more than one symptom that is present

Use of Z Codes in any healthcare setting

Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed Principal diagnosis code in the inpatient setting or a secondary code, depending on the circumstances of the encounter. Certain Z codes may only be used as the first listed or principal diagnosis.

Z codes indicate a Z for an encounter

Z codes are not procedure codes. A corresponding procedure codemust accompany a Z code to describe any procedure prerformed.

Categories of Z codes

category 1 z codes

Uncertain diagnoses

In an inpatient setting, uncertain diagnosis are reported, but in the outpatient setting these uncertain diagnoses are not reported as explained in Section IV.H of the Guidelines

Uncertain Diagnosis

In an inpatient setting, uncertain diagnosis are reported, but in the outpatient setting theses uncertain diagnoses are not reported

Slection of first listed condition

In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis. In determining the first-listed diagnosis the coding conventions of the ICD 10 CM, as well as the general and disease-specific guidelines, take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed. The most critical rule involves beginning the search for the correct code assignment through the Alphabetic index. Never begin searching initially in the Tabular List as this will lead to errors.

Status codes

Status codes indicate that a patient is either a carrier of a disease or has the sequelae or a residual of a past disease or condition. This includes such things as the presence of prosthetic or mechanical devices resulting from past treatment. A status code is distinct from a history code. The history codes indicates that the patient no longer has the condition.

Codes from A00.0 through T88.9, Z00-Z99

The appropriate code(s) from A00.0 through T88.9, Z00-Z99 must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reason(s) for the encounter/visit.

Patients receiving therapeutic service only

The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for when the service is being performed listed second

Sequela

a condition which is the consequence of a previous disease or injury. "the long-term sequelae of infection"