Intro to Coding
According to Guideline II.H., when the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," Possible, or "still to be ruled out," how should the coder proceed with coding?
"Compatible with," "consistent with," or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that corresponds most closely with the established diagnosis. Note: This guideline is applicable only to inpatient admissions to short-term, acute care, long-term care, and psychiatric hospitals.
How does the coder determine if a procedure is a significant code?
All significant procedures are to be reported. For significant procedures, both the identity (by unique number within the hospital) of the person performing the procedure and the data of the procedure must be reported. Significant procedure: A procedure is identified as significant when it— —is surgical in nature —carries a procedural risk —carries an anesthetic risk —requires specialized training Deciding whether a procedure performed is a significant procedure is often the determinant if the coder assigns a procedure code to identify the procedure. Nonsignificant procedures are usually not coded. Principal procedure: This type of procedure is performed for definitive treatment rather than for diagnostic or exploratory purposes, or when it is necessary to take care of a complication. If two procedures appear to be principal, the one most related to the principal diagnosis should be selected as the principal procedure.
According to Guideline II.A., can diagnosis codes for symptoms, signs, and ill-defined conditions be assigned as a principal diagnosis and in what circumstances?
Codes for symptoms, signs, and ill-defined conditions from chapter 18 are not to be used as the principal diagnosis when a related definitive diagnosis has been established. Example: Patient was admitted to the hospital with chest pain to rule out myocardial infarction. After study, myocardial infarction was ruled out; the cause of the chest pain was undetermined. Code R07.9, Chest pain, unspecified, was assigned. Although the code for chest pain (R07.9) is located in Chapter 18, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified, a definitive diagnosis could not be made, so chest pain was coded as the principal diagnosis. Example: Patient was admitted to the hospital with dysphagia secondary to malignant neoplasm of the esophagus. A PEG tube was inserted. Code C15.9, Malignant neoplasm of the esophagus, unspecified, was selected as the principal diagnosis, with code R13.10 as an additional diagnosis, with code R13.10 as an additional diagnosis to describe the dysphagia. Because the dysphagia was related to the malignancy and code R13.10 is from Chapter 18, the principal diagnosis was the definitive diagnosis rather than the symptom.
Identify the difference between assigning a number to a verbal description such as for a zip code and the activity of assigning a diagnosis or procedure code to medical documentation.
Coding is the transformation of verbal descriptions into numbers provided in a classification system. Whereas assigning a zip code is a rather simple activity, the assignment of diagnostic and procedural codes requires a detailed thought process that is supported by a thorough knowledge of medical terminology, anatomy, and pathophysiology. p. 1
What is the purpose of the Official Addendum for ICD-10-CM and ICD-10-PCS?
Documenting changes with annual updates in U.S. to remain current (codes may be added, revised, or deleted) and may be found at the NCHS website.
How do the Electronic Transaction and Coding Standards correlate to coding and why are they important?
Established under HIPAA, designates adopted medical code sets, ICD-10-CM, ICD-10-PCS, CPT-4, HCPCS, CDT-2, NDC (National Drug Codes), see p.4-5.
At times, however, it may be difficult to distinguish between the principal diagnosis and the most significant diagnosis. The most significant diagnosis is defined as the condition having the most impact on the patient's health, LOS, resource consumption, and the like. However, the most significant diagnosis may or may not be the principal diagnosis.
Example: Patient was admitted with a fractured hip due to an accident. The fracture was reduced and the patient discharged home. In this case, the principal diagnosis was fracture of the hip. Example: Patient was admitted with a fractured hip due to an accident. While hospitalized, the patient suffered a myocardial infarction. In this case, the principal diagnosis was still the fracture of the hip, with the myocardial infarction coded as an additional diagnosis. Although the myocardial infarction may be the most significant diagnosis in terms of the patient's health and resource consumption, it was not the principal diagnosis. Another important consideration in determining principal diagnosis is the fact that the coding conventions and instructions of the classification in ICD-10-CM take precedence over the Official Coding Guidelines. See Section I Conventions for the ICD-10-CM.
Between 1838 and 1893, what other early classification systems were developed?
In 1838, William Farr, the registrar general of England, developed a system to classify deaths. In 1893, a French physician, Jacques Bertillon, introduced the Bertillon Classification of Causes of Death at the International Statistical Institute in Chicago.
What did the American Public Health Association recommend to countries to do in 1898, and what occurred in 1900 as a result of the recommendation?
In 1898, the APHA recommended that the registrars of Canada, Mexico, and the United States adopt Dr. Bertillon's system. APHA recommended revising the system every 10 years to remain current with medical practice. As a result, the first international conference to revise the International Causes of Death convened in 1900; subsequent revisions occurred every 10 years. p. 2
How often must the ICD-10-CM and ICD-10-PCS code books be updated and when do the updates go into effect?
In contrast to international ICD updates that occur less frequently, ICD-10-CM and ICD-10-PCS undergo annual updates in the United States to remain current. Codes may be added, revised, or deleted. An Official Addendum documents the changes, which are effective April 1 and October 1 of each year.
In addition to the UHDDS specific items collected pertaining to patient demographics and their episode of care (personal identification, DOB, sex, race, ethnicity, residence, hospital identification, admission and discharge dates, physician identification, deposition of patient, and expected payer); what other specific medical data items are reported?
In keeping with UHDDS standards, medical data items for the following diagnoses and procedures also are reported: —Diagnoses All diagnoses affecting the current hospital stay must be reported as part of the UHDDS. —Principal diagnosis The principal diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient' to the hospital for care. —Others diagnoses These are designated and defined as all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay (LOS). Diagnoses are to be excluded that relate to an earlier episode that has no bearing on the current hospital stay. Within the Medicare Acute Care Inpatient Prospective Payment System (IPPS), other diagnoses may qualify as a major complication or comorbidity (MCC), or other complication or comorbidity (CC). The terms complication and comorbidity are not part of the UHDDS definition set but were developed as part of the diagnosis-related group (DRG) system. The presence of the complication or comorbidity may influence the MS-DRG assignment and produce a higher-valued DRG with a higher payment for the hospital. —Complication —Comorbidity —Procedures and dates —Significant procedure —Principal procedure
What government agencies provide the representatives to chair the ICD-10-CM Coordination and Maintenance Committee, and what is the committee's responsibility?
NCHS and CMS. Responsible for maintaining the United States' clinical modification version of the ICD-10-CM and ICD-10-PCS code sets. p. 6
How does the coder determine if they should capture "other diagnoses?"
Other diagnoses: These are designated and defined as all conditions that that coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay (LOS). Within the Medicare Acute Care Inpatient Prospective Payment System (IPSS), other diagnoses may qualify as a major complication or comorbidity (MCC), or other complication or comorbidity (CC). The terms complication and comorbidity are not part of the UHDDS definition set but were developed as part of the diagnosis-related group (DRG) system. The presence of the complication or comorbidity may influence the MS-DRG assignments and produce a higher-valued DRG with a higher payment for the hospital.
How is the individual patient identified according to the data elements in the Uniform Hospital Discharge Data Set?
Personal identification: The unique number assigned to each patient that distinguishes the patient and his or her health record from all others.
Selection of Principal Diagnosis
Selecting the principal diagnosis depends on the circumstances of the admission, or why the patient was admitted. The admitting diagnosis has to be determined through diagnostic tests and studies. Therefore, the words "after study" serve as an integral part of this definition. During the course of hospitalization, the admitting diagnosis, which may be a symptom or ill-defined condition, could change substantially based on the results of further study. Example: Patient was admitted through the emergency department with an admitting diagnosis of seizure disorder. During hospitalization, diagnostic tests and studies revealed carcinoma of the brain, which explained the seizures. The principal diagnosis was the carcinoma of the brain, which was the condition determined after study.
According to Guideline II.F., how would a coder capture the principal diagnosis when the original treatment plan was not carried out?
Sequence as the principal diagnosis the condition which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances. Example: Patient with ulcerated internal hemorrhoids was admitted for hemorrhoidectomy. Prior to the beginning of surgery, the patient developed bradycardia and the surgery was canceled. The following codes were assigned: K64.8, Ulcerated internal hemorrhoids; R00.1, Bradycardia; and Z53.09, Procedure not carried out because of contraindication, to indicate that the procedure was not carried out due to the complication of bradycardia.
How did the World Health Organization become involved with the classification system in 1948?
The 6th revision of the classification system brought drastic changes, as well as an expansion into two volumes. In 1948, WHO, with headquarters in Geneva, Switzerland, assumed responsibility for preparing and publishing the revisions to ICD every 10 years. WHO sponsored the 7th and 8th revisions in 1957 and 1968, respectively. p. 2
What is the importance of having the Official Guidelines as a required component of the ICD-10-CM and ICD-10-PCS code set in the final rule of the electronic transactions and coding standards?
The ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting were named as required components of the ICD-10-CM and ICD-10-PCS code set in the modified final rule for electronic transactions and coding standards. This made adherence to the guidelines a requirement for compliance with the rule. It is important to note that, upon implementation, these medical code sets became the rule for nearly all insurance payers. p. 5
What did the statistician John Graunt develop in the 17th century that is considered an early classification system?
The London Bills of Mortality, which provided the first documentation of the proportion of children who died before reaching age six years.
What organization released the 11th version of the International Classification of Diseases? What are the main benefits that differentiate it from the current edition?
The World Health Organization. According to WHO, ICD-11 includes more clinical detail, updates to scientific content, and links to other classifications and terminologies, and it is made for ready use in electronic environments. p. 4
Structure of ICD-10-CM Codes
The structure of ICD-10-CM codes includes the following characteristics: Three (3) to seven (7) characters in length. The first character is alpha (all letters except U are used). The second character is numeric. Characters 3-7 are alpha or numeric. Code uses a decimal after after the first three characters. Code uses dummy placeholder "x." Alpha characters are not case sensitive. Some examples of code include: P09 S32.010A O9A.211 M1A.0111
What is the difference between a complication and comorbidity as identified according to the MS-DRG and why are they important to capture as a code?
The terms complication and comorbidity are not part of the UHDDS definition set but were developed as part of the diagnosis-related group (DRG) system. The presence of complications or comorbidity may influence the MS-DRG assignment and produce a higher-valued DRG with a higher payment for the hospital. Complication: This is defined as an additional diagnosis that describes a condition arising after the beginning of hospital observation and treatment and then modifying the course of the patient's illness or the medical care required. Comorbidity: This is defined as a pre-existing condition that, because of its presence with a specific diagnosis, will likely cause an increase in the patient's length of stay in the hospital.
Description of Purpose of the Uniform Hospital Discharge Data Set
There are many uses for the data that are created by coding activity, including compiling statistical data. In order for these data to be useful, everyone gathering the data must collect the same data the same way. The Uniform Hospital Discharge Data Set (UHDDS) was promulgated by the US Department of Health, Education, and Welfare in 1974 as a minimum, common core of data on individual acute care short-term hospital discharges in Medicare and Medicaid programs. It sought to improve the uniformity and comparability of hospital discharge data. In 1985, the data set was revised to improve the original version in light of timely needs and developments. These data elements and their definitions can be found in the July 31, 1985, Federal Register (50 FR 31038, Vol. 50, No. 147, 31038-31040). Since that time, the application of the UHDDS definitions has been expanded to include all nonoutpatient settings (acute care, short-term care, long-term care, and psychiatric hospitals; home health agencies; rehabilitation facilities; nursing homes; and so forth).
Abbreviations
Two abbreviations are used in ICD-10-CM: Not Elsewhere Classifiable and Not Otherwise Specified. NEC: Not Elsewhere Classifiable abbreviation appears in the Alphabetic Index. When NEC appears in the Alphabetic Index, it will direct the coder to the Tabular List showing an "other specified" codes description. The NEC entry appears when a specific code is not available. The NEC code usually directs the coder to an "other specified" code in the Tabular List that includes the number 8 after the decimal point. Examples: K65.8, Other peritonitis; N30.80, Other cystitis without hematuria. NOS: Not Otherwise Specified abbreviation is the equivalent of unspecified. The abbreviation NOS appears in the Alphabetic Index and the Tabular List. The unspecified or NOS codes are available for use when the documentation of the condition identified in the health record does not provide enough information to assign a more specific code. Examples: I50.9, Heart failure, unspecified; L02.93, Carbuncle, unspecified.
According to Guideline II.J., how is the principal diagnosis assigned when a patient is admitted to the hospital from outpatient surgery?
When the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis. When the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.
ICD-10-CM code format
___ ___ ___ . ___ ___ ___ ___ First three characters = category Second three characters = etiology, anatomic site, or severity Seventh character adds specificity
What is the main difference between the ICD-10 annual revision released by the WHO and the ICD-10-CM and ICD-10-PCS annual revisions released by CMS and NCHS? Identify which addenda CMS publishes and which addenda NCHS publishes along with the overall connection to the WHO.
International ICD updates occur less frequently than ICD-10-CM and ICD-10-PCS updates in the United States. NCHS is responsible for maintaining the diagnosis classification; CMS is responsible for maintaining the procedure classification. p. 6.
