Chap 12 Basics of Diagnostic Coding

History and Physical Exam ( H&P)

Start of the patients narrative medical evaluation, CONTAINS CHIEF Complaint, // HP also has in PTs WORDS why they are seeking attention

Steps to ICD-10-CM coding Part 1

Step 1 : Determine the correct diagnosis from the diagnostic statement Step 2 : Use the Main term to find correct diagnosis code in the Alphabetic Index Step 3 : Look up the "See" term in Alphabetic Index

Steps for Coding Neoplasm

Step 1: Use table of neoplasm to, determine site of neoplasm and select the row in the table in which it appears / Step 2: Determine if neoplasm is benign or malignant / Step 3: If neoplasm is BENIGN, select the column that best DESCRIBES ITS BEHAVIOUR: Uncertain behaviour or Unspecified nature / Step 4: If neoplasm is malignant, determine the table column that best fits its behaviour: Malignant primary, secondary or CA in Situ

Steps to ICD-10-CM coding Part 2

Step 4: Review the essential modifiers under the main term Step 5: Choose the correct essential modifier related to the diagnostic statement Step 6: Look up the code in the Tabular Index Step 7: Check for any coding guidelines, conventions, inclusion or exclusion notes, or an addition symbol is needed Step 8: Assign code

Supplementary Sections of the Alphabetic index

Table of neoplasms- Lists neoplasms by anatomical location /// Table of Drugs and chemicals- Used for identifying poisoning and external causes of adverse effects

Subterms

Terms are indented one space to the right of a Essential modifiers // Used when all conditions exist

Essential modifiers

Terms indented one space to the right under the main term // CHANGES THE DESCRIPTION OF THE DIAGNOSIS OF THE MAIN TERM

Main Terms

Terms that appear in bold text in Alphabetic Index // Identifies condition

Coding for Hypertensive disease

If diagnostic statement does not have terms "hypertension" or "high blood pressure" Condition is coded "Elevated blood pressure" not hypertension // Mention of hypertension in diagnostic statement does not mean that a combination code for hypertensive heart disease should be used /// If cause and effect relationship exists between hypertension and heart disease, it should be clearly documented in the clinical record or diagnostic statement

Coding for Health status and contact with Health services

In ICD-10-CM Chap 21 describes encounters or circumstances with a healthcare provider when no current illness or injury exists

Instructional Notes ( Coding Neoplasms)

In Situ: Used only when found in diagnostic statement // Unspecified: Used when no pathology study has been done AND neoplasm has been described with a term such as "tumor" or "growth" // Uncertain: Used only when Neoplasm's behavior is not malignant , the tumor IS NOT IN Situ, or behaviour is unpredictable

"See also" Tab convention

Indicates that another main term may be looked at for additional useful index entries // If the original main term is the needed code do not use "see also" coded

"Code if applicable, any casual condition" note

Indicates that the code can be assigned as a principal diagnosis when the casual condition is unknown or unapplicable

Coding of HIV Infection and AIDS

Key is whether the patient has symptoms Never code HIV unless clearly documented // Patient admitted with HIV-related condition: Code first // Patient with HIV admitted for unrelated condition: Code Unrelated condition FIRST // HIV infection in pregnancy, childbirth, puerperium: Code pregnancy first

Alphabetic Index

List of DIAGNOSTIC terms in and related codes in alphabetical order by main terms

Coding for drug toxicity

Located in Chap 19: Includes poisoning, adverse effect, underdosing, toxic effect

Coding for external causes of morbidity (disease)

Located in Chap 20: External causes of Morbidity // Codes capture how the injury happened, the intent, the setting, the activity of the patient at the time, and the persons status

"With"

"With" means "associated with" or "due to" in the alphabetic index follows the main term ////

Conventions in the Tabular index

Abbreviations, punctuations, symbols, instructional notations, related entities

Manifestation

An indication of disease

Encounter

Any contact between a patient and a provider of service

Nonessential modifiers

Are in parenthesis right past the Main terms used as explanatory information // DO NOT AFFECT CODE ASSIGNMENT

Coding for Myocardial Infarction

As ACUTE if it is documented as such in diagnostic statement or has a stated duration 8 weeks or less // As CHRONIC if documented in diagnostic statement or if symptoms persist after 8 weeks // If MI is specified as "OLD" or "HEALED" with any current symptoms Code with I21 // If Patient is symptomatic , code the underlying condition or SYMPTOMS only if UNDERLYING CONDITION is UNKNOWN

Unspecified nature ( Coding Neoplasms)

Behaviour and histological type of neoplasm is not in the diagnostic statement

Chapters

Broad sections of the ICD-10-CM coding manual grouped by disease and injuries

Encounter form

Can be viewed in the EHR, commonly used to see the medical services rendered and the treating diagnosis when total charges are calculated // MUST BE REVIEWED EVERY YEAR

Coding Impending or Threatened Conditions

Code any condition described At the time of discharge as "impending" or "threatened" // If condition occurred use a code for confirmed diagnosis // If condition DID NOT occur use alphabetic index to see if Condition has a subtermOr Main term for Impending or threatened // If the subterm is not found , code the EXISTING UNDERLYING Condition or conditionS, SIGNS, SYMPTOMS do not code the condition described as threatened or impending

Coding for burns and corrosions

Code each burn separately unless specific combination codes are given in the Tabular list // ICD-10-CM has a distinction between burn and corrosions. Burn is caused by heat // Corrosion by chemicals // Most burn codes are found in chap 19

Tabular conventions Code first

Code first / Use additional codes: Underlying condition must be coded first before manifestation code can be used

Generate Equivalence Mapping (GEM)

Code maps that assist in the change over to ICD-10-CM from ICD-9-CM // GEMs can increase proficiency in ICD-10-CM // GEMs provides code to code translation for both code sets

Place of occurrence guideline

Codes from category Y92 ( place of occurrence of the external cause ) ARE SECONDARY CODES // ONLY USED ONCE AT THE INITIAL ENCOUNTER /// 7th character is used in Y92 codes

Coding for Activities

Codes from category Y93 used to define the activity the patient was involved in at the time of injury or when health condition developed // Code from category Y93 can be used with external cause Y99 and intent codes if identifying the activity provides additional information about the event

Coding guidelines

Coding manual begins with the ICD-10-CM official guidelines for coding and reporting ( OCGR) // Complements the official conventions and instructions

Coding for complication of Care

Complication of care if often not mentioned as part of diagnostic statement/// When coding for CoC two criteria must met: Cause-and-effect relationship AND Documentation must Indicate that the condition is a Complication

Alphabetic Index

Consists of alphabetic list of diagnostic terms, related codes, and includes: Main terms, Nonessential modifiers, Essential modifiers, and subterms

Section 1 : of Official Guidelines for Coding and Reporting

Contains Conventions, General Coding guidelines, and chapter specific guidelines

Diagnostic coding

Converting oral or written descriptions into a alphanumeric designation

Tabular conventions Cross reference notes

Cross reference notes instruct the coder to check elsewhere in the index before assigning a code

Coding for Diabetes mellitus

Diabetes Mellitus are combination codes // When coding Diabetes include Type, Body system affected, and complications affecting that body system // If Insulin-dependant a second code is needed /// Gestational diabetes can cause complications

Section 4: of OGCR

Diagnostic Coding and Reporting guidelines for outpatient services

Treatment or Progress Notes

Diagnostic statement is often found in the Assessment portion of a SOAP note

"See category" Tab convention

Directs the coder to a specific category // "See category" MUST BE FOLLOWED!!

"See" Tab convention

Directs the coder to another main term // Correct code will be found from indicated "See"

Tabular list

Divided in 21 chapters // All the 3 character codes begin with alphabetic letter assigned to that chapter // Each chapter has a color code

Sources of diagnostic statements

Encounter form, treatment notes, discharge summary, operative report, radiology, pathology, and laboratory reports

Coding the Etiology and manifestation

Etiology: Underlying cause or origin of disease ETIOLOGY is CODED FIRST Manifestation: Signs and symptoms Coded second

Tabular List conventions

Excludes 1: DO NOT USE THESE CODES /// Excludes 2: Codes not included in section but a condition might be with patient can be used //

Coding for traumatic fractures

Fractures of specified sites are coded individually by site in accordance with the level of detail provided by the health record // Fracture not indicated as Open or Closed Should be coded as CLOSED

Section 3: of OGCR

Guidelines on Reporting additional diagnosis

Section 2: of OGCR

Guidelines on Selection of Principal Diagnosis

Structure and format of the ICD-10-CM

Has a Alphabetic index and Tabular index // The Center for Medicare and Medicaid Services updates the ICD-10-CM every October 1

"And" convention

Means "And/or"

Coding of Infectious and Parasitic Diseases

Multiple codes are usually needed for infectious or parasitic diseases // First Code: Identifies disease or condition // Second Code: Identifies ORGANISM causing the disease

Exactrating diagnostic statements

Must analyze the patients health record and abstract the diagnostic statement documented in the various reports

NOS ( Not otherwise Specified )

NOS codes always end with 9 // NOS codes used when no documentation exists for a more specific code

Uncertain behaviour ( Coding Neoplasms)

Pathologist is unable to determine whether neoplasm is benign or malignant

Terms defining malignant neoplasm sites ( Coding Neoplasms)

Primary: Identifies originating anatomic site of neoplasm // Secondary: Identifies sites to which primary neoplasm has metastasized // Ca In Situ: Carcinoma in situ is defined as absence of invasion of surrounding tissues

Coding Sequelae

Sequelae are the after effects made by a health condition after the acute phase of a illness or injury has ended //// Coding Sequelae GENERALLY requires that original condition is coded first then Sequela coded Second

Coding of Signs and Symptoms

Signs and symptoms are coded ONLY IF PROVIDER HAS NOT REACHED A FINAL DIAGNOSIS // Pts CC is Subjective // Objective findings are anything measurable indicators during physical examinations

Coding Organism-Caused disease

Two-step process of coding organism-caused diseases BEGINS WITH THE SITE of the condition // Can use " Use additional use" to identify infectious agent

7 Character codes

Typically used to provide specific details about coded condition //// A: Used for first encounter D: Subsequent encounter S: Sequela

Placeholder X uses

Used as the 5th character in certain 6 character codes, also used to fill 6 character space in 7 character codes

NEC codes ( Not elsewhere classified)

Used for diagnostic statement uses specific wording but no specific classification exists to match wording /// NEC codes ALWAYS END IN 8

Operative report

Used for patients who underwent surgery as outpatient or inpatient // Includes preliminary diagnosis and procedure, FINAL diagnosis and procedure

Radiology, laboratory, and pathology reports

Used to establish/support diagnostic statement // Any findings from these reports must be documented in treatment notes in the Health record

Discharge summary

Used to extract diagnostic statement from patient who was hospitalized / Main elements: Patient admission date, H&P findings, Discharge diagnosis, etc