Coding CH4

Category Notes

Occasionally you may see informational notes under the description of a three-character code or at the top of a subsection in the Tabular List. These notes share important information and clarifications that you need to know before you determine the code or codes to report

The Tabular List

Once you have a suggested code from the Alphabetic Index, Neoplasm Table, Table of Drugs and Chemicals and/or Index to External Cause Codes, you will need to find that code in the Tabular List of Diseases and Injuries. You may never report a code directly from the Alphabetic Index

ICD-10-CM Official Guidelines for Coding and Reporting

in the front of your code book are the rules and regulations for accurate reporting of the diagnosis codes. To make sure the codes you are reporting are presented in a legal manner and support clear communications with all parties involved in the care and reimbursement of patients.

Principal Diagnosis

the condition after study that is the primary or main reason for admission of a patient to the hospital for care. The condition that requires the largest amount of hospital resources for care.

First-Listed

-"first-listed diagnosis" is used when reporting outpatient encounters instead of the term "principal diagnosis

Acute and Chronic conditions

. If a patient has a health concern diagnosed by a physician as being both acute (severe) and chronic (ongoing) and the condition offers you separate codes for the two descriptors, you should report the code for the acute condition first, as directed by the guidelines. Remember from your medical terminology lessons, acute is more serious than chronic.

How many codes do you need

Coders job is to tell the whole story about the encounter between the health care provider and the patient. with diagnosis codes, you relate the whole story about WHY the physician provided the services, treatments and procedures to the pt at this time. You must support medical necessity for all these procedures. When more than one diagnosis code is required to tell the whole story of the encounter accurately, you then must determine in which order the codes should be listed (yes it does matter).

Neoplasm Table

Is a breakout section of the Alphabetic Index, listing the suggested codes for benign and malignant neoplasms. These pages are set up as a seven (7) column table organized by the information in column 1, the anatomical location of the tumor, in alphabetic order. Moving to the right, the following six columns show the suggested code in the following order: Malignant, primary, Malignant, secondary, Ca in situ, Benign, Uncertain Behavior, Unspecified Behavior

Section I. Conventions, General Coding Guidelines and Chapter-Specific Guidelines

Section I has three parts, Conventions for the ICD-10-CM, General Coding Guidelines, and Chapter-Specific Coding Guidelines. This section contains the rules and guidelines for determining and reporting accurate, valid diagnosis codes.

Acute

Severe, serious

CODE FIRST

The "code first" note is your hint that two codes may be needed, along with sequencing direction. The "code first" note is an instructional note. If you see "in diseases classified elsewhere" terminology you will assign two codes, with the manifestation code being sequenced after the underlying condition.

PRINCIPAL DIAGNOSIS

The code reporting the most important reason for the encounter is called the

manifestations

The resulting conditions, ex. Circulation or eye problems, are called

Additional Characters Required

a box with a checkmark and number located to the left of a code in the Tabular List is a symbol that notifies you that additional character is required. the number tells you which character, fourth, sixth or seventh is needed. Some publishers of ICD-10-CM code books use a bullet rather than a box. In addition, some versions of the ICD-10-CM book will use a checkmarkxx7 alerting you to the need for a placeholder, the letter x, to be used in 7th character.

Sequela (Late Effect

a cause and effect relationship between an original condition that has been resolved with a current condition; also known as late effect

Manifestation

a condition caused or developed from the existence of another condition

Eponym

a disease or condition named for a person

Anatomical Site

a specific location within the anatomy (body)

The Legends

across the bottom of every page throughout the Tabular List you will find short explanations for many of the symbols you will see among the codes and their descriptions. These legends are an abbreviation of the more complete explanations of each symbol in the front of the code book, found on the pages titled Overview of ICD-10-CM Official Conventions and Additional Conventions. once you become familiar with each symbol and notation, the legends will provide you with a quick reference to confirm you are making the correct interpretation

Other Specified

additional information the physician specified that isn't included in any other code description.

Inpatient Facility

an establishment that provides health care services to individuals who stay overnight on the premises.

External Cause

an event outside the body that causes injury, poisoning, or an adverse reaction

Adverse Effect

an unexpected bad reaction to a drug or other treatment

Underlying conditions

certain conditions and diseases can cause other problems in the body. example, individuals with diabetes are known to have problems with their eyes or circulation.

Systemic Condition

condition that affects the entire body and virtually all body systems, therefore requiring the physician to consider this in their medical decision making for any other condition

Chronic

continuing for a long time

Nonessential Modifiers

description whose inclusion in the physician's notes that are not absolutely necessary and that are provided simply to further clarify a code description, optional terms

Confirmed

found to be true or definite

Unspecified

has the same meaning as NOS, explaining that the physician did not provide more details in their notes. Query the physician for specifics so you can avoid using an unspecified code. Using these codes should always be the LAST resort.

Outpatient Services

healthcare services provided to individuals without an overnight stay in the facility

Systemic Conditions

if a patient has a systemic condition, this means that the condition affects the entire body, for example, diabetes mellitus, hypertension or pregnancy. The physician therefore must take this into consideration in the medical decision making for virtually any other conditions.

See Also

in other places in the Alphabetic Index, you may see that the instruction "see also" is next to the term you are investigating. See also explains that additional details may be found under a different term. The index is providing you with an alternate main term that may show descriptions more accurate to the physician's documentation.

SEE

in the Alphabetic Index of ICD-10-CM you may look up a term and notice that the book instructs you to SEE another term. This is an instruction in the index that the information you are looking for is listed under a different term

HYPHEN

is used in the Alphabetic Index to indicate that additional characters are required. this alerts you to an incomplete code.

Not otherwise specified (NOS

means that the physician did not document any additional details that are identified in any of the other available code descriptions. On occasion, you may find an NOS in the Alphabetic Index, but most often you will see these notations in the Tabular List. Before reporting a code with NOS in the description, you need to reread the physician's documentation and complete patient chart to make certain the specifics you need to report a more complete code are not there. And even then, you should query the physician to obtain the details. An NOS code should be a very last resort to report.

OTHER SPECIFIED

means the same thing as NEC: The physician specified additional information that the ICD-10-CM book doesn't have in any of the other codes in the category

EXCLUDES2

notation is a warning to STOP and DOUBLE-CHECK the DOCUMENTATION so you don't report the code above the notation when a code shown in the notation may be more accurate. You will see specific conditions listed in the notation that are NOT a part of the code above and a suggestion for an alternate code that may be a more accurate match to the physician's notes. In some cases, the EXCLUDES2 notation may be alerting you that an additional code may be needed to complete telling the story about the patient's condition.

CODE ALSO

notation is similar to the Code first and Use additional code notations, just without the predetermination of sequencing. ICD-10CM is alerting you that the physician's notes may contain some additional condition or issue that should be reported with a separate code, in addition to the code above this notation. This notation leaves it up to you to decide whether or not the additional code is needed to tell the whole story. If it is needed, you will need to use the Official Guidelines, Sections II and III to determine the reporting order.

INCLUDES

notation provides you with additional terms and diagnoses that are included in the above code (this code's description). These notations provide you with additional terms, and variations of descriptors that expand the meaning of this code's description, making it easier to match what the physician wrote in the documentation

Underlying Condition

one disease that affects or encourages another condition

Not elsewhere classifiable (NEC):

or not elsewhere classified indicates that the physician provided additional details of a condition but that the ICD-10-CM book did not include those extra details in any of the other codes in the book. NEC may appear in either the Alphabetic Index or the Tabular List. Before reporting a code with NEC in its description, you want to check and double-check that there is not another code with a more complete description that matches the details documented in the physicians notes.

Table of Drugs and Chemicals

provide suggested codes related to the cause of a patient being poisoned or of having an adverse reaction to a medication. This table's first column shows a list of most drugs and chemicals with which a patient might interact, listed in alphabetic order. The six columns that follow to the right are: Poisoning, Accidental (unintentional), Poisoning, Intentional Self-Harm, Poisoning, Assault, Poisoning, Undetermined, Adverse Effect, Underdosing

Parentheses

show you additional terms or phrases that are also included in the description of a particular code. The additional terms are called nonessential modifiers. The modifiers can be used to provide additional definition but do not change the description of the condition. the additional terms are not required in the documentation so if the provider did not use the additional term, the code description is still valid.

Use Additional Code

similar to Code first notation, the Use additional code notation is the ICD-10CMs way of informing you that you may need to report another code in addition to the code above to accurately tell the whole story of a diagnosis. This extra (additional code) should be reported AFTER the code above the "use additional code" notation.

Seventh Character

some ICD-10-CM codes require a 7th character. Different subsections of the code book use this position, 7th character, to add varying types of information. Most often the character choices are listed at the top of the code category to be used for all codes within this category. You must always begin reading at the top of the code category or subsection for this information. The Tabular List contains all the details you need. All you have to do is read and determine what is the most accurate as per the physician's documentation.

Not Elsewhere Classifiable (NEC

specifics that are not described in any other code in the ICD-10-CM book; also known as not elsewhere classified

Official Conventions

symbols and notations. Throughout the ICD-10-CM code book, directions, tips, symbols and notations are available to guide you to the accurate code for a patient encounter

See Condition

the Alphabetic Index may also point you in a less concrete way, such as when you look up a term and the notation tells you to "see condition". This can be confusing. The index is not telling you to look up the term "condition". what it is instructing you to do is find the term that describes the health-related situation involved with this diagnosis and look up that term. You will see this most often next to the listing for an anatomical site.

Neoplasm Table

the Neoplasm Table lists all possible codes for benign and malignant neoplasms, in alphabetical order by anatomical location of the tumor.

Not Otherwise Specified (NOS

the absence of additional details documented in the notes

Unspecified

the absence of additional specifics in the physician's documentation

Index to External Causes

the alphabetic listing of external causes that might cause a patient's injury, poisoning or adverse reaction

Unrelated Conditions

the attending physician may include information in their documentation that reports a condition or diagnosis that is unrelated to this encounter

AND

the guidelines for the accurate use of ICD-10_CM instruct you to interpret the use of the word AND in a code description "and/or". therefore, if the physician's notes include only one part of a code description but not the other, the code may still be correct.

Alphabetic Index

the section of a code book showing all codes; from A to Z, by the short code description.

Table of Drugs and Chemicals

the section of the ICD-10-CM book listing drugs, chemicals, and other biologicals that may poison a patient or result in an adverse reaction

Tabular List of Diseases and Injuries

the section of the ICD-10-CM code book listing all of the codes in alphanumeric order

Condition

the state of abnormality or dysfunction

With

the term "with" can be seen in both the Alphabetic Index and the Tabular List and you should read this as a connection CONFIRMED by the physician. A phrase you may see in the physician's documentation is "associated with". To use a combination code containing "with" you do not need the physician to document the connection between the two diagnoses. The Official Guidelines direct us to avoid using a combination code when the physician's documentation specifies that the conditions are NOT related or associated with each other.

Placeholder Character:

there are times when a fifth, sixth or seventh character is required, yet there are no fourth, fifth or sixth characters. In these cases, ICD-10-CM uses a placeholder character, the letter "x" so the following characters will fall into their correct locations. The symbols in the Tabular List will lead you to filling out your code accurately. just pay attention to each character as well as in what position each character belongs. The symbol check mark xx7, tells you that you need to add a placeholder x in the fifth and sixth position before determining which of the seventh character options to place at the end of the code.

EXCLUDES1

there are times when two diagnostic statements may be close to each other, yet actually conflict with each other. The Excludes1 notation identifies codes that cannot be used together on the same health claim form with the originally listed code. The notation explains that these two codes are: Contradictory to each other, Cannot coexist in the same person at the same time, Are redundant.

Colon

two dots, one on top of the other, used in the Tabular List, emphasizes that one or more of the following descriptors are required to make the code valid for diagnosis.

Italicized or Slanted Brackets

used in the Alphabetic Index will surround an additional code or codes (i.e. secondary codes) that MUST be included with the initial code.it is the Alphabetic Index's way of telling you that you may need to report more than one code, as well as in what order to sequence these codes. The italic brackets tell you that if the pt has been diagnosed with schitosomiasis due to granuloma, you have to use two codes: First, B65.9 for the underlying condition (the schistosomiasis) and, second, G07 for the granuloma itself.

Screenings and other preventative services

when a screening test is performed (patient has no signs, symptoms or diagnosis of a condition) you will still need to report a code to explain the reason WHY patient had her annual mammogram, or patient had a colonoscopy. Many times you can identify such instances because they are usually determined not by a patient's feelings, signs,symptoms or other active health issues but by the calendar.

Differential Diagnosis

when the physician indicates that the patient's signs and symptoms may closely lead to two different diagnoses, usually written as "diagnosis A vs diagnosis B".

Preoperative Evaluations

whenever a patient is scheduled for a surgical procedure (on a nonemergency basis) there are tydiffpical tests that must be done to ensure that the pt is healthy enough to have the operation. Cardiovascular, respiratory and other examinations are often done a couple of days prior to the date of surgery. Often these tests do not necessarily relate directly to the diagnostic reason the surgery will be performed. Therefore, they will need a different diagnosis code to report medical necessity. Coding these encounters carries a specific guideline.in such cases, the principalor first-listed diagnosis code will be from the following category: Z01.8 Encounter for other specified special examinations

Brackets

will show you alternate terms, alternate phrases, and/or synonyms to provide additional detail or explanation to the description

Test Results

you need to know the difference between a positive test result and a negative test result. You are not permitted to affirm a diagnosis from a test result without the physician's documentation. This rule applies to laboratory tests, x-rays and other imaging, pathology and any other screening or diagnostic testing done for a patient. In such cases, especially when the health care provider has ordered additional tests based on abnormal findings, you should query or ask the physician whether or not you should document the results. Be certain to get your answer in writing in the patient's record. If it is not in writing, you can't code it.