chapter 6
DESCRIPTION
TRANSCRIPT
![Page 1: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/1.jpg)
Chapter 6 ICD-9-CM Coding
![Page 2: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/2.jpg)
ICD-9-CM Coding• International Classification of Diseases
(ICD)– Used to code and classify mortality (death) data from
death certificates
• International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)– Used to code and classify morbidity (disease) data
from inpatient and outpatient records
![Page 3: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/3.jpg)
ICD-10-CM/PCS• Will replace ICD-9 CM on October 1, 2013
– More codes
– Enhances accurate payment of services
– Incorporates much greater specificity and clinical information
– See file
![Page 4: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/4.jpg)
ICD-9-CM Tabular List of Diseases
• Must be used to identify diagnoses, symptoms, conditions, problems, complaints, or any other reason for the encounter/visit
• Codes that describe signs and symptoms are acceptable for reporting purposes when the physician has not documented an established or confirmed diagnosis
![Page 5: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/5.jpg)
Level of Detail in Coding• Codes contain three, four, or five digits
• Codes with three digits:– Included in ICD-9-CM as the heading of a category of
disease codes
– Maybe further subdivided into four or five digits• Provide greater specificity
![Page 6: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/6.jpg)
Sequencing ICD-9-CM Diagnosis
• First code for the diagnosis, condition, problem, or other reason for encounter shown in the medical record to be chiefly responsible for the services provided
• Additional codes that describe coexisting conditions that were treated or medically managed during the encounter should also be reported
![Page 7: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/7.jpg)
Encounter for Services
Diagnostic Services
• First, report the diagnosis, condition, problem, or reason for encounter that is documented in the patient record as being chiefly responsible for the outpatient services provided during the encounter.
Therapeutic Services
• Sequence first the diagnosis,condition, problem, or otherreason for the encounter shown in the medical recordto be chiefly responsible forthe outpatient services pro-vided.
• Assign code(s) to other diagnoses (e.g., chronic conditions) that are treated or medically managed or would affect thepatient’s receipt of services .
![Page 8: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/8.jpg)
Supplementary Classifications:V Codes and E Codes
• V codes are assigned when a circumstance other than a disease or injury is present.
• V codes provide codes to deal with encounters for circumstances other than a disease or injury
• Like V codes, E codes are located in the Tabular List: – E codes describe external causes of injury, like poisoning,
accidents, or other adverse reactions affecting a patient’s health.
•
![Page 9: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/9.jpg)
Appendices• Appendices serve in coding neoplasms,
adverse effects of chemicals and drugs, and external causes of disease and injury.
• In addition, the disease category codes are listed as an appendix.
• Classification of industrial accidents according to agency based on employment injury statistics
![Page 10: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/10.jpg)
Index to Diseases
• Step 1– Locate main term in the Index to Diseases
• Step 2– If the phrase “see condition” is found after the main
term look at the descriptive term
• Step 3– When the condition listed cannot be found locate main
terms such as syndrome, disease, disorder
![Page 11: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/11.jpg)
Coding conventions – rules that apply to the assignment of ICD-9-
CM codes– Codes in slanted
brackets
– Eponyms
– Essential modifiers
– NEC
– Nonessential modifiers
– Notes
– See
– See also
– See also condition
![Page 12: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/12.jpg)
Using the Tabular List
• After reviewing main terms and subterms– Locate the first possible code in the Index to Disease.
• In the Tabular List– Locate code, review code descriptions, review any
EXCLUDES notes to determine whether the condition being coded is excluded.
• Assign any required fifth digit
![Page 13: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/13.jpg)
Index to Procedures and Tabular List of Procedures
• Principal Procedures– A procedure performed for definitive treatment rather
than diagnostic purpose
– One performed to treat a complication
– One that is most closely related to principal diagnosis
• Secondary Procedures– Additional procedures performed during same
encounter as the principal procedure
![Page 14: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/14.jpg)
Hypertension/Hypertensive Table
• Malignant– Severe form of hypertension with vascular damage and
a diastolic pressure reading of 130 mmHg or greater
• Benign– Mild or controlled hypertension
• Unspecified– No notation of benign or malignant status
![Page 15: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/15.jpg)
Neoplasm Table
• Neoplasms
• Another term related with neoplasm is lesion
• Primary Malignancy
• Secondary Malignancy
• Carcinoma (Ca) in situ
• TIP: other terms to consider are mass, cyst, dysplasia, polyp, adenosis
![Page 16: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/16.jpg)
Table of Drugs and Chemicals• Poisonings occur as a result of an overdose,
wrong substance administered or taken, or intoxication.
• Six columns in the table:– Poisoning
– Accident
– Therapeutic use
– Suicide attempt
– Assault
– Undetermined
![Page 17: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/17.jpg)
Supplementary Classifications• ICD-9-CM contains two supplementary
classifications:– V codes
• Factors influencing health status and contact with health services
– E codes • External causes of injury and poisoning
![Page 18: Chapter 6](https://reader033.vdocuments.us/reader033/viewer/2022051411/546653acaf7959c1628b4fba/html5/thumbnails/18.jpg)
E Codes• Used to describe the circumstances of an
illness or injury
• Many states require their use; insurance companies do not
• Can expedite claims payment
• NEVER use as a first-listed diagnosis on a claim