Chapter 6


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  • Although the guidelines were originally developed for use in submitting government claims, insurance companies have also adopted them. TIP: Most critical rule involves beginning the search for the correct code assignment using the Index to Diseases/of Diseases.
  • ICD-9-CM is organized into three volumes: Volume 1: Tabular List Volume 2: Index to Diseases Volume 3: Index to Procedures and Tabular List Medical necessity Tabular List and Index to Diseases Used in provider and health facilities to code diagnoses Index to Procedures and Tabular List Used in hospitals to code inpatient procedures Publishers make coding easier by placing the Index to Diseases in front of the Tabular List Volume 2 Index to Diseases – alphabetical listings of main terms or conditions Volume 3 Included in hospital version of commercial ICD-9-CM books Medical necessity: Determination that a service or procedure rendered is reasonable and necessary for the diagnosis or treatment of an illness or injury Criteria; Purpose; Scope; Evidence; Value
  • Results Improved ability to measure health care services Increased sensitivity when refining grouping and reimbursement methodologies Enhanced ability to conduct public health surveillance Decreased need to include supporting documentation with claims Includes updated medical terminology and classification of diseases, provides codes to allow comparison of mortality and morbidity data, and provides better data for Measuring care furnished to patients Designing payment systems Processing claims Making clinical decisions Tracking public health Identifying fraud and abuse Conducting research
  • In the outpatient setting, the first-listed diagnosis is used Documentation should describe patient’s condition using terminology that includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. Term first-listed diagnosis is used Determined in accordance with ICD-9-CM’s coding conventions as well as general and disease-specific coding guidelines Outpatient treated in one of four settings Ambulatory Surgery Center (ASC) Patient is released prior to a 24-hour stay Health care provider’s office 3. Hospital clinic, emergency or outpatient department, or same-day surgery unit 4. Hospital observation setting Patient’s length of stay is 23 hours, 59 minutes, and 59 seconds or less TIPs: Outpatient surgery Code reason for surgery as the first-listed diagnosis (reason for the encounter) Even if surgery is not performed due to a contraindication 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. Outpatient surgery requires observation stay: A patient presents for outpatient surgery and develops complications requiring admission to observation. Code the reason for the surgery as the first reported diagnosis, followed by codes for the complications as secondary diagnoses. An inpatient is a person admitted to a hospital or long-term care facility for treatment with an expected stay of 24 hours or more Inpatient principal diagnosis Condition determined after study that resulted in the patient’s admission to the hospital UB-04 secondary diagnoses include comorbidities and complications
  • 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 Three-digit disease code is assigned only if it is not further subdivided. If fourth-digit subcategories or fifth-digit sub-classifications are provided They must be assigned If not the code is invalid
  • Do not code diagnoses documented as Probable, suspected, questionable, rule out, or working diagnosis, because these are considered qualified diagnoses Instead code condition to highest degree of certainty for that encounter Necessary part of patient chart and are reported on UB-04 for inpatient hospital claims Qualified diagnosis Working diagnosis that is not yet proven or established Example: Suspected pneumonia Code the sign or symptom: Wheezing, shortness of breath, etc. Code all that coexist at the time of the encounter, and require or affect patient care, treatment, or management. Do not code conditions that were previously treated and no longer exist. However, history codes may be reported as secondary codes
  • Assign a code to the diagnosis for which the surgery was performed. If the postoperative diagnosis is different from the preoperative diagnosis when the diagnosis is confirmed, assign a code to the postoperative diagnosis instead
  • For routine outpatient prenatal visits when no complications are present, report code V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy) as the first-listed diagnosis.
  • Morphology of Neoplasms (M codes) contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology Morphology Indicates tissue type of a neoplasm Benign Not cancerous Malignant Cancerous Within the ICD-9CM Index to Diseases Two official tables that make it easier to code hypertension and neoplasms
  • Main terms Printed in boldface type and are followed by the code number Subterms (essential modifiers) Qualify the main term by listing alternate sites, etiology, or clinical status
  • Codes in slanted brackets always coded as secondary Diabetic (cateract) Eponyms named for person Barlow’s Syndrome Essential modifiers are subterms indented below main term NEC not elsewhere classified cant find a more specific code Nonessential modifiers subterms in parenthesis Notes in boxes to define terms See go to more specific term suggested See also may provide additional information See also condition See Table 6-3 page 161 for coding conventions for Tabular List
  • Chapters Chapter heading printed in uppercase letters and preceded by the chapter number Instructional “Notes” that follow the chapter heading detail general guidelines for code selections within the entire chapter EXCLUDES statement , reference applies to entire chapter Major Topic Headings Printed in bold uppercase letters and followed by codes in parentheses Categories Major topics are divided into three-digit categories: Printed in upper and lower case and are followed by three-digit codes Subcategories Four-digit subcategories are indented and printed in the same way as major category headings. Subclassifications Some fourth digits are more subdivided into subclassifications, which require the task of a fifth digit. Fifth digits Required when indicated in the code book Fifth-digit entries are associated with Chapters Major topic headings Categories Subcategories Make sure that the code number is appropriate for age and gender of patient. Return to Index to Disease for other possible code selections. If code description does not fit condition or reason for visit Enter final code.
  • Neoplasms New growths or tumors, where cell reproduction is out of control Provider should specify whether the tumor is benign or malignant Should be coded from pathology report Another term related with neoplasm is lesion Defined as any discontinuity of tissue Primary Malignancy Original tumor site All malignant tumors are considered primary: Unless otherwise documented as metastatic or secondary Secondary Malignancy Tumor has spread to a secondary site. Either adjacent to the primary site or to a distant area of the body Carcinoma (Ca) in situ Tumor that is localized, limited, encapsulated, and noninvasive Benign Noninvasive, nonspreading, nonmalignant tumor Uncertain behavior Pathology impossible to predict subsequent morphology or behavior from the submitted specimen Unspecified nature Neoplasm is identified But no more signs of histology or nature of the tumor is in the documented diagnosis Primary Malignancies Malignancy is coded as the primary site if the diagnostic statement documents Metastatic from a site Spread from a site Primary neoplasm of a site Malignancy for which no specific classification is documented Recurrent (repeating) tumor Secondary Malignancies Metastatic and show that a primary cancer has spread to another Cancer described as metastatic from a site is primary of that site: Assign code to the primary neoplasm. Assign second code to the secondary neoplasm of the specified site or unspecified site.
  • Poisoning Assigned according to classification of drug or chemical Accident Accidental overdosing Wrong substance given Drug inadvertently taken Accidents during a medical surgical procedure Therapeutic use Effect caused by proper substance administered in therapeutic setting Suicide attempt Self-inflicted poisoning Assault Poisoning inflicted by another person who intended to kill or injure the patient Undetermined If used, it will not state whether poisoning was intentional or accidental E codes are used to explain cause of poisoning or effect .
  • Classification of factors influencing the person’s health status These services fall into one of three categories: Problems Issues that could affect patient’s health status Services Patient seen for treatment not caused by illness or injury Factual reporting Used for statistical purposes Persons with potential health hazards related to communicable diseases Persons with need for isolation, other health hazards, and prophylactic measures Person with potential health related to personal or family history Persons encountering services in circumstances related to reproduction and development Live born infants according to type of birth Person with a condition influencing their health Encountering health services for specific procedures and aftercare Encountering health services in other circumstances Person without reported diagnosis encountered during examination and investigation of individuals and population
  • Chapter 6

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