Issues and Trends in HBI Ch 4

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  • Teaching Notes:
    Suggest to students that they review the key terms in this chapter prior to reading the chapter or hearing the lecture. This will enhance their understanding of the material.
     
  • Learning Outcome: 4.1 Discuss the purpose of ICD-10-CM.
    Teaching Notes:
     
    Ask students to define ICD-10-CM and provide an example of how it is used.
    Errors in selecting the correct code can lead to delay in processing, reduced reimbursement, and denied claims.
  • Learning Outcome: 4.1 Discuss the purpose of ICD-10-CM.
    Categories have three characters.
    Most categories then have subcategories that add four or five characters to the code.
    Depending on the number of subcategories, a complete code is from three to seven alphanumeric characters in length.
    This structure allows the coder to assign the most specific diagnosis that is documented in the medical record.
    Sixth and seventh digits, when available, are not optional; they must be used.
  • Learning Outcome: 4.2 Describe the organization of ICD-10-CM.
    Teaching Notes:
     
    Ask students to describe how a medical insurance specialist could use the Alphabetic Index, Tabular List, and Neoplasm Table to locate the appropriate ICD-10-CM code.
    Ask students to refer to the Table of Drugs and Chemicals, explain how the table is used, and provide one example.
    Discuss the use of external cause codes as supplementary codes.
  • Learning Outcome: 4.2 Describe the organization of ICD-10-CM.
    Teaching Notes:
    The correct ICD-10-CM code supports the procedures and treatments the patient receives. 
    Ask students to provide an example of a convention and explain how using them can help in finding codes more efficiently.
  • Learning Outcome: 4.3 Summarize the structure, content, and key conventions of the Alphabetic Index.
    Teaching Notes:
     
    Ask students to identify and discuss the differences between main terms, default codes, and subterms and to explain how each can be used to locate the correct code.
    Note that the coder should always look for the main term related to the condition, never the body part involved.
    For example, wrist fracture would be found under the main term fracture, not wrist.
    Ask students to provide an example of a nonessential modifier and discuss how it can provide more specific details to the third-party payer.
  • Learning Outcome: 4.3 Summarize the structure, content, and key conventions of the Alphabetic Index.
    Teaching Notes:
     
    Eponyms are named for a person, such as the physician who discovered it or invented it.
    Eponyms are usually listed under the person’s name and under the main term disease or syndrome.
    For example, Hodgkin’s disease is listed under Hodgkin’s and under disease.
  • Learning Outcome: 4.3 Summarize the structure, content, and key conventions of the Alphabetic Index.
    Teaching Notes:
      
    Ask students to discuss why codes that describe the manifestation of a disease often require a second code.
    Ask students to describe the relationship between etiology and manifestation codes.
    Provide an example of a combination code.
  • Learning Outcome: 4.4 Summarize the structure, content, and key conventions of the Tabular List.
    Teaching Notes:
     
    Ask students to explain how placeholders and seventh-character extension help raise the level of coding specificity and result in more accurate reimbursement..
    Ask students to describe and discuss how category and subcategory codes help when searching for a diagnosis code (provide examples).
  • Learning Outcome: 4.4 Summarize the structure, content, and key conventions of the Tabular List.
    Teaching Notes:
     Inclusion notes are used to refine the content of the category appearing above it.
    Exclusion notes are used to indicate conditions that are not classified to the code above.
  • Learning Outcome: 4.4 Summarize the structure, content, and key conventions of the Tabular List.
    Teaching Notes:
     Colons indicate an incomplete term; one or more of the entries following the colon is required to complete the term.
    Parentheses are the same as in the Alphabetic Index.
    Brackets indicate synonyms, alternative words, or explanations.
  • Learning Outcome: 4.5 Apply the rules for outpatient coding that are provided in the ICD-10-CM Official Guidelines for Coding and Reporting.
    Teaching Notes:
     The Official Guidelines for Coding and Reporting are a separate set of rules in addition to those incorporated in the Alphabetic and Tabular Indexes.
    These are also known as “Official Guidelines.”
    They have sections for general rules, inpatient coding (hospital), and outpatient coding (office/clinic).
  • Learning Outcome: 4.5 Apply the rules for outpatient coding that are provided in the ICD-10-CM Official Guidelines for Coding and Reporting.
    Teaching Notes:
     
    Often the patient presents to the office with an acute illness.
    An acute illness must be coded with the specific code designated as acute, if available.
    Sometimes a patient will present to the office with both an acute and chronic condition, for example, acute and chronic renal failure.
    In this case, if both illnesses have a code, both must be coded with the acute being listed first.
    Sequelae may happen soon after a disease is over or occur much later.
    The diagnostic statement may read: “due to” or “late effect of.”
    Either a combination code or two codes are required—one for the specific effect and the second for the cause. A combination code provides both elements.
  • Learning Outcome: 4.5 Apply the rules for outpatient coding that are provided in the ICD-10-CM Official Guidelines for Coding and Reporting.
    Teaching Notes:
     A sign is an objective indication that is evaluated by the physician, such as weight loss.
    A symptom is a subjective statement by the patient that cannot be confirmed on diagnosis, such as pain.
  • Learning Outcome: 4.6 Briefly describe the content of Chapters 1-21 of the Tabular List.
    Teaching Notes:
     
    Ask students to provide an example of a specific disease in each category.
  • Learning Outcome: 4.6 Briefly describe the content of Chapters 1-21 of the Tabular List.
    Teaching Notes:
     
    Ask students to provide an example of a specific disease in each category.
  • Learning Outcome: 4.6 Briefly describe the content of Chapters 1-21 of the Tabular List.
    Teaching Notes:
     
    Ask students to provide an example of a specific disease in each category.
  • Learning Outcome: 4.6 Briefly describe the content of Chapters 1-21 of the Tabular List.
    Teaching Notes:
     
    External cause codes are located by first using the third section of the Alphabetic Index, Index to External Causes; they are then verified in Chapter 20 of the Tabular Index.
    The Index to External Causes is organized by accident, circumstances, or event that caused the injury.
    Z codes are researched in the same way as other codes, beginning with the Alphabetic Index.
    The terms that indicate the need for a Z code are different from those for researching other codes. They usually have to do with the reason for the visit, such as contraception, exposure to, or history of.
  • Learning Outcome: 4.7 Assign correct ICD-10-CM diagnosis codes.
    Teaching Notes:
     There are six steps to correctly assigning a diagnosis code.
    1) In the outpatient setting, the process begins with the patient’s chief complaint (CC).
    This is documented, by the physician, in the medical record.
    2) The diagnosis may be listed on the encounter form, or the coder may need to locate it in the medical record.
    3) Remember that the main term is the condition and not the location.
    4) Once the main term is located, look for subterms to find the most specific match for the diagnosis.
    5) Be careful to follow rules for 5th, 6th, and 7th digit requirements.
    6) Be careful to always list the primary diagnosis first, and not to report suspected conditions.
  • Learning Outcome: 4.8 Differentiate between ICD-9-CM and ICD-10-CM.
    Teaching Notes:
     
    Ask students to describe and discuss the differences and similarities between ICD-9-CM and ICD-10-CM.
  • Learning Outcome: 4.8 Differentiate between ICD-9-CM and ICD-10-CM.
    Teaching Notes:
     Both files for equivalent codes and conversion tools can be located via an Internet search.
    It is important not to confuse ICD-9-CM E-codes with ICD-10-CM codes that begin with the letter E.
  • Issues and Trends in HBI Ch 4

    1. 1. CHAPTER 4 Diagnostic Coding: ICD-10-CM © 2014 by McGraw-Hill Education. This is proprietary material solely for authorized instructor use. Not authorized for sale or distribution in any manner. This document may not be copied, scanned, duplicated, forwarded, distributed, or posted on a website, in whole or part.
    2. 2. Learning Outcomes When you finish this chapter, you will be able to: 4.1 Discuss the purpose of ICD-10-CM. 4.2 Describe the organization of ICD-10-CM. 4.3 Summarize the structure, content, and key conventions of the Alphabetic Index. 4.4 Summarize the structure, content, and key conventions of the Tabular List. 4-2
    3. 3. Learning Outcomes (continued) When you finish this chapter, you will be able to: 4.5 Apply the rules for outpatient coding that are provided in the ICD-10-CM Official Guidelines for Coding and Reporting. 4.6 Briefly describe the content of Chapters 1 through 21 of the Tabular List. 4.7 Assign correct ICD-10-CM diagnosis codes. 4.8 Differentiate between ICD-9-CM and ICD-10-CM. 4-3
    4. 4. 4-4 Key Terms • • • • • • • • • • • acute Alphabetic Index category chief complaint (cc) chronic code coexisting condition combination code convention default code diagnostic statement • • • • • • • • • • eponym etiology excludes 1 excludes 2 exclusion notes external cause code first-listed code GEMs ICD-9-CM ICD-10-CM
    5. 5. Key Terms (continued) • ICD-10-CM Official Guidelines for Coding and Reporting • inclusion notes • Index to External Causes • laterality • main term • manifestation • NEC (not elsewhere classified) • Neoplasm Table • nonessential modifier 4-5 • NOS (not otherwise specified) • placeholder character (x) • primary diagnosis • principal diagnosis • sequelae • seventh-character extension • subcategory • subterm • Table of Drugs and Chemicals • Tabular List • Z code
    6. 6. 4.1 ICD-10-CM 4-6 • Used to code and classify morbidity data • Clinical modification (CM) codes describe conditions and illnesses more precisely than ICD-10 • Mandated for diagnoses under HIPAA Electronic Health Care Transactions and Code Sets standard beginning October 1, 2014
    7. 7. 4.1 ICD-10-CM (continued) • Code Makeup – 3-7 character alphanumeric • • Category has three characters Subcategories have four or five character codes • Updates called addenda available on government website 4-7
    8. 8. 4.2 Organization of ICD-10-CM 4-8 • Alphabetic Index – lists diseases and injuries alphabetically with appropriate diagnosis codes • Tabular List – lists diagnosis codes in chapters alphanumerically • Neoplasm Table – table of code numbers for neoplasms by anatomical site, divided by description • Table of Drugs and Chemicals – index of drugs and chemicals from Tabular List • Index to External Causes – index of external causes from Tabular List
    9. 9. 4.2 Organization of ICD-10-CM (continued) 4-9 • Diagnostic statement – physician’s description of the main reason for the patient encounter; begins the process of assigning ICD-10-CM code • Conventions – technique providing visual guidance for understanding coding information
    10. 10. 4.3 The Alphabetic Index • Main Terms, Subterms and Nonessential Modifiers – – – – – Main term – identifies disease or condition Default code – listed next to main term Subterm – word or phrase describing a main term Etiology – cause or origin of disease or condition Nonessential modifier – supplementary word or phrase helping to define a code 4-10
    11. 11. 4.3 The Alphabetic Index (continued) 4-11 • Common terms – similar names for conditions • Eponyms – name or phrase formed from or based on a person’s name • Indention: Turnover lines – indented farther to the right than subterms • Cross-references see and see also indicate further information is available • Not elsewhere classifiable (NEC) – if disease or condition cannot be placed in any category • Not otherwise specified (NOS) – if disease or condition is not completely described in medical record
    12. 12. 4.3 The Alphabetic Index (continued) • Multiple Codes, Connecting Words, and Combination Codes – manifestation – disease’s typical signs, symptoms or secondary process – needs second code indicated by brackets after the term – first-listed code – diagnosis that is the main condition – combination code – single code describing etiology and manifestation(s) of a particular condition 4-12
    13. 13. 4.4 The Tabular List • placeholder character (x) - character “x” inserted in a code to fill a blank space • seventh-character extension – necessary assignment of a seventh character to a code; often for the sequence of an encounter • category – three-character code for classifying disease or condition • subcategories - four- or five- character code number 4-13
    14. 14. 4.4 The Tabular List (continued) 4-14 • inclusion notes – entries addressing applicability of certain codes to specified conditions • exclusion notes – entries limiting applicability of particular codes to specified conditions – excludes 1 – used when two conditions could not exist together, such as an acquired and a congenital condition; means “not coded here” – excludes 2 – means a particular condition is not included here, but a patient could have both conditions at the same time
    15. 15. 4.4 The Tabular List (continued) 4-15 • Punctuation – colon (:) – indicates an incomplete term – parentheses ( ) – used around descriptions that do not affect the code – brackets [ ] – used around synonyms, alternative wordings, or explanations – NEC and NOS used with same meanings as in Alphabetic Index • etiology/manifestation coding – may include instructions on required use of additional code or to code first the underlying disease • Laterality – documents side of the body being classified with the fourth, fifth or sixth characters of a code
    16. 16. 4.5 ICD-10-CM Official Guidelines for Coding and Reporting 4-16 • ICD-10-CM Official Guidelines for Coding and Reporting – General rules, inpatient (hospital) coding guidance, and outpatient (physician office/clinic) coding guidance from the four cooperating parties (CMS, AHA, AHIMA, NCHS) • primary diagnosis – listed and coded first • coexisting condition – additional illness that either has an effect on the patient’s primary illness or is also treated during the encounter
    17. 17. 4.5 ICD-10-CM Official Guidelines for Coding and Reporting (continued) 4-17 • acute – illness or condition with severe symptoms and a short duration • chronic – illness or condition with a long duration • sequelae – conditions that remain after an acute illness or injury has been treated and resolved
    18. 18. 4.5 ICD-10-CM Official Guidelines for Coding and Reporting (continued) • Code to the highest level of certainty – principal diagnosis – in inpatient coding, the condition established after study to be chiefly responsible for the admission of the patient – If different, postoperative diagnosis would have a higher level of certainty than primary diagnosis • Code to the highest level of specificity – coder must be able to distinguish between not mentioned in the documentation or not specified in the code listing 4-18
    19. 19. 4.6 Overview of ICD-10-CM Chapters 4-19 • A00-B99 – Certain Infectious and Parasitic Diseases • C00-D49 – Neoplasms • M codes – used by pathologists • D50-D89 – Diseases of the Blood and Bloodforming Organs and Certain Disorders involving the Immune Mechanism • E00-E89 – Endocrine, Nutritional, and Metabolic Diseases
    20. 20. 4.6 Overview of ICD-10-CM Chapters (continued) • • • • • • • F01-F99 – Mental and Behavioral Disorders G00-G99 – Diseases of the Nervous System H00-H59 – Diseases of the Eye and Adnexa I00-I99 – Diseases of the Circulatory System J00-J99 – Diseases of the Respiratory System K00-K94 – Diseases of the Digestive System L00-L99 – Diseases of the Skin and Subcutaneous Tissue • M00-M99 – Diseases of the Musculoskeletal System and Connective Tissues 4-20
    21. 21. 4.6 Overview of ICD-10-CM Chapters (continued) • N00-N99 – Diseases of the Genitourinary System • (O00-O9A) – Pregnancy, Childbirth, and the Puerperium • P00-P96 – Certain Conditions Originating in the Perinatal Period • Q00-Q99 – Congenital Malformations, Deformations, and Chromosomal Abnormalities • R00-R99 – Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified 4-21
    22. 22. 4.6 Overview of ICD-10-CM Chapters (continued) 4-22 • S00-T88 – Injury, Poisoning, and Certain Other Consequences of External Causes • V00-Y99 – External Causes of Morbidity – external cause code reports cause of injuries from events such as transportation accidents, falls, and fires and are not used alone or as first-listed codes • Z00-Z99 – Factors Influencing Health Status and Contact with Health Services – Z code is abbreviation for codes identifying encounters not due to illness or injury
    23. 23. 4.7 Coding Steps • Step 1: Review complete medical documentation – chief complaint – patient’s reason for seeking care • Step 2: Abstract the medical conditions from the visit documentation • Step 3: Identify the main term for each condition • Step 4: Locate the main term in the Alphabetic Index • Step 5: Verify the code in the Tabular List • Step 6: Check compliance with any applicable Official Guidelines and list codes in appropriate order 4-23
    24. 24. 4.8 ICD-10-CM and ICD-9-CM 4-24 • ICD-9-CM – previous HIPAA-mandated diagnosis code set • ICD-10-CM provides many more categories for disease and other health-related conditions with higher level of specificity possible • Codes in ICD-10-CM combine etiology and manifestations, poisoning and external cause, or diagnosis and symptoms
    25. 25. 4.8 ICD-10-CM and ICD-9-CM (continued) 4-25 • ICD-9-CM had 17 chapters and two supplemental classifications, V codes, and E codes • ICD-10-CM has 21 chapters and the order of chapters has changed • ICD-9-CM codes were 3-5 characters and ICD-10CM codes are 5-7 characters to reach a higher level of specificity • GEMs – general equivalence mappings to assist in the transition from ICD-9-CM to ICD-10-CM
    26. 26. Summary
    27. 27. Summary
    28. 28. Summary

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