Download as PDF, PPTX
Uploaded byAra Venice Sarmiento
Using the ICD-10-CM
This document covers Chapter 4 of a coding manual focused on the ICD-10-CM guidelines, emphasizing accurate coding practices including the correct use of the alphabetic index and tabular list. Key topics include level of specificity, integral conditions, multiple coding scenarios, and the proper reporting of diagnoses involving laterality and sequela. It outlines the official coding guidelines and conventions developed by leading health organizations, providing essential coding instructions for both outpatient and hospital settings.
Using the ICD-10-CM
- 1. CODING 101-CHAPTER 4 USINGTHE ICD-10-CM DERIVEDFROM BUCK'S 2019 STEP-BY-STEP MEDICAL CODING AVLS
- 2. CHAPTER HIGHLIGHTS TOPICS Organization of theGuidelines Accurate Coding Alphabetic Index and Tabular List Level of Specifity Integral Conditions Multiple Coding Acute and Chronic Combination Codes Late Effects (Sequela) Reporting Same Diagnosis Code More Than Once Laterality
- 3. CODING 101 |USING THE ICD-10-CM ORGANIZATION OF THE GUIDELINES Official Guidelines for Coding and Reporting developed and approved by the American Hospital Association (AHA), American Health Information Management Association (AHIMA), Center for Medicare and Medical Services (CMS), and National Center for Health Statistics Sections Section 1- structure and conventions of the classification and general guidelines that apply to the entire classification and chapter specific guidelines Section 2- guidelines for selection of principal diagnosis for non-outpatient (hospital) settings Section 3- guidelines for reporting additional diagnoses in non-out patient setting Section 4- outpatient coding and reporting
- 4. ACCURATE CODINGHOW-TO Identify the mainterms in the diagnostic statement 1. 2. Locate the main terms in the Alphabetic Index. 4. Follow any cross-reference instructions such as see. 3. Review any subterms under the main term in the Index. CODING 101 | USING THE ICD-10-CM| MADE BY AVLS 5. Verify the codes selected from the Index in the Tabular List. 6. Refer to any instructional notations in the tabular. 8. Code the diagnosis until all elements are completely identified. 7. Assign codes to the highest level of specifity
- 5. ALPHABETIC INDEX AND TABULARLIST First locate the term in the Alphabetic Index, and then verify the code in the Tabular List. Then, read and be guided by instructional notations that appear in both the Alphabetic Index and the Tabular List. The Alphabetic Index does not always provide the full code. Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List. dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required
- 6. definition: the levelof detail when coding an encounter LEVEL OF SPECIFITY REMEMBER: ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and/or fifth characters and/or sixth characters, which provide greater detail. A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.
- 7. CODING 101 |USING THE ICD-10-CM INTEGRAL CONDITIONS When the sign or symptom is due to a diagnosed condition, the sign or symptom are not reported separately. ex. Fever and shortness of breath due to pneumonia Abdominal pain due to gastric ulcer When the signs or symptoms are not due to a diagnosed condition, the signs and symptoms should be reported. ex. Dehydration and pneumonia Ascites and cirrhosis of the liver
- 8. MULTIPLE CODING “Code first”notes are also under certain codes that are not specifically manifestation codes but may be due to an underlying cause. underlying condition should be sequenced first, if known “Code, if applicable, any causal condition first”- indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. Multiple codes may be needed for sequela, complication codes and obstetric codes to more fully describe a condition.
- 9. ACUTE AND CHRONICIfthe same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first. EXAMPLES ACUTE AND CHRONIC THYROIDITIS 1. E06 Thyroiditis E06.0 Acute Thyroditis E06.5 Other chronic thyroiditis CODE: E06.0, E06.5 2. ACUTE AND CHRONIC PERICARDITIS I30 Pericarditis I30.9 Acute Pericarditis I31.9 Other diseases of pericardium CODE: I30.9, I31.9 3. ACUTE AND CHRONIC RHEUMATIC FEVER I00 Rheumatic fever without heart involvement (INCLUDES) I09.9 Rheumatic Heart Disease, unspecified CODE: I00, I09.9 4. ACUTE AND CHRONIC BRONCHITIS J40- Bronchitis J20.9 Acute Bronchitis, unspecified J42 Unspecified chronic bronchitis CODE: J20.9, J42 usually occurs in respiratory system
- 10. CODING 101 |USING THE ICD-10-CM COMBINATION CODESused to classify: Two diagnoses A diagnosis with an associated secondary process (manifestation) A diagnosis with an associated complication identified by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List Assign only the combination code when it fully identifies the diagnostic conditions involved or when the Alphabetic Index so directs. Streptococcal Pharyngitis TABULAR: J02 Acute Pharyngitis J02.0 - Streptococcal Pharyngitis Diabetes Mellitus Example:
- 11. LATE EFFECTS (SEQUELA) REPORTINGSAMEDIAGNOSIS MORETHANONCE Each uniqueICD-10-CM diagnosis code may be reported only once for an encounter If the patient has two different conditions that are both in included in one dicagnosis code, report diagnosis only once. LATERALITYspecifying whether the condition occurs on the left, right or is bilateral If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. The bilateral code would not be assigned for the subsequent encounter. SEQUELA residual effect (condition produced) after the acute phase of an illness or injury has terminated. Coding sequence of sequela: residual first condition that caused the residual CODING GUIDELINES report only when the acute phase has passed but a residual remains When only sequela is mentioned- still follow coding sequence
- 12. THANK YOU! Source: Buck,C.J., Koesterman,J.G.(2019). Buck's Step- by-Step Medical Coding, 2019 Edition. Elsevier Health Sciences.