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Chapter 4

Chapter 4. ICD-9-CM with ICD-10 Coding Guidelines. TERM REVIEW. DIAGNOSIS SIGN SYMPTOM MEDICAL NECESSITY. (continued). ICD-9 PROVIDES. A CODING SYSTEM THAT PROVIDES AN ACCURATE WAY TO COLLECT STATISTICS TO: Keep people healthy Plan for need health care resources

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Chapter 4

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  1. Chapter 4 ICD-9-CM with ICD-10 Coding Guidelines

  2. TERM REVIEW • DIAGNOSIS • SIGN • SYMPTOM • MEDICAL NECESSITY (continued)

  3. ICD-9 PROVIDES A CODING SYSTEM THAT PROVIDES AN ACCURATE WAY TO COLLECT STATISTICS TO: • Keep people healthy • Plan for need health care resources • Record MORBIDITY (disease) data • Record MORTALITY (death) data • Report patients’ conditions on claims (continued)

  4. ICD-9 PROVIDES A CODING SYSTEM THAT PROVIDES • A mandated code set for diagnosis under HIPAA Electronic Health Care Transactions and Code Sets standards. (Codes must be current at the date of the service/patient encounter) (continued)

  5. SEVEN STEPS TO ACCURATE CODING • READ SUPERBILL CAREFULLY • REREAD PHYSICIAN NOTES • ASK QUESTIONS • CODE DIAGNOSIS(ES), SIGNS AND SYMPTOMS • CODE EACH PROCEDURE • LINK EACH PROCEDURE CODE TO AT LEAST 1 DIAGNOSIS • DOUBLE CHECK YOUR CODES (continued)

  6. TERMS • SUPPORTING DOCUMENTATION • UPCODING • UNBUNDLING • DOUBLE BILLING

  7. DETERMINING WHAT TO CODE Raymond went to see Dr Langston because his throat has been scratchy and sore. After examining the patient and taking a throat culture, Dr Langston determines that Raymond has strep throat and writes him a presciption

  8. Abstracting Physician’s Notes • What are the patient’s signs and symptoms (chief complaint)? • What is the diagnosis? (Why is the physician caring/treating or providing services for this patient?)

  9. ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting • Rules developed by cooperating parties for ICD-9-CM and ICD-10-CM to accompany and complement official conventions and instructions provided within ICD-9-CM and ICD-10-CM • Companion to ICD-9-CM and ICD-10-CM (continued)

  10. CASE STUDY Darlene Jones broke a drinking glass in her hand. After cleaning it, she went to the doctor because it was still hurting. He removed additional pieces of glass from the wound What is the diagnostic-related key word? (Index/Volume 2)

  11. LOOK A LITTLE FURTHER IS THE GLASS? A SPLINTER? FOREIGN BODY? IS THE LOCATION OF THE WOUND IN- HER HAND? IN SOFT TISSUE?

  12. WHAT IS YOUR DIAGNOSIS CODE?

  13. HIPAA Alert! • HIPAA regulations require providers and third-party payers to adhere to ICD-9-CM Official Guidelines for Coding and Reporting • Violation of coding guidelines is violation of HIPAA

  14. FUTURE OF ICD-9 • Effective October 1, 2014, ICD-10-CM/PCS replaces ICD-9-CM

  15. ICD-9 Official Guidelines for Coding and Reporting • Organized in FOUR sections • Section I ( Conventions, General Coding Guidelines, and Chapter –specific Guidelines) • Section II (Selection of Principle Diagnosis) • Section III (Reporting Additional Diagnosis) • Section IV- (Diagnostic Coding and Reporting Guidelines for Outpatient Services)

  16. GUIDELINES FOR CODING AND REPORTING • Contain rules that accompany and complement the official conventions and instructions provided within icd-9 • Based on coding and sequencing instructions in the coding manual

  17. GUIDELINES FOR CODING AND REPORTING • Assists the physician and coder to accurately code patient visit (achieve complete and accurate documentation, code assignment, and reporting of diagnosis and procedures

  18. ICD-9 Official Guidelines for Coding and Reporting PAGES 1-2 (ICD-9) -Section I ( Conventions, General Coding Guidelines, and Chapter –specific Guidelines) • Section II (Selection of Principle Diagnosis (OP SETTINGS)) • Section III (Reporting Additional Diagnosis (NON-OP SETTINGS)) • Section IV- (Diagnostic Coding and Reporting Guidelines for Outpatient Services)

  19. ICD-9 Official Guidelines for Coding and Reporting PAGES 3-31 (ICD-9) APPENDIX 1- (PRESENT ON ADMISSION REPORTING GUIDELINES)

  20. General Guidelines • Use both Index to Diseases and Tabular List of Diseases • Locate term in Index to Diseases first and verify code in Tabular List of Diseases • Assign highest level of digits available

  21. Guidelines Signs and symptoms integral to disease should not be assigned as additional codes EXAMPLE 1: Hearing loss, fever, swollen axillary lymph nodes, and infective otitis externa, left ear What is the SYMPTOM? SIGN? What does axillary lymph nodes have to do with the other symptoms? (continued)

  22. EXAMPLE 1 (CON’T) Signs and symptoms integral to disease should not be assigned as additional codes What ICD-9 codes are assigned to this patient visit? (continued)

  23. Guidelines Etiology and manifestation convention requires two codes to be reported to completely describe a single condition EXAMPLE: Peripheral neuropathy DUE TO type 2 diabetes mellitus 1)What is the main term found in the index? 2) What is the subterm? (continued)

  24. Example: Peripheral neuropathy DUE TO type 2 diabetes mellitus What are the codes chosen? Why are they in a certain order? Which code points to the manifestation of the disease? Etiology and manifestation convention requires two codes to be reported to completely describe a single condition (continued)

  25. Guidelines • Multiple coding • Use additional code • Code first • If applicable, code any causal condition first • Acute (or subacute) and chronic conditions • Combination code versus multiple code

  26. Late Effect • Residual condition that develops after acute phase of illness or injury has ended • No time limit on reporting EXAMPLE: Osteoarthritis of left hand due to previous crush injury 1) What is the residual condition? 2) What is the late effect condition? 3) How is this example coded?

  27. Chapter 2: Neoplasms • ICD-9-CM: 140-239 • ICD-10-CM: C00-D499 • Neoplasm • “New growths or tumors in which cell reproduction is out of control” • Benign • Malignant (continued)

  28. Revisiting Neoplasms • Six classifications: • Primary malignancy • Secondary malignancy • Carcinoma (CA) in situ • Benign • Uncertain behavior • Unspecified nature (continued)

  29. Revisiting Neoplasms • How to use the Neoplasm Table • Review example • Assigning code(s) from the neoplasm table • Primary and secondary malignancies • Sequencing the neoplasm codes (continued)

  30. Revisiting Neoplasms Cancer described as, “metastatic to a site” is considered SECONDARY to the site. Assign one code to the secondary site and a second code to the specified primary site or unknown primary site (continued)

  31. Revisiting Neoplasms EXAMPLE 1: Metastatic carcinoma from breast to lung Code (s)? EXAMPLE 2: Metastatic carcinoma from breast Code (s)? (continued)

  32. Chapter 2: Neoplasms • When anatomic sites are documented as metastatic, assign secondary neoplasm code(s) to those sites and assign an unspecified site code to the primary malignant site EXAMPLE 1: Primary renal cell carcinoma of lung. Code(s)? EXAMPLE 2: Metastic osteosarcoma of brain. Code(s)?

  33. Chapter 2: Neoplasms If the diagnostic statement does not specify whether the neoplasm site is primary or secondary, consider the site as PRIMARY, except for the following sites which are considered secondary sites (unless the physician states it is a primary site): Bone Brain Diaphragm Heart Liver Lymph Nodes Mediastinum Meninges Pleura (NOT LUNG) Neoplasms (Category 195) Retroperitoneum Spinal cord

  34. Chapter 2: Neoplasms If the cancer diagnosis does not contain documentation of the anatomic site but the term metastatic is documented, assign the codes for “unspecified site” for both the primary and the secondary sites Example 1: Metastatic chromophobe adenocarcinoma Code(s)?

  35. Chapter 2: Neoplasms If the primary site of malignancy is no longer present and no further treatment is directed to the site, DO NOT assign the code for primary of unspecified site. Classify the previous primary site by assigning the appropriate code from Category V10 Example 1: Metastatic carcinoma to right lung from right breast (left radical mastectomy performed last year) Code(s)?

  36. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders • ICD-9-CM: 240-279 • ICD-10-CM: D50-D89 • Diabetes mellitus (5th digit needed to determine) • Type 1 • Patient’s body unable to produce insulin • Type 2 • Patient’s body unable to properly use insulin produce • Controlled/uncontrolled? • Manifestations?

  37. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders Complete (Textbook) Exercise 4.5

  38. Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders Homework examples: Premature menopause Code? Postsurgical testicular hypofunction Code?

  39. Chapter 4: Diseases of the Blood and Blood-Forming Organs • ICD-9-CM: 280-289 • ICD-10-CM: D50-D89 • Hematopoiesis • Anemia • Red cell volume • Hemoglobin content (continued)

  40. Chapter 4: Diseases of the Blood and Blood-Forming Organs • Shape (morphology) • Purpura • Homework : • Pancytopenia, congenital

  41. Chapter 5: Mental Disorders • ICD-9-CM: 290-319 • ICD-10-CM: F01-F99 • WHO guidelines • When classifying behavioral disorders, organically based illnesses reported before functional illnesses • Within functional group, classify disorders as psychoses, neuroses, personality disorders, and others (continued)

  42. Chapter 5: Mental Disorders • WHO guidelines • When coding mental illnesses associated with physical conditions, assign as many codes as necessary to fully describe clinical picture • New for ICD-10-CM • Pain disorders in psychological factors

  43. Chapter 6: Nervous System and Sense Organs • ICD-9-CM: 320-389 • ICD-10-CM: G00-G99, H00-H95 • Nervous system, including meninges • Central nervous system • Brain • Spinal cord • Peripheral nervous system

  44. Chapter 7: Circulatory System • ICD-9-CM: 390-459 • ICD-10-CM: I00-I99 • Hypertension, hypertensive table • Malignant (accelerated) • Benign • Unspecified COMPLETE Exercise 4.9 (textbook page 162) HOMEWORK- Right heart failure Benign hypertension (continued)

  45. Chapter 7: Circulatory System • Cerebral infarction, stroke, CVA • Late effects of cerebrovascular disease • Myocardial infarction

  46. Chapter 8: Respiratory System • ICD-9-CM: 460-519 • ICD-10-CM: J00-J99 • Nose, sinuses, pharynx, larynx, trachea, bronchi, and lungs • Chronic obstructive pulmonary disease • Refer to main term “obstruction” (continued)

  47. Chapter 8: Respiratory System • Pneumonia • Asthma (status asthmaticus) • Acute exacerbation

  48. Chapter 9: Digestive System • ICD-9-CM: 520-579 • ICD-10-CM: K00-K94 • Major digestive organs include pharynx, esophagus, stomach, and intestines • Accessory (secondary) organs include salivary and parotid glands, jaw, and teeth (continued)

  49. Chapter 9: Digestive System • Structures that support digestive process are gallbladder, pancreas, and liver HOMEWORK Reacurring femoral hernia, with gangrene, unilateral

  50. Chapter 10: Genitourinary System • ICD-9-CM: 580-629 • ICD-10-CM: N00-N99 • Chronic kidney disease (CKD) • Kidney transplant status • ICD-9-CM: V42.0 • ICD-10-CM: Z94.0 • CKD with other conditions

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