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Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition

Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition. Chapter 1: Characteristics of ICD-9-CM and ICD-10-CM. Learning Objectives . Review the chapter’s learning objectives

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Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition

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  1. Basic ICD 10-CM/PCS and ICD-9-CM Coding, 2015 Edition Chapter 1: Characteristics of ICD-9-CM and ICD-10-CM

  2. Learning Objectives • Review the chapter’s learning objectives • A thorough understanding of the basic concepts of the ICD-9-CM and ICD-10-CM classification systems is critical in order to comprehend the more advanced theory to follow in the rest of the chapters.

  3. Characteristics of ICD-9-CM • Single codebook, 3 volumes • Volume 1 Diseases: Tabular List • Volume 2 Diseases: Alphabetic Index • Volume 3 Procedures: Tabular List and Alphabetic Index • Official version available only on CD-ROM from US Government Printing Office

  4. ICD-9-CM Volume 1: Tabular List • Tabular List of Diseases and Injuries • Classification of diseases and injuries • Classify conditions according to etiology (cause of disease) or by specific anatomical (body) system • Supplementary classifications • V Codes • E Codes • Appendices

  5. ICD-9-CM Classification of Diseases and Injuries • 17 chapters • Specific anatomical system • Etiology (cause of disease) • Codes 001–999

  6. ICD-9-CM Chapter Format • Each chapter is structured into the following subdivisions • Sections • Categories • Subcategories • 5th-digit subclassifications

  7. ICD-9-CM Sections • A group of 3-digit categories • Represent a single disease entity or a group of similar or closely related conditions • Example: • Disorders of Thyroid Gland (240–246)

  8. ICD-9-CM Categories • Consist of 3 digits • Represent a single disease entity or a group of similar or closely related conditions • Example: • 520 Disorders of tooth development and eruption

  9. ICD-9-CM Subcategories • Represented by 4th digit • Provide more specificity or information regarding the condition’s • Etiology • Site • Manifestation • 4th-digit subcategories are collapsible to the 3-digit level • Example: 476.0 Chronic laryngitis

  10. ICD-9-CM Fifth-Digit Subclassifications • The 5th digit adds greater specificity to certain 4th-digit codes • 5th-digit assignments and instructions appear at the beginning of a Chapter • For example, in Chapter 13, Diseases of Musculoskeletal System, certain categories must be assigned a fifth digit to describe the affected body site

  11. Fifth-Digit Subclassifications (continued) • 5th-digit assignments and instructions appear at the beginning of a Section • For example, at beginning of section 200–208, Malignant Neoplasm of Lymphatic and Hematopoietic Tissue, fifth digits must be assigned to categories 200–202 to describe the site of the lymph node involved.

  12. Fifth-Digit Subclassifications (continued) • 5th-digit assignments and instructions appear at the beginning of a Category • For example, at the beginning of category 250, Diabetes mellitus, a fifth digit should be assigned to describe the type of diabetes mellitus

  13. Fifth-Digit Subclassifications (continued) • 5th-digit assignments and instructions appear at the beginning of a Subcategory • For example, the fourth-digit subcategory 786.5, Chest pain, is further subdivided to the fifth-digit level to describe specific types of chest pain

  14. 3, 4, or 5 Digits? • Must code to the highest level of specificity • 3-digit code only used when there is no subcategory or subclassification with it • 4-digit code only used when there is no subclassification with it • When available, all 5 digits must be used • Watch for required 4th and 5th digits

  15. ICD-9-CM Residual Subcategories • Code titles that include: • Other • Unspecified • Allows every disease or condition to have a code

  16. Residual Subcategories (continued) • .8 = other • Describes a specific condition that is not otherwise classified to preceding fourth digits in same category • .9 = unspecified • Describes a condition that has not been described as specific enough to assign it to another 4th digit in the same category • .9 = sometimes is both “other and unspecified” in some categories

  17. ICD-9-CM Supplementary Classifications • V codes: Supplementary classification of factors influencing health status and contact with health services • E codes: Supplementary classification of external causes of injury and poisoning

  18. ICD-9-CM Appendices • Appendix A: Morphology of Neoplasms • Appendix C: Classification of Drugs by the American Hospital Formulary Service (AHFS) List • Appendix D: Classification of Industrial Accidents According to Agency • Appendix E: List of Three-Digit Categories

  19. ICD-9-CM Volume 2: Alphabetic Index to Diseases • Three major sections • Index to Diseases and Injuries • Table of Drugs and Chemicals • Alphabetic Index to External Causes of Injury and Poisoning (E Codes)

  20. Volume 2: Alphabetic Index to Diseases (continued) • Three levels of indentation • Main terms • Subterms • Carryover lines

  21. ICD-9-CM Alphabetic Index Main Terms • Word that must be used in Alphabetic Index to locate possible code in Tabular List • Boldface type • Left margin of each column

  22. Alphabetic Index Main Terms (continued) • Main terms represent: • Diseases: Influenza, bronchitis • Conditions: Fatigue, fracture, injury • Nouns: Disease, disturbance, syndrome • Adjectives: Double, large, kink • Usually not an anatomical site; entry for anatomical site tells coder to “see condition”

  23. Alphabetic Index Main Terms (continued) • May be more than one way to find a term • Complications • Name of complication or “Complications” • Obstetrical conditions • “Delivery,” “Labor,” “Pregnancy,” and “Puerperal” • “Disease” or “Syndrome”

  24. ICD-9-CM Alphabetic Index Subterms • Indented under main term to the right by one standard indentation • Alphabetical order • Exception: “with” and “without” appear at the beginning of all the subterms • Describe differences in condition • Anatomic site • Cause • Clinical type

  25. Alphabetic Indec Subterms (continued) • Subterms may have more specific terms indented beneath • Farther to the right, one standard indentation • Alphabetic order • Review all subterms following the main term to determine appropriate code

  26. ICD-9-CM Carryover Lines • Carryover lines are needed for main terms or subterms because the number of words that fit on a single line of print in the Alphabetic Index is limited • Indented two standard indents • Do not confuse with another subterm • Example: review “Rubella” with subterm “complicating pregnancy, childbirth, or puerperium”

  27. ICD-9-CM Nonessential Modifiers • Series of terms in parentheses that may follow main term or subterm • Presence or absence of parenthetical term has no effect on code assignment • Word in parentheses can be in the diagnostic statement (or not appear in the diagnostic statement) and it does not affect the code assignment • Example: Review “Pneumonia” in Alphabetic Index

  28. Eponyms—Proper Names • The name of a disease, structure, operation, or procedure named after a person, usually the person who discovered or described it first • Proper name • Index entries • Eponym (proper name) • Disease, syndrome, or disorder

  29. Terms Not Listed in Tabular List of ICD-9-CM • Many more disease or condition entries in Alphabetic Index than under code in Tabular List • Tabular List includes the most common related phrases but not all possible • Example: “Listlessness” • Guidance of the Alphabetic Index should be trusted

  30. Index Tables in ICD-9-CM • Main terms and subterms are arranged in tables instead of standard columns • Hypertension • Neoplasm • Simplifies access to complex combinations of subterms

  31. Conventions Used in ICD-9-CM • Cross-reference terms • Used in the Alphabetic Index • See: points to an alternative term • See also: requires review of another main term for more information • See category: instruction to consult a specific category in Volume 1, Tabular List

  32. ICD-9-CM Instructional Notations • Appear in Tabular List to clarify information or provide additional direction • Appear at the beginning of a chapter or section or directly below a category or subcategory code • Includes notes • Excludes notes

  33. ICD-9-CM Includes Notes • Further define or provide an example of code(s) • The notes usually list other common phrases used to describe the same condition but it may not be an exhaustive list • Because an inclusion note is not repeated, coder must look back to beginning of chapter, section, category, or subcategory

  34. ICD-9-CM Excludes Notes • Appear in italicized print with a box around it • Provide a direction to code the particular condition listed elsewhere, usually with the code listed in the exclusion note Excludes:

  35. Excludes Notes (continued) Excludes notes have three different meanings 1. Code under consideration cannot be assigned if the associated condition specified in the exclusion note is present. Example: subcategory code 424.3 Exclusion note indicates that code 397.1 should be assigned if the pulmonary valve disorder is specified as rheumatic

  36. Excludes Notes (continued) • Condition may have to be coded elsewhere • The etiology of the condition determines whether the code under review or the code suggested in the exclusion note should be assigned. • One or the other code is used but not both. • Example: See category 603. Code 603 is not used for congenital hydrocele

  37. Excludes Notes (continued) • Note indicates that an additional code may be required to fully explain the condition • The condition in the exclusion note is not included in the code under review • If the condition specified in the exclusion note is present, the additional code should be assignedExample: Chapter 4 codes 280–289 states anemia complicating pregnancy or the puerperium requires a different code (648.2)

  38. ICD-9-CM Notes • Appear in Tabular List and Alphabetic Index • Describe needed 5th digits • Provide additional coding instruction • Provide definition of terms • Alphabetic Index notes are boxed and in italic type • Tabular List notes are located at various levels and are not boxed

  39. Notes (continued) • Examples • Tabular List: 831 Dislocation of Shoulder • Fifth digits are required • Alphabetic Index: Main term “injury” • Gives direction on how to code certain injuries • Tabular List: 326 Late Effect • Describes when this category code is used • Tabular List: 765.0 Extreme Immaturity • Defines what extreme immaturity implies

  40. ICD-9-CM Multiple Coding • In ICD-9-CM, it is often necessary to use more than one code number to fully identify a given condition • A diagnostic statement that includes phrases such as “due to,” “secondary to,” or “with” may require multiple codes • Coder must follow the directions in the Tabular List for the use of additional codes • The Alphabetic Index may refer the coder to a combination code through the use of connection terms • When no combination codes are available, multiple codes are assigned to fully describe the condition

  41. ICD-9-CM Multiple Coding • Mandatory multiple coding • Certain conditions require multiple coding • one code for the underlying condition (cause, etiology) and • another code for the manifestation(s) • Alphabetic Index identifies both codes with the second code in brackets • Example: Diabetic amyotrophy 250.6 [358.1]

  42. Multiple Coding (continued) • Mandatory multiple coding (continued) • 1st code is the underlying condition • 2nd code in brackets is the manifestation • Both codes must be assigned • Codes must be sequenced in the order listed in the Alphabetic Index • Brackets are not used by the coder but are used to highlight the second required code in the book

  43. Multiple Coding (continued) • Indiscriminate multiple coding • Multiple codes should not be used to code irrelevant medical information • Signs and symptoms that are characteristic of an illness are not coded once the cause is identified • Conditions listed in diagnostic test reports should not be coded unless the diagnosis is confirmed by the physician

  44. Multiple Coding (continued) • Indiscriminate multiple coding (continued) • Follow UHDDS guidelines for reporting additional diagnoses • Coding both an unspecified and a specified type of condition is not done to describe the same general condition

  45. Multiple Coding (continued) • Use additional code, if desired • Appears in the Tabular List • The use of an additional code may provide more complete description of the condition • “If desired” should be ignored • Additional code must be assigned if the health record provides supportive documentation

  46. Multiple Coding (continued) • Code first underlying condition • Appears in the Tabular List • Found under codes that should not be listed first or as a single code • The underlying condition and code number(s) appear after the phrase, “Code first” • Note appears after codes in italicized print, which indicates this code should not be listed first or appear as a single code

  47. ICD-9-CM Connecting Words • Appear in Alphabetic Index • Subterms indicate a relationship between the main term and the associated condition or etiology

  48. ICD-9-CM Connecting Words • Associated with • Complicated (by) • Due to • Of • During • Following • In • Without • Secondary to • With • With mention of

  49. Examples of Connecting Words • Point to remember • The connecting words “with” and “without” are sequenced before all other subterms in the Alphabetic Index immediately under the main term • All other connecting terms are listed in alphabetic order in the Alphabetic Index under the main term

  50. Abbreviations and Punctuation Marks in ICD-9-CM • NEC • Not elsewhere classified • NOS • Not otherwise specified • Parentheses • Square brackets • Slanted brackets • Colon

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