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CHAPTER 4

Diagnostic Coding: ICD-10-CM. CHAPTER 4. See the ten-step Revenue Cycle figure (at the beginning of the chapter). This chapter focuses on the following steps : Preregister patients Establish financial responsibility Check in patients Review coding compliance Review billing compliance

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CHAPTER 4

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  1. Diagnostic Coding: ICD-10-CM CHAPTER 4

  2. See the ten-step Revenue Cycle figure (at the beginning of the chapter). • This chapter focuses on the following steps: • Preregister patients • Establish financial responsibility • Check in patients • Review coding compliance • Review billing compliance • Check out patients • Prepare and transmit claims • Monitor payer adjudication • Generate patient statements • Follow up payments and collections Chapter 4Diagnostic Coding: ICD-10-CM

  3. 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. Learning Outcomes (1)

  4. 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. Learning Outcomes (2)

  5. Key Terms (1) • 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

  6. Key Terms (2) • ICD-10-CM Official Guidelines for Coding and Reporting • inclusion notes • Index to External Causes • laterality • main term • manifestation • NEC (not elsewhere classifiable) • Neoplasm Table • nonessential modifier • 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

  7. Used to code and classify morbidity (disease) data U.S. federal government ICD-10-CM clinical modification (CM) codes describe conditions and illnesses more precisely than WHO’s ICD-10 Mandated for diagnoses under HIPAA Electronic Health Care Transactions and Code Sets standard beginning October 1, 2015 Expertise in diagnostic coding requires knowledge of medical terminology, pathophysiology, and anatomy, as well as experience in correctly applying the guidelines for assigning codes 4.1 ICD-10-CM (1)

  8. ICD-10-CM Code Makeup • Code—three- to seven-character alphanumeric representation of a disease or condition • Category has three-character code • Subcategory has four- or five-character code • When available, sixth and seventh characters are REQUIRED Updates called addenda are available on government website • New codes must be used when they go into effect 4.1 ICD-10-CM (2)

  9. Two major parts (with subsections): • Alphabetic Index – part of ICD-10-CM listing diseases and injuries alphabetically with corresponding suggested diagnosis codes (see Figure 4.1) • Neoplasm Table – summary table of code numbers for neoplasms by anatomical site (and divided by the description of the neoplasm) • Table of Drugs and Chemicals – index in table format of drugs and chemicals listed in the Tabular List • Index to External Causes – index of all external causes of diseases and injuries classified in the Tabular List • Tabular List – part of ICD-10-CM listing diagnosis codes in chapters alphanumerically (see Figure 4.2) 4.2 Organization of ICD-10-CM (1)

  10. Process of assigning ICD-10-CM diagnosis codes: • In the medical documentation, find the main reason the patient is receiving care • In the Alphabetic Index, find the description of the condition and proposed (suggested) code • In the Tabular List, look up the proposed code, and study any conventions (notations/rules) to guide you in selecting the right code This process (including verifying in the Tabular List) must be followed when assigning all codes 4.2 Organization of ICD-10-CM (2)

  11. Diagnostic statement – physician’s description of the main reason for the patient encounter; begins the process of assigning ICD-10-CM codes • Convention – typographic technique that provides visual guidance for understanding information 4.2 Organization of ICD-10-CM (3)

  12. Alphabetic Index is organized by condition, not body part • Main Terms, Subterms, and Nonessential Modifiers • Main term – word that identifies a disease or condition in the Alphabetic Index • Default code – ICD-10-CM code listed next to the main term in the Alphabetic Index that is most often associated with a particular disease or condition • Subterm – word or phrase that describes a main term in the Alphabetic Index • Etiology – cause or origin of disease or condition (or a description of a particular type or body site for the main term) • Nonessential modifier – supplementary word or phrase that helps to define a code in ICD-10-CM 4.3 The Alphabetic Index (1)

  13. Common terms – similar names for the same condition (example = flu, influenza) Eponym – name or phrase formed from or based on a person’s name (example = Hodgkin’s disease) Turnover lines – term is too long to fit on one line (indented farther to the right than subterms) Cross-references—“see” and “see also” indicate further information is available 4.3 The Alphabetic Index (2)

  14. Not elsewhere classifiable (NEC) – abbreviation indicating the code to use when a disease or condition cannot be placed in any other category (if disease or condition is not listed/classified in the code book) Not otherwise specified (NOS) – term that indicates the code to use when no information is available for assigning the disease or condition a more specified code (if disease or condition is not completely described/specified by the provider in the medical record documentation) 4.3 The Alphabetic Index (3)

  15. Multiple Codes, Connecting Words, and Combination Codes • Manifestation – characteristic sign or symptom of a disease • Typical signs, symptoms or secondary process – needs second codeindicated by brackets after the term • First-listed code – code for diagnosis that is the patient’s main condition • In cases involving an underlying condition and manifestation, the underlying condition is the first-listed code • Combination code – single code describing both the etiology and manifestation(s) of a particular condition 4.3 The Alphabetic Index (4)

  16. The Tabular List is divided into: • Category – three-character code for classifying a disease or condition • Subcategory - four- or five- character alphanumeric code (see Figure 4.2) • Placeholder character (x) - character “x” inserted in a code to fill a blank space (also known as the “dummy placeholder”) • Code – three, four, five, six, or seven alphanumeric characters (starting with a letter) • Seventh-character extension – necessary assignment of a seventh character to a code; often for the sequence of an encounter 4.4 The Tabular List (1)

  17. Inclusion notes – Tabular List entries addressing the applicability of certain codes to specified conditions (indicated by the word “includes”) • Exclusion notes – Tabular List entries limiting applicability of particular codes to specified conditions (indicated by the word “excludes”) • Excludes 1 – exclusion note used when two conditions could not exist together, such as an acquired and a congenital condition; means “not coded here” • Excludes 2 – exclusion note meaning that a particular condition is not included here, but a patient could have both conditions at the same time; means “not included here” 4.4 The Tabular List (2)

  18. Punctuation • Colon (:) – indicates an incomplete term • Parentheses ( ) – used around descriptions that do not affect the code • Brackets [ ] – used around synonyms, alternative wordings, or explanations • Abbreviations: NEC and NOS are used in the Tabular List with the same meanings as in the Alphabetic Index 4.4 The Tabular List (3)

  19. Etiology/manifestation coding – notes may include instructions on required use of additional code • code first the underlying disease • Laterality – use of ICD-10-CM classification system to capture the side of the body that is documented; the fourth, fifth, or sixth characters of a code specify the affected side(s) • documents the side of the body (left or right) being classified 4.4 The Tabular List (4)

  20. 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 advisers and participants from the AHA, AHIMA, and NCHS) • Overview of key points: (see Figure 4.3) • Code the primary diagnosis first, followed by current coexisting conditions • Code to the highest level of certainty • Code to the highest level of specificity 4.5 ICD-10-CM Official Guidelines for Coding and Reporting (1)

  21. Breakdown of key point: (see Figure 4.3) • Code the primary diagnosis first, followed by current coexisting conditions • Primary diagnosis – first-listed diagnosis • Coexisting condition – additional illness that either has an affect on the patient’s primary illness or is also treated during the encounter • Acute vs. chronic conditions: • Acute – illness or condition with severe symptoms and a short duration (list acute code before chronic) • Chronic – illness or condition with a long duration • Sequelae – conditions that remain after an acuteillness or injury has been treated and resolved 4.5 ICD-10-CM Official Guidelines for Coding and Reporting (2)

  22. Breakdown of key point: (see Figure 4.3) 2. Code to the highest level of certainty • Signs and symptoms—only code if there is no definitive diagnosis • Suspected conditions—do not code unconfirmed diagnoses (“rule out,” “suspected,” “probable,” or “likely”), but code signs and symptoms instead • Principal diagnosis – in inpatient coding, the condition established after study to be chiefly responsible for the admission of the patient • Postoperative vs. primary: if different, the postoperative diagnosis would have a higher level of certainty than the primary diagnosis 4.5 ICD-10-CM Official Guidelines for Coding and Reporting (3)

  23. Breakdown of key point: (see Figure 4.3) 3. Code to the highest level of specificity • Additional characters in a code add to the clinical picture of the patient • Other vs. unspecified—coder must be able to distinguish between not mentioned in the documentation or not specified in the code listing 4.5 ICD-10-CM Official Guidelines for Coding and Reporting (4)

  24. A00-B99 – Certain Infectious and Parasitic Diseases • C00-D49 – Neoplasms • malignant • benign • uncertain • unspecified • M codes – Morphology (used by pathologists) • D50-D89 – Diseases of the Blood and Blood-forming Organs and Certain Disorders involving the Immune Mechanism • E00-E89 – Endocrine, Nutritional, and Metabolic Diseases 4.6 Overview of ICD-10-CM Chapters (1)

  25. F01-F99 – Mental, Behavioral, and Neurodevelopmental Disorders G00-G99 – Diseases of the Nervous System H00-H59 – Diseases of the Eye and Adnexa H60-H95 – Diseases of the Ear and Mastoid Process I00-I99 – Diseases of the Circulatory System J00-J99 – Diseases of the Respiratory System K00-K95 – Diseases of the Digestive System L00-L99 – Diseases of the Skin and Subcutaneous Tissue 4.6 Overview of ICD-10-CM Chapters (2)

  26. M00-M99 – Diseases of the Musculoskeletal System and Connective Tissue • N00-N99 – Diseases of the Genitourinary System • O00-O9A – Pregnancy, Childbirth, and the Puerperium • Note: When coding, be careful of zero (0) versus the letter oh (O) • P00-P96 – Certain Conditions Originating in the Perinatal Period • Q00-Q99 – Congenital Malformations, Deformations, and Chromosomal Abnormalities 4.6 Overview of ICD-10-CM Chapters (3)

  27. R00-R99 – Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified • 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; they are not used alone or as first-listed codes • Z00-Z99 – Factors Influencing Health Status and Contact with Health Services (see Table 4.2) • Z codes = used to report encounters for circumstances other than a disease or injury 4.6 Overview of ICD-10-CM Chapters (4)

  28. Step 1: Review complete medical documentation • Chief complaint (cc) – patient’s description of the symptoms or other reasons for seeking medical 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 (do not skip this step!) • Follow conventions; read notes and instructions • Step 6: Check compliance with any applicable Official Guidelines, and list codes in appropriate order 4.7 Coding Steps

  29. ICD-9-CM – previous HIPAA-mandated diagnosis codeset (covered in chapter 18) • ICD-9-CM vs. ICD-10-CM • Both ICD-9-CM and ICD-10-CM contain Alphabetic and Tabular lists, with the same Coding Steps (section 4.7) • ICD-10-CM provides many more categories for disease and other health-related conditions with higher level of specificity possible than ICD-9-CM • ICD-9-CM has about 14,000 codes • ICD-10-CM has about 70,000 codes 4.8 ICD-10-CM and ICD-9-CM (1)

  30. ICD-9-CM vs. ICD-10-CM (continued) • ICD-9-CM has 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 are three to five characters, and ICD-10-CM codes are five to seven alphanumeric 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 *end of presentation* 4.8 ICD-10-CM and ICD-9-CM (2)

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