INTRODUCTION TO ICD-9-CM

1. INTRODUCTION TO ICD-9-CM • What is coding? • Transformation of verbal descriptions into numbers • Describes: • Diseases • Injuries • Procedure

2. Official Guidelines • Official Guidelines for Coding and Reporting • Appendix I • Used by ALL healthplans • Volumes 1-2 • Cover diseases, injuries, impairments • Cover other health problems • Cover Causes of injury and disease • Volume 3 covers procedures or other actions taken for disease, injury, or impairments • HCPCS and CPT-4 are used for physicians and other healthcare services (i.e. ambulance, tests, therapy)

3. Tabular List • Classifications of Diseases and Injuries • Supplementary Classifications ( V and E ) • Appendices • 17 Chapters/categories • Volume 1 • Sections (groups of 3 digits) Single disease or group of similar conditions • Categories (3 digit) More specific than sections • Subcategories (4th digit) More specific re:signs, symptoms, secondary illness)

4. Tabular List (cont) • Fifth digit – Even greater specificity. • (See page 5 in your book) • Includes notes – further defines or provides an example. • Excludes notes – directs you to look elsewhere • Two supplementary classifications • V Codes – Factors influencing Health Status and contact with Health Services • E Codes – External Cause of Injury and Poisoning

5. Appendices • Appendix A: Morphology of Neoplasms • M code • Appendix B: Abbreviations • Appendix C: Mocroorganisms • Appendix D: Commonly Used Drugs • Appendix E: Morphology Terminology • Appendix F: Sample Billing Forms • Appendix G: Ethics in Coding • Appendix H: Data Quality • Appendix I: Previous slide - Guidelines

6. Alphabetic Index • Index to Diseases and Injuries • Main terms- boldface type • Subterms- indented (modifiers) affect selection • Carryover lines- needed to fit long term onto another line • Nonessention modifiers- in parentheses- no effect on selection • Eponyms – named after discovering physician, etc. • Not all terms are in Tabular list that are in Alphabetic Index • Cross-reference – item states see to send to alternate term. Direction must be followed. See also requires viewing another main term for best info.

7. Alphabetic Index (cont) • Table of Drugs and Chemicals • Alphabetic Index to External Causes of Injury and Poisoning (E codes)

8. Mandatory Multiple Coding – need to use more than one code to fully identify a given condition; includes “due to”, “secondary to”, or “with” – these may require multiple codes. When no combination codes available – use multiple codes. AVOID indiscriminate multiple coding. • Not Elsewhere Classifiable • Use with ill-defined terms • More precise info is not available • Not Otherwise Specified (Unspecified) • Symbols • Lozenge – square IDs code as unique to US • Parentheses – enclose words or info that may or may not b present in statement of diagnosis • Square brackets – enclose alternate words or phrases.

9. Procedures • Volume 3 – includes Tabular and Alphabetic • Combines with HCPCS • Connecting words – subterms with as, by, or with • Code also – reminder to code additional procedures when they have been performed • Omit code – only used in volume 3 – no code is to be assigned • Code incomplete procedures • Code failed procedures

10. Procedures (cont) • Principal procedure – was performed for definitive treatment rather than for diagnosis or exploratory purposes or for treatment of a complication

11. Uniform Hospital Discharge Data Set (UHDDS) • Minimum core data needed for payment: • Personal ID – number assigned to patient • DOB Sex Race Ethnicity Residence • Hospital ID – assigned to physician • Disposition of patient – to home, AMA, another hospital, long-term, short-term, deceased • Principal diagnosis – condition established after study to be chiefly responsible for the admission of patient • Other diagnosis – All must be listed • Complication Comorbidity(preexisting) • Procedures w/dates - significant or principal

12. Guidelines • Principal Diagnosis: selection depends on the circumstances of admission, diagnostic tests, studies, symptom or illness could be changed after admission. • Pages 51-55 CAREFULLY read the guidelines for principal diagnosis