Medical Billing & Coding: Heald College: Chapter 5 | Diagnostic Coding

Why must diagnostic coding be accurate?

1. Payment for inpatient services rendered to a patient may be based on the diagnosis.

2. In the outpatient setting, the diagnosis code must correspond to the treatment or services rendered to the patient or payment may be denied.

What is the Primary Diagnosis?

1. Related to the chief complaint

2. Main reason for the encounter

3. Used in the OUTPATIENT SETTING.

What is the Secondary Diagnosis?

1. May contribute to the primary diagnosis

2. Not the underlying cause (etiology)

What is the Principal Diagnosis?

1. Only applicable to inpatient cases/claims

2. Similar to primary diagnosis for outpatient

3. CONDITION RESPONSIBLE FOR HOSPITAL ADMISSION

4. Used in the INPATIENT SETTING.

What is the difference between the Primary Diagnosis and Principal Diagnosis?

The Primary Diagnosis is related to the chief complaint and the main reason for the encounter form in the OUTPATIENT SETTING. The Principal diagnosis is the condition responsible for admission in INPATIENT SETTING.

What are the reasons for development and use of diagnostic codes?

1. Tracking of disease processes

2. Classification of causes of mortality

3. Medical research

4. Evaluation of hospital service utilization

What are the 3 volumes used in the ICD-9 system?

Volume 1: Tabular List of Diseases

Volume 2: Alphabetic Index of Diseases

Volume 3: Tabular List and Alphabetic Index of Procedures

What is Volume 1 in the ICD-9 book?

Tabular List of Diseases

What is Volume 2 in the ICD-9 book?

Alphabetic Index of Diseases

What is Volume 3 of the ICD-9 book?

Tabular List and Alphabetic Index of Procedures

What healthcare setting is Volumes 1 and 2 used?

In Physician Offices and hospitals for diagnoses

What healthcare setting is Volume 3 used?

Hospitals for procedures

What does NEC mean?

Not Elsewhere Classifiable

What does NOS mean?

Not Otherwise Specified

Why are brackets used?

Used to enclose synonyms, alternate wordings or explanatory phrases

What are the Steps for Coding?

1. Look for the main term in the diagnosis.

2. Look for the main condition in Volume 2.

3. Go to Volume 1 to assign the code.

What is a compilation of statistics regarding services and payments made to a physician over a period of time?

Physician's Fee Profile

How many digits does an ICD-9 code have?

3-5 digits

What are V codes used for?

Used for a person who is not currently sick encounters health services for some specific purpose.

What are E codes used for?

Used when some circumstance or problem is present that influences the person's health status but is not in itself a current illness or injury.

When are V Codes used?

1. When a person who is not currently sick encounters health services for a specific purpose (vaccination, etc.)

2. When a person with a resolving disease or injury seeks aftercare

3. When a circumstance influences an individual's health status but the illness is not current

4. When it is necessary to indicate the birth status of a newborn

How are E Codes used?

1. Used to explain the mechanism for the injury

2. Used to gather data about injury causes

3. Should be reported in addition to the appropriate procedural/diagnostic codes

4. NEVER the primary diagnosis

Benign Tumor

One that does not have properties of invasion and metastasis and is usually surrounded by a fibrous capsule

Malignant Tumor

Has the properties of invasion and metastasis

Carcinoma

Refers to a cancerous or malignant tumor

Carcinoma in situ

Cancer confined to the site of origin without invasion of neighboring tissues.

What is V25.2 used for?

Sterilization for contraceptive purposes, elective purposes.

Where can you find 5th digits?

1. At the beginning of each chapter.

2. At the beginning of a section.

3. At the beginning of a 3 digit category.

4. In a 4th digit subcategory.

What will ICD-10 replace in ICD-9?

1.) ICD-10-CM will replace ICD-9-CM Volumes 1 and 2 (diagnosis codes)

2.) ICD-10-PCS will replace ICD-9-CM Volume 3 (procedure codes)

Why was ICD-10 developed?

1.) ICD-9-CM was not expandable, comprehensive, or multiaxial

2.) ICD-9-CM did not have standardized terminology and included diagnostic information

What are differences in ICD-10 vs ICD-9?

1. Change in code book organization

2. New categories and chapters

3. New six- to seven-digit alphanumeric codes

4. Old injuries are to use S and T codes, by site

5. Expanded explanatory notes and instructions

6. Expanded dual classification system

7. E and V codes are now separate chapters

8. New procedures get unique codes

9. Combination diagnosis/symptom codes added

10. Postoperative complication codes describe type and site or

11. New activity code category

12. ICD-10-PCS is more specific than CPT

What are some special points to remember in Volume 1?

1. Use two or more codes if necessary to completely describe a diagnosis.

2. Search for one code when two diagnoses or a diagnosis with an associated secondary process or complication is present.

3. Use category codes only if there are no subcategory codes.

What are some special points to remember in Volume 2?

1. Notice that appropriate sites or modifiers are listed in alphabetic order under the main terms, with further subterm listings as needed.

2. Examine all modifiers that appear in parentheses next to the main term.

3. Check for nonessential modifiers that apply to any of the qualifying terms used in the statement of the diagnosis found in the patient's medical record.

Other special points to remember in Volume 2?

1. Notice that eponyms appear as both main term entries and modifiers under main terms such as "disease" or "syndrome" and "operation."

2. Look for sublisted terms in parentheses that are associated with the eponym.

3. Locate closely related terms, code categories, and cross-referenced synonyms indicated by see and see also.

What is a default code?

A code shown next to the main term in the Alphabetic Index and represents the condition that is commonly associated with the main term.

What are 2 major differences between ICD-9 and ICD-10 coding?

1. ICD-9 does not have Z-codes.

2. ICD-10 does not have V or E Codes.

What is the definition Adverse Effect?

A pathogenic reaction that occurs to a drug with appropriate dosage is given.

What is the definition of Intoxication?

An adverse effect rather than poisoning when drugs such as digitalis and steroid agents are involved.

What is the definition of Poisoning?

A condition resulting form an intentional overdose of drugs or chemical substances or from a drug or agent given or taken in error.

What are Z codes used for?

1. When a person who is not currently sick encounters health services for a specific reason. Examples are organ donor, receiving vaccine, family planning.

2. When a person with seeks aftercare after a resolving condition.

3. When the circumstance influences the person's health but the illness is not current.

4. When indicating the birth status of a newborn.

AHA

American Hospital Association

AHIMA

American Health Information Management Association

CAC

Computer Assisted Coding

CC

Chief Complaint

CM

Clinical Modification

CPT

Current Procedural Technology

DM

Diabetes Mellitus

DRG

Diagnosis-Related Group

ICD-9-CM

International Classification of Diseases, 9th Revision, Clinical Modifications

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modifications

ICD-10-PCS

International Classification of Diseases, 10th Revision, Procedural Coding System

MRI

Magnetic Resonance Imaging

NCHS

National Center of Health Statistics

Z Codes

Factors influencing health status and contact with health services are reported with the range of Z00-Z99.