Medical coding shay

History of present illness categories

Off: what relieves pain (modifying factors)

Location: where

Duration: how long

Context: what are you doing when it hurts

Associated signs/ symptoms

Redness, burning: how would you describe it (quality)

Timing: continuous? doe it get better or worse?

Severity: how does it compare to past issues

What can go wrong with diagnosis coding? Why can’t computers do it?

Poor physician handwriting, diagnosis, or documentation

Transcription errors

Patient’s medical record does not support diagnosis

Lack of specificity

ICD-10-CM’s 7 parts

(Sue) Section

(Buys) Body system

(Root) Root operation

(Beer) Body part

(At) Approach

(Dairy) Device

(Queen) Qualifier

Section

16 section codes for ICD-10-CM

What are root operations

Goal of the procedure

Devices

Only coded if left after the procedure (except sutures)

Brackets [ ]

Used in the tabular list to enclose synonyms, alternative working, or explanatory phrases that provide additional information about the code.

Parentheses ( )

used to enclose supplementary words that may be either present or absent in the statement of a disease without affecting the code number to which it is assigned.

Example : Hallucinosis (chronic) F28 : It makes no difference if the work chronic is in the diagnosis or not

Colons :

used in the tabular list after an incomplete term that needs one or more of the words following the colon to make it assignable to a specific categoryExample: Hypertension: essential, secondary

NEC

Not elsewhere classifiable. Equivalent to “other specified” which means the documentation in the medical record provides detail for which a specific code does not existand is used when a specific code is not available for a condition.

NOS

Not otherwise specified. Equivalent to “unspecified” indicating that the documentation in the medical record is insufficient to assign a more specific code.

And

Can mean either and, or

With

Can mean associated with or due to

See

Follows a main term in the alpha index means another term should be referenced. The correct code will not be found unless the instruction is followed

See also

Means there is another main term that may be useful with additional index entries, but it is not mandatory to follow this instruction if the necessary code is found under the original main term

Code first

Mandates that the underlying etiology or cause of the condition to be coded must be coded first, and then the manifestation

Use additional code

will be found at the etiology listing to remind coders that the manifestation should also be coded

Code also

Means that two codes may be needed to fully describe a condition, but hte sequence of those codes is not defined

Excludes type 1

Is used when two conditions cannot occur together and should not be coded together

Excludes type 2

Means the excluded condition is not part of the condition represented by the code, but the two codes may be used together, if appropriate

What to do if there is no diagnosis?

There are codes that describe signs and symptoms

What to do when one condition is noted as chronic and acute?

Sequence acute code first, but code both

Combination codes

Single codes used for a combination of two diagnoses, or a diagnosis with an associated manifestation or complication

Example: Acute cholecystitis is K81.0, while chronic is K81.1. Acute and chronic is K81.2, K81.2 would be used to describe both.

Sequela

Late effect, or residual effect after the acute phase of an illness or injury has terminated. There is no time limit to when a sequela code can be used. The condition or nature of the sequela is coded first, then the sequela coded second.

NDC (National drug codes)

11 digits long, which is problematic for the billing system

Root operations that take out some or all of a body part

Excision

Resection

Detachment

Destruction

Extraction

Root operations that take out solids/fluids/gases from a body part

Drainage

Extirpation

Fragmentation

Root operations involving cutting or seperation only

Division

Release

Root operations that put in/put back or move some/all of a body part

Transplantation

Reattachment

Transfer

Reposition

Root operations that alter the diameter/route of a tubular body part

Restriction

Occlusion

Dilation

Bypass

Root operations that always involve a device

Insertion

Replacement

Supplement

Change

Removal

Revision

Root operations involving examination only

Inspection

Map

Root operations that define other repairs

Control

Repair

Root operations that define other objectives

Fusion

Alteration

Creation

ICD-9-CM Vs. ICD-10 code sets

Procedure 3,000 vs. 71,000

Diagnosis 14,000 vs. 69,000

ICD-10 diagnosis code structure changes

9: 3-5 characters

1st is numeric or alpha

2-5 are numeric

10: 3-7 characters

1 is alpha

2 is numeric

3-7 can be alpha or numeric

ICD-10 Procedure code structure changes

9: 3-4 characters

all are numeric

all codes have at least 3 characters

10: 7 characters

Either alpha or numeric

Numbers 0-9, letters A-H, J-N, P-Z (No I or O because they looks like 1 and 0)

Who is responsible for updating ICD-10-CM, who approves updates, and when is it updated?

CMS and NCHS

Approved by WHO

October

Who handles procedure coding updates, and who handles diagnosis coding updates?

Procedure: CMS

Diagnosis: NCHS

What does a complete diagnostic statement include?

Site (location and which side)

Etiology (cause)