ICD-10-CM

ICD-10-CM

international classification of diseases 10th edition clinical modification

CMS

centers for medicare and medicaid services

WHO

world health organization

HPI

history of present illness

H&P

history and physical

CC

chief complaint

HIV

human immunodeficiency virus

AIDS

acquired immunodeficiency syndrome

DM

diabetes mellitus

example of medical necesity proof

diabetes mellitus needs an A1C

diagnostic coding classification system

• abstract correct diagnosis from diagnostic statement in pt HR

• use main term to look up diagnosis in alphabetic index

• review essential modifier under main term

• choose correct code from alphabetic index in tabular list

• check for coding guidelines, convention, inclusion notes, exclusion notes, additional character symbol

• assign ICD-10CM code

ICD-10-CM can have up to how many characters?

7

dummy place holder

‘‘x’’ to fill for positions that don’t have any charcaters

A, D, S seventh characters for encounters types

• A: initial encounter

• D: subsequent encounter, follow up

• S: sequela, condition that happened

parenthesis

words inside are optional

brackets

show another word for some condition

colon

term incomplete, needs more words

braces

synonyms

main term

appear in bold

found after main term enclosed in parenthesis

nonessential modifiers

indented under essential modifiers

subterms

essential modifier

indented under main term, change description of diagnosis in bold type

Georgia Summers went into anaphylactic shock after drinking milk

• Main term: shock

• Essential modifier: anaphylactic

Betty White has allergic gastroenteritis

• Main term: inflamation (gastroenteritis)

• Essential modifier: allergic

SOAP notes system of documentation

• S: subjective

• O: objective

• A: assesement

• P: plan

preparing medical coding

analyze pt’s HR and abstract diagnostic statement

Diagnostic statement may be found in

• ncounter notes

• progress notes

• radiology reports

• pathology reports

• H & P

• discharge notes

H & P

provider’s health history evaluation and physical assesment of pt

Operative report

for extracting procedure and diagnostic info for pt’s that went under surgery

CC

pt’s own words for reason for seeking medical attention