Y khoa - Dược - Chapter 18: Diagnostic coding

18Diagnostic CodingLearning Outcomes (cont.)18.1 Recall the six ways that ICD codes are used today.18.2 Describe the conventions used by  ICD-9-CM.18.3 Outline the steps to code a diagnosis using ICD-9-CM.18.4 Explain the purpose and usage of V codes and E codes.Learning Outcomes (cont.)18.5 Name the appendixes found in ICD-9-CM.18.6 Compare ICD-9-CM and the ICD-10-CM.18.7 Summarize the ICD-10-CM general coding guidelines.18.8 Illustrate unique coding applications for neoplasms, diabetes mellitus, fractures, R codes, poisonings, and Z codes.Introduction Diagnosis – translated into ICD codes Reimbursement is based on codes entered so you mustUnderstand what the codes meanKnow how to chose correct codes The Reasons for Diagnostic CodesChief complaint (CC)Diagnosis (DX)Proves medical necessity of treatmentDiagnostic codeCoexisting conditionsThe Reasons for Diagnostic CodesInternational Classification of Diseases9th edition ~ ICD-9-CM10th edition ~ ICD-10-CMOriginal purpose of ICD-9-CMClassification of morbidity and mortality statisticsMedical research, education, and administrationThe Reasons for Diagnostic Codes (cont.)Current uses Facilitation of paymentEvaluation of utilization patternsStudy healthcare costsResearch Prediction of trendsPlanning for futureApply Your KnowledgeHow are ICD codes used?ANSWER: ICD codes are used for:Facilitation of payment for medical servicesEvaluation of utilization patterns Study of healthcare costsResearch regarding quality of healthcare Prediction of healthcare trendsPlanning for future healthcare needsCorrect!An Overview of the ICD-9-CMDiseases and Injuries Tabular List (Volume 1)17 chapters of disease descriptions and codesV codes E codesAlphabetic Index (Volume 2)Volume 3 ~ edition for hospitalsAppendicesConventions NOS – not otherwise specified NEC – not elsewhere classified [ ] – brackets [ ] – slanted bracketConventions (cont.) ( ) Parentheses : Colon } Brace Includes Excludes Use additional codeConventions (cont.)Code first underlying diseaseCode, if applicable, any causal condition first. Be aware ofBoldface typeItalicized typefaceConventions (cont.)Alphabetic IndexOmit CodeSee ConditionSee AlsoRead Coding Guidelines The Alphabetic IndexContains terms needed to locate codes Organized by conditionMain termsSubtermsNonessential terms Cross-references The Tabular ListOrganized by source or body systemCode structure - categoriesRubrics ~ three digit Subcategories ~ four digit Subclassifications ~ five digitCode to highest level of specificityThe Tabular List (cont.)V codesEncounters not related to illness or injuryPrimary or supplemental codesMay not be covered by insurance carrierThe Tabular List (cont.)E codesExternal causes of injuries and poisoning“How did that happen?”Only a supplemental codeApply Your KnowledgeMatching___ contains synonyms or alternative wordings A. NOS___ surround nonessential or supplementary terms B. NEC___ used after an incomplete term C. [ ]___ ICD-9 does not contain a code specific enough D. [ ]___ used if condition cannot be better descriped E. ( )___ a directive; refers you to a different term F. :___ indicates that 2 codes are needed G. See Also___ a suggestion; you might find a better code H. See ConditionANSWER:HGFEDCBASteps to Locating an ICD-9-CM CodeLocate the patient’s diagnosisFind the diagnosis in the Alphabetic IndexLocate the code from the Alphabetic Index in the Tabular ListRead to find the best codeRecord the codeCoding with ICD-9Coding with ICD-9 (cont.)Acute vs. chronic conditions – list acute code firstCombination codes – used in place of single codesMultiple coding – more than one code required to describe diagnosisCoding with ICD-9 (cont.)Coding unclear diagnosesPrincipal vs. primary diagnosisPrincipal diagnosisPrimary diagnosisSecondary diagnosisApply Your KnowledgeWhat are the steps to code a diagnosis?ANSWER: Locate the diagnosis in the medical recordFind the diagnosis in the Alphabetic IndexLocate the correct code in Alphabetic Index and then in the Tabular IndexRead all instructions to find the best codeRecord the codeGood Answer!V Codes and E CodesV codes – Supplementary Classification of Factors Influencing Health Status and Contact with Health ServicesE codes – Supplementary Classification of External Causes of Injury and PoisoningV CodesOutpatient useExamples:V04.81 Influenza vaccination V58.11 (Encounter for) Chemotherapy treatmentV14.0 History (personal) of allergy to penicillinE CodesGeneral useInitial treatment only, except fracturesUse as many codes as requiredPoisonings and Adverse EffectsRefer to poisoning column then to how it occurredMust be documented in the medical record to codeE Codes (cont.)Poisoning AccidentalTherapeuticSuicide attemptAssault BurnsDegree of burnExtent (% of body burned)How it occurred (E code)E Codes are never the primary code patient required stitches to close a wound from a knife patient was exposed to a chemical that caused a rash patient was seen for a shingles vaccination patient had an annual physical patient presented with a fractured wrist child came to office for a sports exam patient is requesting birth control pillsApply Your KnowledgeDetermine whether a V code or E code should be used:ANSWER:V codeV codeV codeV codeE codeE codeE codeAppendices of ICD-9Morphology of NeoplasmsDeletedClassification of DrugsClassification of Industrial AccidentsList of the Three Digit CategoriesApply Your KnowledgeList the appropriate Appendix: deleted in 2004 Classification of Drugs Three Digit Categories Morphology of Neoplasms Classification of Industrial Accidents ANSWER: ADECB Basic Comparison of ICD-9-CM and ICD-10-CMInternal List of Causes of Death – 1893ICD-9 ~ 197514,200 codes No expansionVolume 3 for hospital codesICD-10-CMOver 68,000 diagnostic codesGreater specificityProvides for expansion ICD-10-PCS – hospital codesICD-10 InformationAlpha IndexTabular (numeric) List21 chaptersCategory ~ 3 charactersSubcategory ~ 4-5 charactersFinal code ~ up to 7 charactersCharacters and SpecificityCodes begin with an Alpha characterPossible characters ~ 3-7More precise clinical pictureEnhances trending analysisICD-9 (limited specificity)ICD-10 (expanded specificity)Code: 233.0 Carcinoma in situ breast (vague as to cancer type)Code: D05.01 Lobular carcinoma in situ of right breastORCode: D05.11 Intraductal carcinoma in site of right breastPlaceholders“x” – placeholder for future expansion of code’s specificityDo not drop placeholder when adding charactersICD-9-CMICD-10-CM910.0 Face, neck, and scalp; abrasion or friction burn without mention of infectionS00.01 Abrasion of scalp (code noted to √x7th)910.1 Face, neck, and scalp; abrasion or friction burn, infectedS00.01xA Abrasion of scalp, initial encounter S00.01xD Abrasion of scalp, subsequent encounter S00.01xS Abrasion of scalp, sequelaCombination CodesMore combination codes availableDecreased need for multiple codesICD-9-CMICD-10-CM995.92 Severe sepsisand 785.52 Septic shockR65.21 Severe sepsis with septic shockApply Your KnowledgeList at least two ways that the ICD-10 is an improvement over the ICD-9.ANSWER: The ICD-10 contains many more codes, allows for expansion; has more combination codes, and incorporates placeholders all of which enables more precise coding.Good Answer!Basic Coding Guidelines for ICD-10Locate term in Alphabetic Index Refer to notesRead and follow terms in ( ) and [ ]Go to Tabular listFollow instructional terms to appropriate codeAssign the appropriate code with highest degree of specificityAssign additional code for s/s not associated with diseaseBasic Coding Guidelines for ICD-10 (cont.)Conventions are similar to ICD-9ICD-10 More detailed documentation by physicianNever code from the Alpha IndexVerify codes in Tabular list3-*Apply Your Knowledge What are the general coding guidelines for the ICD-10?ANSWER: Locate the diagnosis in the Alphabetic IndexRead and follow all notes and conventions.Locate in Tabular list.Follow instructions to the appropriate code.Assign the code with highest degree of specificity.Good Job!Synopsis of ICD-10 Coding Guidelines by ChapterChapter 1 – HIV codingR75 ~ inconclusive laboratory evidenceB20 ~ positive serologyZ21 ~ HIV positive, asymptomaticZ71.7 ~ counseling providedSynopsis of ICD-10 Coding Guidelines by ChapterChapter 2 – Neoplasms Type of neoplasmLocation Additional codes Primary vs. secondary neoplasmsTreatments Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 4 – Diabetes mellitusTypeBody system affectedComplications Use of insulinChapter 5 – Pain PsychologicalF45.41Appropriate code from G89 categorySynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 6Eye and ear not includedG89 ~ pain diagnosesIf present, list underlying cause first then the pain codeChapter 9 –  Hypertension I10 ~ essential hypertensionCode underlying etiology then code hypertensionR030.3 ~ transient hypertensionSynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 10Avian or H1N1 influenzaOther types of influenzaChapter 13 – FracturesLaterality Unilateral – 4th digit “1”Designated by 5th digitRequired 7th characterInitialSubsequent SequelaSynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 14Four stages of chronic kidney diseaseESRDChapter 157th digitRead instructions carefullySynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 17Congenital or chromosomal Primary or secondary diagnosisChapter 18 (NEC)R codes No definitive diagnosisMultiple combination codesSynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 19Poisoning5th digit – placeholder “x”6th digit – how occurred7th digit – type of encounterBurns and CorrosionsDepth, extent, agentCorrosive material sequenced firstSynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 20Replaces E codesAccidents or injuriesResearch and preventionAbuse codes take prioritySynopsis of ICD-10 Coding Guidelines by Chapter (cont.)Chapter 21Z codes replace V codesExpanded to includeChemo, radiation, and immunotherapyAfter careAdministrative exams Family history Personal history Synopsis of ICD-10 Coding Guidelines by Chapter (cont.)PracticeRead guidelines carefullyAsk questionsApply Your KnowledgeWhen a code requires a 7th code, what does it indicate? ANSWER: The 7th character of a code indicates the type of encounter: initial, subsequent, or sequela.Right!In Summary18.1 ICD codes are used to facilitate payment for medical services; evaluate utilization patterns; study healthcare costs; research quality of healthcare; predict healthcare trends; and plan for future healthcare needs.18.2 There are conventions used in the ICD. Bold and italics are used in both the Alphabetic Index and Tabular List. Instructions to omit code, see condition, and see also are found exclusively in the Alphabetic Index.In Summary (cont.)18.3 To choose an ICD code, locate all applicable diagnoses. Find the key term in the Alphabetic Index and any applicable subterms. Verify the code’s description in the Tabular List, reading all applicable notations for other coding options and instructions. Document each code carefully using instructions as to code sequencing on the CMS-1500 claim form.In Summary (cont.)18.4 V codes are used for patients who, though not ill, are seeking healthcare. E codes are used to explain how an illness or injury came about. 18.5 The following appendices are found in ICD-9-CM: Appendix A Appendix B Appendix C Appendix D Appendix E In Summary (cont.)18.6 ICD-10-CM is intended to provide a more precise clinical picture of the patient and enhanced trending analysis for data reporting. The number of codes increases in the ICD-10 and the characters change from 3–5 numerical to 3–7 alphanumeric. Both contain the Alphabetic Index of the diseases, conditions, and related terms. The I-10 Tabular List incorporates 21 chapters Many codes use an “x” as a placeholder for future expansion; which was not possible with ICD-9.In Summary (cont.)18.7 The technique of coding with ICD-10 is very similar to that of coding with ICD-9-CM. Locate the diagnosis or symptom in the Alphabetic Index and consider all notes. You then move to the Tabular List as instructed in the Alpha Index. After following terms, abbreviations and symbols, the appropriate code with the highest specificity supported by medical record documentation is selected.In Summary (cont.)18.8 The majority of ICD-10 CM codes follow the general guidelines. However, unique coding applications do exist and chapter guidelines must be followed. These include but are not limited to the chapters on neoplasms, diabetes mellitus, fractures, R codes, poisonings, and the new Z codes.End of Chapter 18Fraud and falsehood only dread examination. Truth invites it. ~ Samuel Johnson