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US Army Medical Course MD0753-101 Book2 - Medical Records Administration Branch

US Army Medical Course MD0753-101 Book2 - Medical Records Administration Branch

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Published by: Georges on Nov 11, 2008
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05/09/2014

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U. S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOLFORT SAM HOUSTON, TEXAS 78234
MD0753
MEDICAL RECORDSADMINISTRATION BRANCH I(BOOK 2 OF 2)
EDITION 101
 
MD0753 A-1
APPENDIX A - CODING PRINCIPLESEXPLANATION
There are specific guidelines for coding diagnoses and surgical procedures. Thisappendix contains excerpts of coding principles (modified for instructional purposes)from the Individual Patient Data System (IPDS) User's Manual published by the U.S.Army Patient Administration Systems and Biostatistics Activity (PAS&BA). Theseexcerpts provide coding principles for diagnostic and operative coding using theICD-9-CM. The IPDS User's Manual includes additional principles that are not providedin this appendix. The numbers for each of the principles in this appendix are the sameas the corresponding principle in the IPDS User's Manual so you will be able to identifythe principles that are not covered in this subcourse.In previous lessons, you have reviewed the preliminary coding guidelines that, for themost part, are applicable generically; i.e., they apply to all coding processes. Toprovide more specific guidance, this appendix includes 18 principles in short, narrativeform. However, each coder should have his/her own copy of the Triservice Disease andProcedure Coding Guidelines ICD-9-CM, which became effective 1 January 1991.
Principle I. SUSPECTED CONDITIONS
1. Qualifying adjectives used in the final diagnostic statement imply that a final judgment has not been made. When words such as "suspected," "probable,""questionable," "likely," etc., are used in the diagnosis, code the condition as if it were aconfirmed diagnosis.2. The code assigned to the questionable condition may be used as the principaldiagnosis if it was proven to be the condition, after study, that occasioned thisadmission.3. Qualifying adjectives such as "Rule Out," "R/O," and "Ruled Out" present specialproblems for which the following coding rules have been developed.a.
Rule Out and R/O.
When these words appear in the final diagnostic statement,they have the same meaning as "suspected" and are to be coded as if the conditionwere confirmed.b. When "Ruled Out," "Not Proven," "Not Confirmed," and "No Evidence Of" appearas part of the diagnosis or the diagnosis is stated in terms which indicate the absence ofthe condition under investigation, the appropriate code from the SupplementaryClassification (V71 category) will be used. The medical record documentation mustsupport the investigation of the suspected condition. Admissions following head traumawhere there is no visible evidence of injury and which after observation show noevidence of after effects are coded to V71.4--Ø, the code extender for Observation,head injury, ruled out. (V713-V716 categories require STANAG Cause of Injury Codeand Trauma code.) Note that codes from the V71 category may only be used as aprincipal diagnosis.

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