ICD-9-CM LU LE THEORY AND PRACTICE TH 2013/2014 Edition Karla R. Lovaasen, RHIA, CCS, CCS-P Jennifer Schwerdtfeger, BS, RHIT, CCS, CPC, CPC-H Gey Dee acy2013/2014 ICD-9-CM CODING THEORY AND PRACTICE with ICD-10, 2013/2014 Edition Karla R. Lovaasen, RHIA, CCS, CCS-P AHIMA Certified ICD-10 Trainer Coding and Consulting Services Abingdon, Maryland Jennifer Schwerdtfeger, BS, RHIT, CCS, CPC, CPC-H AHIMA Certified ICD-10 Trainer Partner, Auditing & Coding Experts, LLC Crofton, Maryland Bahan dengan hak cipELSEVIER 3251 Ri SAUNDERS St Louis, Miseouri 65043 2019/2914 EDITION Copyright © 2018, 2012, 2011, 2010, 2609, 2908 by Saunders an impriet of sever fe. Garren Procedural Terminology (CPT) ix copyright 2012 American Medical Awociation. All Rights Reserved. Ne fee schedules, baie nity, relave wales, or related listings are inched in CPT. The AML asumes no liabilty forthe data contained here, Applicable EXRS /DEARS restctions apply to AU rights reserved. 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Ohm Frbling Seve Manag a Jones Dalgety Bose Working together to grow libraries in developing counties ELSEVIER BO°KAI Sabre Foundation Printed in CamaContents The Rationale for and History of Coding, 1 ‘The Health Record as the Foundation of Coding, 11 ICD-9-CM Format and Conventions, 47 Basic Steps of Coding, 81 General Coding Guidelines for Diagnosis, 90 General Coding Guidelines for Procedures in ICD-9-CM, 118 Introduction to ICD-10-PCS, 136 Symptoms, Signs, and Il-Defined Conditions, and V Codes (V Codes and ICD-9-CM Chapter 16, Codes 780-799, and ICD-10-CM Chapters 18 and 21, Codes R00-R99, 200-299), 176 Infectious and Parasitic Diseases (ICD-9-CM Chapter 1, Codes 001-039, and ICD-10-CM Chapter 1, Godes A00-B99), 211 Neoplasms (ICD-9-CM Chapter 2, Codes 140-239, and ICD-10-CM Chapter 2, Codes C00-D49), 245 Diseases of the Blood and Blood-Forming Organs (ICD-9-CM Chapter 4, Codes 280-289, and ICD-10-CM Chapter 3, Codes D50-D89), 202 xvi Bahan dengan hak ciptawii CONTENTS 12 13 7 19 20 21 Endocrine, Nutritional, and Metabolic Diseases, and Immunity Disorders (ICI M Chapter 3, Codes 240-279, and ICD-10-CM Chapter 4, Codes E00-E89), 310 Mental, Behavioral, and Neurodevelopmental Disorders (ICD-9-CM Chapter 5, Codes 290-319, and ICD-10-CM Chapter 5, Codes F01-F99), 349 Diseases of the Nervous System and Sense Organs (ICD-9-CM Chapter 6, Codes 320-389, and ICD-10-CM Chapter 6, Codes G00-G99, Chapter 7, Codes H00-H59, and Chapter 8, Codes. H60-H95), 369 Diseases of the Circulatory System (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes 100-199), 400 Diseases of the Respiratory System (ICD-9-CM Chapter 8, Codes 460-519, and ICD-10-CM Chapter 10, Codes J00-J99), 451 Di 520. ses of the Digestive 579, and ICD-10-CM tem (ICD-9-CM Chapter 9, Codes Chapter 11, Codes K00-K95), 482. Diseases of the Skin and Subcutaneous Tissue (ICD-9-CM Chapter 12, Codes 680-709, and ICD-10-CM Chapter 12, Codes L.00-L.99), 507 Diseases of the Musculoskeletal System and Connective Tissue (ICD-9-CM Chapter 13, Codes 710-739, and ICD-10-CM Chapter 13, Codes M00-M99),, Diseases of the Genitourinary System (ICD-9 Chapter 10, Codes 580-629, and ICD-10-CM Chapter 14, Codes NOO-N99), 555 Complications of Pregnancy, Childbirth, and the Puerperium (ICD-9-CM Chapter 11, Codes 630-679, and ICD-10-CM Chapter 15, Codes 000-09A), 58922 23 24 25 26 27 contents | xix Congenital Anomalies and Perinatal Conditions (ICD-9-CM Chapter 14, Codes 740-759, and Chapter 15, Codes 760-779, and ICD-10-CM Chapter 16, Codes P00-P96, and Chapter 17, 00. g a s 2 Injuries and E Codes (ICD-9-CM Chapter 17, Codes 800-995, and External Causes, E800-E999, and ICD-10-CM Chapters 19 and 20, Codes S00-Y99), 647 Burns, Adverse Effects, and Poisonings (ICD-9-CM Chapter 17, Codes 800-995, ICD-10-CM Chapters 19 and 20, Codes S00-Y99), 691 Complications of Surgical and Medical Care, 719 Reimbursement Methodologies, 744 Outpatient Coding, 760 GLOSSARY, 775 ABBREVIATIONS/ACRONYMS, 787 ILLUSTRATION CREDITS, 792 INDEX, 795This page intentionally left blankCHAPTER OUTLINE LEARNING OBJECTIVES ABBREVIATIONS/ ACRONYMS The Rationale for and History of Coding Background of Coding What Is Coding and What Are Its Applications? Nomenclature and Classification History of Coding Comparison of 1CD-9-CM and ICD-10-CM Preparation for Transition to 1CD-10-CM Coding Organizations and Credent Coding Ethics Compliance Confidentiality Chapter Review Exercise Chapter Glossary References, 1. Describe the application of coding 2. Define nomenclature and classification 3. Identify the historical timeline of coding 4. Explain the difference between ICD-9-CM and ICD-10-CM 5. Delineate coder training needs for transitioning to ICD-10-CM 6. Describe different coding organizations and credentials 7. Recognize the importance of the Standards of Ethical Coding 8. Define compliance as it relates to coding 9. Explain confidentiality as it applies te coding |AAP© Americen Academy of Professional Coders AWA American Hospital Association ‘AHIMA American Health Injormation Management Assocation CCA Cetlfied Coding Associate COS Certified Coding Specialist CUS-P Cetitied Coding Specialst—Physician Based CEUs continuing oducaton units OMS Centers fr Medicare and Medicaid Senices PE Corttied Professional Coder CPC-H Cottified Professional oder—Hospital Based CPT Current Procedural Terminology DRGs ciagnosis-rlated groups HIPAA Heath Insurance Portability and Accoustabilty Act IC0-9-CM International Classitication of Diseases, 3th Revision, Clinical Modification ICD-10-CM fnternational Glasstication of Diseases, 10th Revision, Clinical Modification ICD-10-PCS tnternational lasstication of Diseases, 10th Revision, Procedure Coding ‘Sysiem MS-DRG Nedicare Severity iagnosis-telated group NCHS National Center for Health Statistics (IG Office of the Inspector Consral RHIA Registered Health Information Adminstrator RHIT Registered Health Information Technician SNOMED Systematizd Nomenclature af Medicine WHO Worlé Heath Organization 1 Bahan dengan hak cipta2 CHAPTER 1 Tho Rationale for and History of Coding BACKGROUND OF CODING What Is Coding and What Are Its Applications? Asa student in this field, you will often be asked these questions. Why does one study this subject? What type of work does a “coder” dor Basically, medical coding consists of translating diagnoses and procedures into numbers for the purpose of statistically capturing data. This process is done for us every day in all aspects of daily life. If you buy @ banana at the grocery store, the cash re which, in turn, provides data on the number of bananas sold in that store or by that grocery chain; italy yields data of importance to the store on replenishing their inventory, details regarding what time of year the greatest number of bananas are sold, and so forth. Translation of a disease and/or a procedure into an [CD code is not as simple as it may scom. This process requires. thorough knowledge ofanstomy and physiology, dis processes, medical terminology, laboratory values, pharmacology, surgical procedures, and last but not lesst, a myriad of coding rules and guidelines. Diseases and procedures are translated into a coding system known as the International Classification of Diseases, 9th Resi- sion, Clinical Modification (ICD8-CM). This classification system has been used worldwide ul has been clinically modified for the United States, Coded data are used for many purposes. Prior to the advent of diagnosisrelated groups (DRGs), which are used by Medicare and other payers as the basis for hospital reimburse- ment (payment), coding was used for research and planning. healthcare provider or facility could use these data to find out how many cases of appendicitis were treated in a year. This information could be used by a healtheare facility in decisions about the possible ise of more equipment, the addition ofan operating room, oF the hiring of additional ser captures that banana sts a number, pure staff, or by the provider to gain additional skills. Since the implementation of DRGs—now Known as MS-DRGs—coded data are also used for reimbursement purposes, and they are increasingly used for risk management and qualigy improvement, as well asin murs g clini ‘cal pathways. Coded data were important from the start, but use ofthese data for reimburse- ment has clevated the importance of accurate coding to new heights. Capture of health data through IGD-9 and ICD-10 codes that are used worldwide has proved useful for the suidy of patterns of disease, disease epidemics, causes of mortality, and treatment modalities. Without the use of a classification system, comparison of data, would he impossible Nomenclature and Classification A nomenclature and a clastic jon of diseases are required for development of a coding, system, A nomenclature is a system of names thatare used as preferred terminology, in this case, for diseases and procedures. Often, diseases in different areas of the country or in diferent countries are identified by dissimilar terminology, which makes the capture of comparative statistical data next to impossible. For example, another name for “amyo~ trophic lateral sclerosis’ is “Low Gehrig's disease,” which is also known as a “motor neuron disease.” Nomenclatures of disease were first developed in the United States around 1928. The Systematized Nomenclature of Medicine (SNOMED), published by the College of American Pathologists, is the most up-to-date system in current use. Classification stems group together similar tems for easy storage and retrieval. Within a classification system, items are arranged into groups according to specific criteria. The history of classificaion systems goes back as far as Hippocrates, During the 17th century, London Bills of Mortaliyy represented the first attempts of scientists to gather statistical dat .9-CM classification system is a closed system thal comprises diseases, injuries, surgeries, and procedures. Ina closed classification ssstem a disease, condition, oF pracedure can he classified in only one place ‘on disease. The ICCHAPTER 1 The Rationsle for and History of Coding I 3 HISTORY OF CODING ICD-9.CM is the coding classification system that is currently in use in the United States. This classification system dates back to Bertillon’s Classification of Causes of Death, which was developed in 1899. This system was adopted by the United States in 1898 under the recommendation of the American Public Health Association. System revisions were sched uled co take place every 10 years, and the dlassification was maintained by the World Health Organization (WHO). Revisions became known as the Intermational Chasifieat of Death, Oxer the years, this system has been changed to allow its use not only in mortality reporting but in morbidity reporting as well. Since its inception, this classification has bet revised 10 times The Clinical Modifieation (CM) war developed in 1977 by the States to more accurately capaure morbidity data for study within the United States, as well as information on operative and diagnostic procedures that were net included in the origi- nal publication of ICD. ICD9-CM, a publication of the U.S. Department of Health and Human Services, consists of three volumes. Currently, many countries are using IGD-10, which was published tn 1998 by the WHO. TED-10 has also deen clinically modified for use in the United States with implementation proposed for October I, 2014. ICD-10-CM will replace the 30-year-old 1G The final rule for adoption of 1OD-10-CM and ICD-L0-PCS was releaned in January of 2008. Work on ICD-L0 was begun in 1983, The tabular volume was published in 1992, and the instructional volume followed in 1993; the Alphabetic Index was published i 1994. In 1004, the United States began the process of determining whether a clinieal modification (CM) would be necessary. A draft version was made available in 2002, updated in July 2007, and updated aguin in 2009. This version can be found at the National Center for Health Statistics website Clinical modifications made to ICD-10 allow a higher level of specificity. Since 1992, ICD-10 has been used in the United States for the reporting of morality data, A total of 90 countries, including Canada and Australia, are currently using ICD-10, ICD4-CM may be updated biannually in April and October. Updates contain additional codes, revised codes,and codes that are deleted. These updatesare published in the Federal Register (the official daily publication for nules, proposed rales, and notices of US. federal agencies and organizations) as a proposed rule and then as. final rule. They are available fat the Centers for Medicare and Medicaid Services (CMS) website (womcmsgor). It is of the utmost importance that code books and coding software (encoder) be updated to ensure that coding is accurate and to facilitate accurate reimbursement. n of Causes sitet ‘The ICD-0-CM Coordination and Maintenance Committee meets vice a year and is used asa forum for propostls to update ICDC. This Committee serves in an advisory ‘apacity. Two Federal agencies are responsble for maintenance of ICD-9-CM. The classifica. tion of diagnoser ix the responsibility of the NCHS (National Center for Health Statistics) and the classification of procedures is the responsibility of CMS (Centers for Meilicare and Medicaid Services). ‘The Coordination and Maintenance Commitice meetings are open 10 the public and comments are encouraged, All comments and recommendations are evahi- ated before a final decision on new codes is issued. The development and maintenance of the guidelines of |GD-9-CM is the responsibilty of the National Genter for Health Statistics (NCHS), CMS, the American Hospital Associa tion (AHA), and the American Heakh Information Management Association (AHIMA), which are also Kuown as the Cooperating Parties. Many publications proxide coding advice and information, but only one publication is official. This publication, AHA Cuding Clinic for ICD-CM (referred to as Coding Clinic), which is published quarterly by the AHA, pro vides codingadviee ane guidelines that hare been approved by the Cooperating Partios and must be followed by coders. Coding Clinicreferences will be used throughout the text with specific issue information provided, such 9s 200:4Q:p126-130, This reference lerts th tained in the fourth quarter 2002 issue and the associated page numbers. The Cading Clinic reterences used throughout this text may be relerred to for more detailed information about the subject being referenced. Cading Clinir has publications dating back to 1985. student of information con4 L cuapter + The Rationale for and History of Coding al ieo-9.0m 14,000 coves 69,000 codes (Codes begin with number exceot for VAE Codes begin with 2 letter susplementay classification Naximum number code 3 107 characters All codes end in » number Codes may end in’ number or # letter Norptology codes begin with M Both morphology and musculoskeletal codes teegin with M Three tables: Neoplasms, Drugs and Chemicals, Two tables: Neoplasms, Drugs and Chemicals Hypertension 17 chapters with 2 cupnlements 21 chapters 1 chapter for Oseases of the Nervous System, Eyes, 3 chapters for Nervous System, Eyes, fa No laterality included in codes Laterality included in codes Sometimes combine NEC (not elsewhere classifi) Neva combina NEC and NOS ané NOS (nc otherwise specified) No 7th cheracter extensions 7th character extensions No placeholder letter Placeholder letter Excludes nates Excludes nates 1 and 2 "The index ard the tabula of CD-10-CH are vay Sinliar in sive To ICD-BEM, Unless superseded or clarified hy additional Coding Clinic references, the original publica- tion of anyadvice remains in effect. Although reference may be made to ailviee in an issue from 1994, this may be the most current advice available. A date of 1984 for a given source does nat mean that the publication is outdated. As the transition to ICD-10-CM/PCS begins, and ICD+10. this textbook will have all examplesand exercises coded using ICD. COMPARISON OF |CD-9-CM AND ICD-10-CM Asnoted in Table 1-1, considerable differences ean be seen between ICD-10-CM and ICD- 9-GM, Most notable is the inerease In he number of codes and code categories, dhe change from numeric to alphanumeric codes with an increase in digits from 5 to 7, and the increase from 17 chapters to 21 chapters The best way co appreciate these differences is to view code assignments for the same disease process from beth classification systems. EXAMPLE — Newbarn baby delivered via c-section V30.01 (ICD-9-CM) Newborn baby delivered via c-section 738.01 (ICD-10-0M), EXAMPLE Dsplaced spiral closed fracture shaft of left femur, initial encounter 821.01 (ICD-9.cM) Displaced spiral closed fracture shaft of left fernu, initial encounter S72.342A (ICD-10-CM) PREPARATION FOR TRANSITION TO ICD-10-CM ‘The steps necessary for transition t9 ICD-10-CM and ICD-10-PCS involve many different areas within the healthcare ystem, inehading Information Systems (IS), Billing, healthcare: providers, Utiliaution Review (UR), Researchers, Compliance, and Accounting, to name a few, Most articles written on the subject recommend & team approach across the facility. Existing coding staff will need to he trained on both [CD-10-OM and ICD-10-PCS Bahan dengan hak cipiaCHAPTER 1 The Rationsle for and History of Coding I 5 Reports suggest (see Practice Brief Destination 10: Healtheare Organization Prepara on for [GD-10-CM and IGD-10-PGS)' thatthe knowledge base of coders must be broadened. so they have deuiled knawledge of anatomy and medical terminology, enhanced compre hension of operative reports, and a greater understanding of ICD-0-PCS definitions. It may be necessary to assess the skills of coders before selecting the type of uaining needed. It has been suggested that training should not take place too early, and probably around 3 months before implementation would be preferable. Aside from more intensive training in anatomy and physiology (ASP) and terminology, the following education om ICD-10.CM is, recommended by AHIMA: m= Structure change Disease clauification Definitions Guidelines ICD-10-PCS, AHIMA is currently offering ICD-10 courses via the Web, JCD-TEN isa monthly newslet- in the transition 19 TGD-1GGM and ICD-10-PCS. The need is great for qualified instructors to teach both of these classification systems 10 the many users who will need to know them. AHIMA’ Gommission on Certification for Health Information and Informatics (CCHIIM) has implemented a new recertification policy specific to ICD-10GM/PCS. This policy requites that CEU education hours based on ICD-10-CM/PCS content will be required and will be part of the existing CEU requirement, The CEUs required are based on the credential held and are as follows: RHIT 6 CEUs RHIA 6 CEUs ccsP 12. CEUs ccs «1B CEUs CCA «18 CEUs Ifa person holds more than one credential, the CEUs necessary are based on the ere dential fequiting the highes! number of ICD-10-CM/PCS CEUs, These CEUs should be earned from Jannary 1, 2011 to December 31, 2013, All AHIMA Certified Professionals who completed AHIMA’s Academy for ICD-10 prior to Janary 1, 2011 will be allowed to use those CEU hours to fulfill the IGD-10-CM/PGS CE CODING ORGANIZATIONS AND CREDENTIALS Coders come from a variety of educa college programs in Health Information Administration; others have completed 2-year college programs in Health Information Technology. Some community colleges oller pro grams geared only to medical coding. Whatever their background, mos cailers take certi= fication examinations 10 carn credentials (which are certificates that recognize a course of study taken in a specific held and acknowledge that competeney is required) and become members ofa profesional organization, Many employers include a requirement for certi= fication as part of their coding job description, Coders can work ina variety of settings; most offen, they are cmployed by hospitals, physician offices, outpatient surgical centers, longterm panies, Itis predicted that the demand for coding professionals will far exceed the number of coders in the workforce. backgrounds, Many coders have attended 4-year are facilities, and insurance com- The two most well-known professional associations for coders are AHIMA (wwwahima corg) and the American Academy of Professional Coders (APC) (wwwaape.com). Both of there organizations offer a viriety of coding credentials, AHIMA, which hae been in exis: tence for over 75 years, has undergone several name changes along the way to keep up with the ever-changing technological skills, educational requirements, and roles of itsmembers, Ie hoastsa membership of over 60,000. Traditionally, this organization has provided support6 IT cuapte + The Rationale for and History of Coding PASE eR a CUAL SUT) TUT ‘Organization CEUs Required Gredential offering Credential E¢ucation Required jer 2-Year Cycle cca AHIMA, High school diploma or equivalent 20 ces AHIMA, High school diploma or equivalent 20 cos anima, High s2ne0! aiploma or equivalent 20 RRIT AHIMA 2.Year degree in accredited HIM program 20 RHIA AHIMA, 44Year degree in acorecited HIM pregram 30 cee AAP, High school dipisma or equivalent and 36 2 years coding experience ce. Aare High schoo! diploma or equivalent and 26 2 years coding experience ror ane. Fgh senoo| aipioma ar equivalent ang 36 2 years coding experierce crea aneC. High school diploma or equivalent 36 CPCHA —ARPC High school diploma ar equivalent 36 CPC-RA ARBC High school diploma or equivalent 36 for facility coders, but in recent years, it has expanded to include coders who provide services in physickin’s offices and outpatient settings, AHIMA. offers the following credentials: cca Centtied Coding Associate ccs Certified Coding Specialist CCS-P —_Cerlfied Coding Specialist—Physician Based HIT Ragistered Health Information Technician RHIA Registered Health Information Administrator AAPG has over 100,000 credentialed members and was started in 1981. It was founded to assist covers in providing services to physicians and offers the following credentials: cre Cerlfied Professional Coder PCH Cerlified Pratessicnal Code1—Hospital Certified Professicnal Coder—Peyer Cerlfied Professicnal Coder—Apprentice Certified Protessicnal Coder—Hospital Apprentice Cerlfied Professional Coder—Payer Apprentice To obiain credentials trom either organization, a coder must sit for a certification examination and complete college coursework in several areas such as medical terminology and anatomy and physiology. To maintain their credentials, coders must earn continuing, education units (CEUs). The munber of CEUs requited is dependent on dhe credential (s) of the coder (Table CODING ETHICS Along with providing credentials, both AHIMA and AAPG have set standards for Coding, Ethies, which are reprinted in Figures 1-1 and 1-2. (Please see the Evolve companion website for “How to Interpret the Standards of Fihieal Cading.*) Members of these organizations are expected to abide by these coding standards. A coder who is asked to disregard a guide- line to facilitate payment should decline on the basis of these standards, by which coders are bound Bahan dengan hak cipia‘Standards of Ethies! Coding Coding protessionals should 4. Apply accurate, complete. and censistent ceding practces forthe production of high-quality healthcare date 2 Reportall heathcare cata ements (eg, diagnosis and procedure codes, present on admission indicator discharge status) required {or external reporting purposes (6.9. imbursement and other administrathe uses, populaton health, quali and patent safety ‘measurement, and research) completely ané accurately, in accordance with regulatory and cocumentaion standards and requirements ard applicable coding conventions, rules, ard gudelines. ‘3. Assign and repor only the codes and data that are cleary end censistenty supported by heath ecord documertatin in accordance: ‘wth applicable cede set and abstraction conventions, rules, and guidsines 4, Query provider (physician or othe: qualified heatheare practioner for clarification and additenal documentation porto code assignment when there is confictng incomplete, or ambigucus information in the health recerd regarding a significant reportable ‘conden or proceaure ar other reportable data element dependent on health record documentation (@.3, present on admission ndicatoy ,oluse lo change reported codes or he naratves of codes a that meanings are misiepresented. Refuse to participate in or support coding or documenation pracices ntendes to inappropriately inorease payment, cual for insuraree policy coverage, et skew data by mears that do rot comply wih edaval an state statutes, regulations, ané afcal rules ard gudelinos. 11. Fucltate interaiseipinery calaboration in situations supporing proper coairg prectes, ‘Advance coding knowledge and practise through continuing education. Refuse to paricigate in or conceal unethical coding or abstraction practices or procedures, 0. Protec! he conficentiaty ofthe heath record at al times and reluse i access protected health information not required for coding related activties (examples of coding-elated acti include compleson of code assignment, cther health record dala abstraction, ating audits, and educational purposes) “+1, Demonstrate behavior that rflect integrity, shows a commtment to ethical and egal coding pravtices, and fosters ist in professional activites. Revised and approved by the House of Delegates 08/08 FIGURE 1-1. AHIMA’s Standards of Ethical Ceding, AAPC Code of Ethics Commimentio sical professional sonductis expected of every AAPC member ‘The specication af a Cade of Ethice enables AAPC toclary lo cirenl and false members, and io hoce served by members, the nature af the ethical ‘esponsbiltzs hed in common by ils members, Tis document establishes Dineinae that dafna the ston! banavir of AAPC mamoer® All KAPC members 41 requiredto adhere othe Code of Ethics and the Gade cl Ehice wil serve as the base for processing ethial eamplainisntiated against AAPC members AAPC members shal (© Maintain and enhance the dignity, status, integrity, competorce, and slendards of aur profession, (© Respact the privacy of others and honer confidentiality © Stive to achieve he highest qualty, effectiveness and dignity in both the proses snd products of profesional work © Avanos the profession through continued professional development lard education by acquting and maintain profesional competence, (© Krow and respect existng federal slats andlocal aus regulations, ceriicctions and icencing requiremenss aplicable to professionel ‘work © Use ony logal and ethical pinciples that react the professions core values and report atiuy thst is parcaited to violate the Code of Ehhies b the APS Ethes Commitee © Accuratoly represent the credentials) earned and the status of APC membership © Avoid actions and circumstances that may appeat to compremise good business judgment or cealea conliel between pereonal and protessonal nterests ‘Adhorence to thaco stondarée aceutoo pubs corvdeneo in tho itogrity ane ‘service of medical coding, auditing, compliance and practoe management Frllure to adhere fo these standards, as determined by AAPC's Ethics Commitee, ‘may result inthe bes ef eredentas and membership with AAPC, FIGURE 1-2. AAPC's Code of Ethical Standards,8 1 cuapter 1 COMPLIANCE Tho Rationale for and History of Coding ‘Compliance is defined as “acting according to certain accepted standards or, in simple terms, abiding by the roles.” In health care, this requires following the rules and guidelines asset forth by the government through Medicare and Medicaid and all professional onga- nizations which a ficility or provider may’ belong to ar is participating with, and following the policies and procedures of that organization, omplianee officers and programs are found in many industries. It wasn't until after the passage of the Health Insurance Portability and Accounsability Act of 1996 (HIPAA) that compliance officers became a standard presence in healhewre fucilides. HIPAA gave additional funding to the US. Department of Health and Haman Services, the Office of the Inspector General (OIG), and the U.S. Department of Justice to increase penalties for healthcare fraud and abuse. Ongoing investigations in healthcare institutions across the United Stares are exploring violations of the Fale Claim Act and other laws As explained in an article by Joeue Hanna that appeared in the fowmnal of AHIMA, entitled “Constructing 3 department wishes to ensure that it is in compliance. Coding deparimen Following: = Abide by AHIMA’ Standards of Ethical Coding & Develop ceding policies and procedures & Develop a working relationship with the billing department = Develop a coding compliance work plan . . ‘oding Compliance Plan,” soveral steps must be ken if'a coding s must do the Conduct coding audits Develop san action plan based on audit resus Likewise, a practice brief published by AHIMA in 2001, entided “Developing a Coding. ‘Compliance Policy Document," states that the following bulleved items should be included ina coding compliance plan: Policy statement regarding the commitment of the organization to carrect assignment and reporting of codes = The Official Coding Guidelines used by the facility am The people responsible for code assignment What needs to be done when clinical information is not clear enough to assiga codes If there are payer-specific guidelines, where these may be found A procedure for correcting codes that have been assigned incorrectly Plan for education on areas of risk as identified by audits = Identification of essential coding resources that ure available and to be used by coding professionals Procedure for coding new and/or unusual diagnoses or procedures & A poliey for which procedures will be reported = Procedure for resolving coding/documentation disputes with physicians ® Procedure for processing claim rejections = Procedure for handling requests for coding amendments = Policy that requires coders to have available coding manuals and not just encoder Process for review of coding on those records coiled with incomplete documentation CONFIDENTIALITY. Employees in a healthcare setting must be aware of the confidentiality of the information that inall around them. When they tike the Hippocratic Oath, physicians swear to mainsin patient confidentiality. Likewise, in the Patient Bill of Rights as prepared by the AHA, the patient’s right 10 privacy is sttted. The Code of Ethics of the AHIMA also addresses confi- lerstialiy wh embers will promote andl protect the confidentiality and security of health records and information.” Goders must read patient’s personal medical information before they can code the encounter and/or patient admission. It is important that this information not he sharedCHAPTER REVIEW EXERCISE CHAPTER 1 The Rationsle for and History of Coding I 9 with anyone, including other employees, unless they have a legitimate need to know to perform their job; patien: information should never be discussed ina pla could overhear whereany visivor Write the correct ensiver(s) in the space(s) provided. 1, What does a coder do? 2, What coding system is currently used in the United States for diagnoses coding? 3. What Joes the CM of ICD-9-CM stand for? 4, List three uses for coded data. 1 a 3. eee 5, What payment system does Medicare use for inpatiant reimbursement? 6, Describe the difference between a nomenclature ard a classification system, 7. What nomenclature of disease is used in the United States? 8, Define a closed classification system, 9. ‘hen was the International Classification of Diseases first adopted by the United States! 10. When and how often is this system (ICD-9-CM) updated? 11. What four groups constitute the Cooperating Parties? Te 2 2. 4 —_ 12. Who publishes official coding advice and guidance? 13, What organizations award coding credentials? 14, What is another word that is used in the industry for “following the rules"? 15. If you were coding a neighbor's record, would it be okay for you to tell your other neightors the reason the patient was hospitalized? 16, What does HIPAA stand for! Bahan dengan hak cip10 1 cHAPTER 1 The Rationale for and History of Coding 17, Most industrialized countries do nat use ICD-10. A. True B. False 18. Coders will equite greater technical skill if they are to master ICD-10-CM and ICD-10-¢S. A. True CHAPTER GLOSSARY classification: grouping together af items as for storage ané retrieval ‘Compliance: acherence to accepted standards. Credentiak: degree, certificate, or avard that recognizes a course of study taken in a specific field and thot acknowledges the competency required. Diagnosis: identiieation of a diseass through signe, sympteme, and tests Encoder: coding softnare that is used to assign diagnesis and procedure codes. Ethies: moral standard Feieral Register: the official daly publication for rules, propased rules, and nctices of U.S. federal agencies and organizations Nomenctature: systern of names that are used as the preferred terminology. Procedure: & diagnostic or therapeutic process performed on a patient. Reimbursement: payment for healtheare services Teminclogy: words and phrases that apply te a particular tela, REFERENCES 1, Amesican Heath Information Management 2. AHIMA Coding Practice Team, Developing ‘Association, Destination 10: healtheare ong compliance poly decument QAI Opinion prepantion for ICD-10.CN and Pte bit, PATHE 72884 888C, 201 ICD OPCS, PATINA 755645500, 2004 anna J- Consiraeting 2 coding eampliance plan, AHIMA 734856, 2002 Bahan dengan hak cipiaCHAPTER OUTLINE LEARNING OBJECTIVES ABBREVIATIONS/ ACRONYMS The Health Record as the Foundation of Coding The Health Record Sections of the Health Record Administrative Data Clinical Data UHDDS Standards for Diagnoses and Procedures Principal Diegnosis Principal Procedure Other Diagnoses Coding from Documentation Found in the Health Record The Use of Queries in the Coding Process When to Query When Not te initiate a Query Who to Query Elements of a Query Form Unacceptable Types of Queries Qualifications for Individuals Submitting Queries Chapter Review Exercise Chapter Glossary References 1. Explain the purpose of the various forms or reports found in a health record 2. Detine “principal diagnosis” 3. Define “principal procedure” 4, Identify reasons for assigning codes for other diagnoses List the basic guidelines for reporting diagnoses/procedures 6. Identify types of documentation acceptable for assigning codes 7. Explain the query process AHQA American Health Qualiy CPT Covent Pocedual GD esophagogastoduadeno- Association Terminology scopy ‘BPH benign postatc hypertephy COPD chronic obstructive EKG electrcaniogtam CBC complete blooé count pulmonary disease ER Emorgency Room CC chief complaint DOB dete of bith GERD gastoesaphagealrlux CMS Centers or Medicare and EO Emergeney Department disease Nedicad Sewices EEG electroenceptalogam H&P histoy and physical "Wl Bahan dengan hak cipta12 | CHAPTER 2 The Health Record as the Foundation of Coding ABBREVIATIONS/ ACRONYMS—conra HEI history of present iness MIRA. magnetic resonance SOAP Subjectve/Objective/ |eD-9-0M international angography AssessmentPlan Classification of Diseases, th IRI magnetic rsonence imaging TC The bint Comaistion Revision, Clinical Modification 44 265 Medicare Severty ‘TPR temperature, pulse, and IcD-10:CM Intemational diagnosis-elated groups respiration Dtasstcation of Diseses, 10th ‘epmilonse LUHODS Unio Hesptal Revisan, Clinical Modifeation VP. mite vale pray Discharge Data Set NPI National Provider denitier ICU intensive care unit LUPIN Unique Physisian MAR medication administration OP ete operative rate Identification Number record POA present on admission UT urinary trac infection THE HEALTH RECORD health record must be maintained for every individual who isassessed or treated. Athough Eana Tuffinan’s elasie Health Information Management! book is no longer in print, her deti- nhidon of dhe purpose ad use ofa health record aill holds ruc today. She sates, “The sain purpose of the medical record isto accurately and adequately document a patient’slife and Health history, including past and present iineswes and treatmenss, with « ‘events affecting the patient during the current episode of care.” Huffman goes on to “The medical record must be compiled in & timely manner and contain sufficient data to identify the paient, suppor: the diagnosis or reason for health care encounter, justify the ely document the results.” According to Abdelhak’s Heal Informa phasis on the treatment and aceur tion: Management of a Strategie Resourer’ the health record serves five purposes 1, Describes the patient’s health history 2. Servesasa method for clinicians to commune patien's rves.as a legal document of care and services provided Servesas a source of data Servesas a resource for healthcare practitioner education The paticnt’s health record in today's environment may be anaintained in seversl formats or hybrids. The traditional health record consists of documentation on paper pre= pared by healtheare providers that describes the condition of the patient and the plan and c of treatment, As the world advances through clectronie forms of documentation, regarding the plan of care for the paper notes become more and more obsolete. Most health records are currently in a sate of wansition, Some paper documentation and some wanscribed or elecwonically stored documentation may be available. Some tly electronic heakh record, One of the advantages of storing the record electronically is that many users ire able to access the record at the Sa hybrid form, documentation serves as the hasis of a health record, The Genters for Medicare and Medicaid Services (CMS) has provided physicians with Genera Prvuciptes of Metical Record Derumentation = Medical records should be complete ané legible @ The documentation of each patient encounter should include: = Reawn fOr encounter and relevant history © Physical examination findings and prior diagnostic cest results » Assessment, clinical impression, and diagnosis + Plan for care = Date and legible identiy of the observer @ The rationale for ordering diagnostic and ancillary services (if not documented, shotilel be easily inferred) = Past and present diagnoses should be physician = Appropriate health risk Factors should he identified acilities have tually achieved s predomi .¢ time. Whether in electronic, paper, oF sible for weating and /or con: ingCHAPTER 2 The Health Record as the Foundation of Coding | 13 Patient's progress, response to changes int treatment, and revision of diagnasis should be documented = Cunent Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Mosification ICD9-CM) codes reported on health insurance claim forms should be supported by documentation in the medical record SECTIONS OF THE HEALTH RECORD Every facility has its own policies and procedures regarding the organization of the health record. Records will differ slightly depending upon the course of the patient’s condition and weatment. Ita record were t be organized similarly to a novel that tells a story, the elements discussed in the next sections would be included. Administrative Data @ Demographie fm Personal data = Consents Information contained in this section will facilitate identification of the patient, Some of the UHDDS dat elements included are personal identification, Gate of birth, sex, race, residence, admit date, and discharge date, See Figure 2-1 Clinical Data Inpatient records may be organizeil in a reversechronological order. The discharge summary nay be found at the beginning of the record. = Emergeney room record (when applicable) (see Figure 2-2) Admission history and physical (see Figure 2-3) Physician orders (sce Figures 2-4 and 2-3) Progress notes recorded by healthcare providers (see Figure 2 Anesthesia forms (when applicable) (see Figure 2) Operative report (when applicable) (see Figute 2-10) Reeovery room notes (when applicable) Consultations (when applicable) Laboratory test resus (when applicable) (sce Figure 2-8) Radiology report (when applicable) (see Figure 211) Miscellaneous ancillary reports (when applicable) Discharge summary (see Figure 2-12) Data are collected from the health revord as mandated by governmental and nongow ernmental agencies. The Joint Commission (1JC) places data requirements and time frames for documentation within the health record. The federal government and stare licensing. agencies may have similar requirements. Medical staff bylaws often include these documen- tation requirements. In 1974, the Uniform Hospital Discharge Data Set (HDDS) man- dated that hospitals must report a common core of data, Since that time, the requirements, have been revised! and will continue to change as nevessiry, The UHDDS required data elements are listed in Figure 241 Emergency Room Record The emergency room record is a mini health record, It contains a chief complaint (GO), Which isthe reason, in the patient's own words, for presentation to the hospital. It contains, a history, physical examination, laboratory results, radiology reports (if applicable), plan of care, phisician orders, and deciimentation of any procedures performed, Last but not leat, it contains a list of working diagnoses and information on the disposition of the patient See Figure 22 for a sumple of an ED (Emergency Department, or also called ER for Emer gency Room) record14 | HAPTER 2 The Health Record as the Foundation of Coding a a. a88 14, 8. + 7 0. Uniform Hospital Discharge Data Set Porsonal identification Date of birt (month, day, and year) Sex Face and ethnicity Residence (usual residence, full address, and zip code {ninedigh zip code, it available), Hospial aenunication number “Thrae options are given for ‘his insiutonal number, with the Medicare proxider number asthe recommended choice, The federal tax dertiieaton numberof the American Hospital ‘Assocation number i preferred fo creating a new number. ‘Admission date (mort, day, and year) ‘Type of admission (scheduled ar Unscheduled) Discharge date month, day, ard yeu) ‘tending physician identfication (NPD) Operating physician identification (HPI) Principal dagnesis Tho cendition stabiched ater ctudy ts ba chil roepancisle for ecazionng the admiceien ‘lhe patient tothe hospital for cae, | Other diagnoses [Al conditions thal coexist a the tme of acission or hat develop subsequently that affect he Iroatmant received andor the length of stay. Diagnoses that relate fo an eerler episod ard have ma bearing on the currant hospital say are excluded. Qualifer for other disgnoses ‘Aqualiir is given for each diagnosis coded under “other diagnoses” indate whether the ‘onset of the diagnosis preceded or flowed admission tothe hospital, The option “uncertan” igpernitieg Exterral cause-of-injury code Hospitals stould comglete tis item whenever there isa diagnass of an ity, poisoring, or averse effect Birth weight of neonate Procedures and dates: a. Allsignieant procedures are to be reported. A sigtcant procedure is one that (1) 6 ‘surgical n nature, @) caries a procedural ris, (3) caries an anesheticrisk, or (4) eqiifes specalized taining, ‘The date of each significant procedure must be reported |When muliple procedures are reported, the prnetpal procedure is designates, The principal procedures one that was performes for aefnive treatment rather than ene performed for claghostc or explanetory purpcses of was neosssaty Io ake cate o Complication. I! two procedurss appear io be principal, then fe ore mest related othe bricipal diagnosis is selected as the principal procedure 1d. The UPIN of the person performing the principal procedure must be reported Disposition ofthe patient Bissharcod home (nt tc hore health service) Diesharced to acute care hostel Discharged to nursing facility Dissharged fo hm fo be undar the oare of ahoms hesth service Dischareed fo cthar health cae facily Le aganst madiesl dice ‘Alive, other; or alive, not stated Diet Patient's expected source of payment ‘a. Primary source Otter souree Total charges LLetall charges biled by the hospital fr ths hositalization. Protessicnal charges for individual patientcare by physicians are excluded, FIGURE 2-1. Uniform Hospital Discharge Data Set elementsCHAPTER 2 The Health Record as the Foundation of Coding Date oom: ‘ine in room: Ae Hx souree:CPation)) spouse / family iene / EMS / other E History & AOS teites by medical or other condition cal pu Pt mene PSH none Me eee Seylo $ Chepes 2 filing renal te epeept lagea nepteites BP page osttr @), ecetelle on Melos (rr eijeeter of net op (ast eo) th imnetetn mes thier “fed Prrsbie n Hing bord Sauk 2 poeclesh Nats © Hempel Ceili Ie en ese Made ons ager he AAI Sn een iat Neneste! “tena te Welw Zacks erancp Maden Téetel ronnie Tid Pe 10) 1 i Lanta Orc trimn, Enon c/n Ober AMlralps MOA COD oon fem SH Toba Curent Past) Pekar ‘eohot( Nab /Oce Med Hea. Feed oon Pe care fa ve emeneet Rogen a a es ORT Eran oa TE TT SS Se ee oo a pe eee ee Se ee F vee | Endo lhe ROSS A Tha ci ytona reson yi Pan Sore 7 Kos [ite | Onn tA cers [Bas revenes oP 47 8TH G2 pq. /O WS op eat: 97 ron $24 Normattiypoxia ees VEER Daereer Sema al Samnge a) Sane et -" as, Cortina! =a £01 (ia) Fit Noma rh 2 s-0) et = now ie C4| 5 a oO GaP eee ee ct | S| one] 26 a caee r a ey OG sear whers frentplere k 2.4 7 on ay, sae 0.9 pa ty apt oF eet samy giuterrng spun bameneaty baglcet Ken ree Orne ileal hoc! y Pavtehing ~ slap sehen pr port ex prem igs seengen fis Gee. Goremwem aps very unsteacty wherreleres aaa 5 fleets odaneoet asaeTOPRRT MEDICAL RECORD FIGURE 22. 15 mergency Roam record Continued16 | CHAPTER 2 The Health Record as the Foundation of Coding MEDICAL DECISION MAKING PLAN Ditferentiat Ox: Hegel 1 Sees eu 2 deena Sons Lady sete ofPeey TD Lice) eae el or rae ae Faclology Results: (ED nerreaton ([] Dscused wth Rasoogit SAS ee Or -Mearendince ofacete rschenta SE ing EMS to vane 1D Thepatert as gent 17 exammythn: NER Anja Cr Fatwa 1 aarcae [ATTENDING PHYSICIAN NOTE: Tine eon LL 33a PD 3 Ireviened the rasdentnidivel's note stove and agro aw WK Th TO eh SY otto, les uth th residentimilevel durrg the patent’ history and physical and discuss teir management with here ‘anand avast the Seon tence ha os Procedire/Propress Note: Tine:__AM/PM Cone: Cates anon Me aucte mrorsines pertleeress Placeptelte Leckie ns Zize whem rover Procedures: Cantal Venous’ Intubation LP Suture / Chest tbe Nasal Pack/ Secon Split / IAD Othe: Biagrents: = See socedure dosaneniaion v theew> 4 Sew tna dactmentnion 2. —— SS — eS apo Dies A Ta AN ri Sable $60) Far Selon xpind heerooe MEDICAL RECORD FIGURE 2-2, cont'd, Emergency Room racer.CHAPTER 2 Tho Health Record as the Foundation of Coding I 17 Admission History and Physical Examination Admission history and physical documentation normally contains the following elements: Chief complaint (CO) History of the present illness (HPL) Past medical history Family medical history Social history Review of systems Physical examination Impression “Assessment Plan See Figure 28 for an example ofa history and physical form (H&P) Physician Orders This is the arca of the record in which the attending physicians, ax well as physician con- sultants, give directives to the house staffand to nursing and ancillary services. Physician orders are dated, timed, and signed and become part of the record. Verbal erders by physi cians are guided by medical staff regulations. See Figure 2-f for an example of handwritten, physician ontersand Figure 2-5 for an electronic physician orcer, Progress Notes Progress notesare a record of the course of a patient's hospital care. They are usually written by the attending physician (Figure 2-6, A). Academic medical centersmay have notes written by medical students, imiems, and residents, as well as attending physicians and consultants, Some facilities have integrated progress notes, which allow individuals from several disci plines to write in the same area of the record, An integrated progress note may include notes written by dietitians, physical th Progress notes written by the attending physician are recorded on a daily basis: the frequency of such nove takings governed by medical staff regulations. These notes describe how the p plan of care for the patient, In an electronic patient record, these notes may be dictated and uanscribed or typed by physicians them- selves, Physicians are usually taught to document progress notes according to the SOAP format. SOAP stands for the following: Subjective—The problem in the patient's own words (chief complaint) Objectie—The physician identifies the history, physical examination, and diagnostic test results Assessment—Where the subjective and objective combine for a conclusion, Plan—Approach the physician is taking t sohe the patient’s problem See Figure 246, 2, for an example of @ progress note written in SOAP forma pists, respiratory therapists, and nurses nt is progressing and putforth th Nursing Notes Tenuesing notes are not integrated, they are often found in their own section of the record on forms that lend themselves to the wpe of information nurses are required to document, Nursing notes usually consist of an admission note, graphic charts, medication /treatment records. and temperature, pulse, and respiration (IPR) sheets. 8 example of an electronic medication adminisration record (MAR) and Figure 2-8 for an example of laboratory results e Figure 2-7 for an Anesthesia Forms ‘The anesthesiologist is required to write preanesthesia and postanesthesia notes, The anes- thetic agent, amount gien, administration technique used, duration of the procedure, amount of blood los, fluids given, and any complications or additional procedures per formed by the anesthesiologist must be documented. See Figure 2-9 for an example of anesthesia documentation Tesco om ps 23 Bahan dengat18 | CHAPTER 2 The Health Record as the Foundation of Coding ADMISSION NOTE Mo. Pager: Date Tine: Chief Complaint: twitching History of Presert linoss: ‘Ths is@ 61 year od woman with a history oflupus, lupus nephritis, ané cadaveric ‘eral ransplant in 2000 who now presents with 2 weeks of worsening wutching, The patient descrbes staring neurontin for Meadaches approximately 2 weeks ago. She Subsequently noted firs! subtetwiching of an extromiy or her faca. The marements have progressed to include amicuty speaking, dysarhtia (1 zouldyt say what was thinking) ane ciety walking ‘The patent has also noiced worsening fatigue, a change inher akin (I's ashy’) \Wersening ecema (including LE ard petra end (On Friday the patient celled te transplant nurse who recommended she come tothe Emergency room. There, she Was seen by neuro, who felt mast o! her sympioms were moat key related io worsening renal lelurewith gabapente. They alse noted bi posis and ndings suggestive ofa peripheral neuropathy ‘The patent reports no improvement in sympioms since arrival, ED Course: Asabove, Fina Emerseny Conse Review of Systeme: <> bay sever -Sil,ight Sone Fags) ‘Wor Lace Wegnt Gan, tt TnSleranss Colentaianes Kissa eawen:Synopeighenes [waren Deane enor Weakness | sentnen ning ecw. ser ange CHGPD Carat, Clascoma, Hesagt, Tints, Sust, Ghusewn, Eeeckeracnes Aesoratoy: [SSE Pcie Pin, ness, Ona | Spain, ecole LAbiminaain, Mawar ong, | xan, conaaton use, sole eich Oa. Covopnag eu: [Sremme- Fesuency. ganey. Hestanoy, Nias yen |Sopieson Mocs Changes, SH Pan |X All other systems negative FIGURE 2-3, History and physicalCHAPTER 2 The Health Record as the Foundation of Coding I 19 mo. Pager: Date Time Past Medical History: ‘Social History: Lupus diagnosed 1981. ho lupus arthritis and musde pan = Noprior lupus invavement in brain Tobaceci none: “Norecent fais pa ies Iicit: none Residence: lves wth daughter ‘Cccupation: euned her own hai salon, now not woking Family son and daughter in area Other Allergies: Medications: Imaran 1509 po ge Prednisone 10mg 90 ad Progratamg po be nexium 40mg po ai Biresata 4 sno folate 11g p0.0d Fe300%g po tel “Toprol ML 100mg po ad Calva 0.59 pogo Phoslo2 tabpo TD Aranesp 100.0 week ‘Lasix 46mg po bid ‘Clenicine 0.41a po bid Family History ‘Mo -Kidney stones No lupus, no tena fare Tyee a 7a —— |r 5p i ca AR 2 93% ‘None ‘S20; Fo, Pain? Dex! we wo Sioa! FIGURE 2-3, cont'd. History and physical20 1 cuapter 2 The Health Record as the Foundation of Coding Cranial Nerves: inact ADMISSION NOTE Mo. Pager Date Tine: Genera: Pleasant, NAD. Periodic jerking movements of | Affect: full large muses, small muscles, and facial nuscles HEENT, _ Bi/Lplocia,no ecloralictorus, MM al dr. OP elo. Neck: Neck supple, No LAD. Chest: CTAAIL Skin: ey Hear: AR, so SM alLUSE vase: Aba: ‘Soft fall BSNA No ascites Ext 1 edema Joints: n9 elluson or erthema GuiRectal: defened Neuro: Sensation ) Mental Status: atentne, oriented Motor grossly intact. sustained clonus bl Coordination’ Bete row Nov err Ee = geo < basi, otherwise clear on ee eat Me (am din) ee oe des tec eatn eG cheatin FIGURE 2-3, cont'd. History and ahysicalCHAPTER 2 The Health Record as the Foundation of Coding I 21 ADMISSION NOTE Mo Pager: Date Time Radiographic Data Impression ‘51 year of wonan with worsening renal talure ane muscle twtching, Plan: 1, Neuro-Musole twiching i likely due to urerva in he setting of wersened renal function. Suspect contribution of gabopenin, which can cause tilching ad's corelaed fi Ue. Plan ist stat dialysis Nondey. Continue progal (can ‘Slop monday per real. 2, Renal-Continue progral, nephrovte, phoslo, lenel diet Renal has seen patent 43 Rheure-Coninus imuren, Ne evicence of acute fir, but check ESR & CP. Coninue predrisone. HIN Continua clonidine, top. ntesipine 9. 5. Dispo-See PMD. DVT Prophyiaxis? heparin 5009 units sq bd, siop Sun fr cialsis Monday 1. 692.0. Trembling paralysis 2.586; Fenalaiure, unspeciied 3, 401.9. HTN [Hypertension} 4,710.0 Lupus nephnits Date FIGURE 2-3, cont'd. History and piysical. n dengan hi cip2 CHAPTER 2 The Health Record as the Foundation of Coding ORDER SHEET Page. al = 2) Date | Time Sotlbes bal poniper: pees my ba Date [Time Se Igfitfat?” \oQrtva Tr foOGts po taxol = lOnaaiiictiant 1209 pa Wig os : 6 * Qloacanie 350 ol a ities! i Go laiel Vitornel os go aE : - we ORF 22S word Va gi au ete batiepebites—Bloncy Nig ale icfHloo ccs, I FIGURE 2-4, Handwritten physician orders.CHAPTER 2 The Health Record as the Foundation of Coding | 23 ‘Cumulative Order Summary Orders Med Ree No: Location: Birth dates Age Re: Sec ALLERGIES: Sweling-dexamethasone Ord Order Start date COLBXMXLH ——_Immunofluation-Electro, Serum LAB. 1 or mare nat roouts rsived Entered DTM: Auth presciber: ‘Auth presciber aumboe 01BXNXiI Immunoglobulins, Serum LAB Tor mare inab resus received, Entered O1/TM: Auth presciber: ‘Auth presciber sumbee COIBINBHF ——_—Transfuse Red Blood Cells Competed slart date: Urgency: when avallable, vansfuse 2 censert obtained units. Transfuse each unit ‘ver Zhouss, ndlalyis. When te patents ready ard the procuct is avaiable, call or fax blood bank for deivery win ease Entered OUTM: Auth proseiber Auth prescriber number FIGURE 2-5. Elecironic physicien order. Operative Report An operative report must be included in the health record for paticnts who undergo surgi cal procedures. The operative report should include a preoperative diagnosis, a postoperse live diagnosis, dates, names of surgeons, descriptions of findings, procedures performed, and the condition of the patient at completion af the procedure. The operative report should be dictated and should be in the record within 24 hours of completion of surgery See Figure 211) for a sample of a dictated operative report Consultations Gonsultations are requested by the attending physician who wishes t gain an expert opinion on treatment of a particular aspect of the patient’s condition that is outside the expertise of the attending. A preoperative consukation may be requested as part of the determination of the surgical risk of the patient. Information acquired during consults inay be integrated within progress nots or recorded on a se} ate consult form, Laboratory, Radiology, and Pathology Reports Laboratory data are often captured electronically and may or may not appear in the papet health record, Laboratory data would include sch items as complete blood count (CBC), and the physician may often find the actual image available electronically. Pathology repor's, Which are’ also increasingly found in wanscribed reports online, consist of a gross Tet contd on fr 33 dholic levels, Radiology reports are increasingly captured electronically,24 1 cuapter 2 The Health Record as the Foundation of Coding PROGRESS NOTES (or addressogaph plate Dae | Tine gle 8 [Roles / chur! Im’ tatneg Ne 20 1W2t-o ae 5 So 2 Leisinced AG” giglicleg EF Admlog sp A FIGURE 2-6. A, Progress notes.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.CHAPTER 2 Tho Health Record as the Foundation of Coding I 27 PLEASE WRITE LEGIBLY roceoure TLE aancats Sie ries EDICATIONS Motes) VEIN Formed sive C1 EON corte 5 Biman aL toa = Seuniose ‘Negative cg Oiiares 2 Neate Sereriemn 3 me Seater oom 8 eelapmre fee ee ie ! Le 2 oe co camae tse eee 5 Fantom eta ek Bergan, near Gl coxtil 2 uncenne teat Senta o Ramee oo wih” Lice See fy cline 5 see se Be eens | a) sae Bee 2 on es So meeT Acti 3 me . a Senenie tear haan ae Se a Set Bl 9 Sita 5 Stamtan OF wane Si i eee = i ¢ Ru See one ies aoe i eee Sean a sencton, ene Cees oe B mace ee ee Som Eero eg eet ade ee Secrest Wiad gyi EE 8 ae ee | aoe oe ea Wyo. % fn La ength sroteniaa J Pel a 4, PREVOISSURGERY MO ANESTHESIA PALNONE 12 eee 41 SP ad hea ©) ass 18 sdilias 3 Ore wl $b OA or Gf caf 6! 0 (eararwal OOAaLIC IO) ston pneonuen: he one we FIGURE 2-9. Anesthesia record Continued Bahan dengan hak cipia2B CHAPTER 2 The Health Record as the Foundation of Coding PLEASE WRITE LEGIBLY Physical Examination worl inal lesa | aa ee ee NE Pate ag and MDS ref Gen 7 == == [REST ESAATTERONG PRE TNESTESAASESSSUENT NO COMSENT eccaecuninemsynevmG7 Pee amy asastarus (#leis[s[s] 18) ‘Alay Assessment fae a Geween TD Sy ee Pe en 0 ca Nestodsopadhoss eve Shor loner iCh cresC] pe Seep) oor Spel ear iinet Nace Ewensenni 70) 2G ramtpooamecrs reuGy (0 one feo 00 75 SS 4 p-D A foe CAO a fete Cine cower at bine ht ta eagentcoiane! epatent ‘he pin fot rastassandpostpttuepain ragenen er alert, nte ks rer lee lay and teres ae et ‘Naa ne agin custo have bean anvaaaomy Sacon. he mcd. ‘json Pavoni Guan, ath Gre Aa Tape car woe ‘pais ol ih cr poe acing one dnerbesciog site ommoe a. a [SURGIGACATTENING PAE OPERATE ASSESSVENT-D be OMEIO Dy get bat as a TgE so an VEST coum ora een calor. andzecert ey est met rani aaow= NONE surgeon signee tmnme ne unr soy pacezot2 FIGURE 2-9, cont'd, Anesthesia record.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.38 CHAPTER 2 The Health Record as the Foundation of Coding EXAMPLE, EXAMPLE EXAMPLE, EXAMPLE, EXAMPLE Previous Conditions Olen, in a discharge summary or a history and physical, physician will list diagnoses and/or procedures from previous admissions that are not applicable to the current hospital sy. These conditions are generally not reported, V codes may be used if this historical condition has an impact on current care or influences treatment, ‘A patient is admitted with acute bronchitis, The patient was admilled two years ago for an appendectomy and has a history of shingles. In the discharge summary, the physician documents ‘acute bronchitis, status post appendeciomy, and a history of shingles. In this case, the only diagnosis to be coded is acute brenchitis. V codes may be assigned for any histoy of or status post conditions, Reporting of Coexisting Chronic Conditions Clarification of this guideline is reported in Coding Clinic (2000:2Q)p2021).' Often, patients may have multiple chron conditions when they are admitted £0 & hospital, Coding Clinic sas, “Chronic conditions such as, but no: limited 10, hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson's discase, and diabetes mellitus are reportable These chronie conditions may not be specifically cated with medications or procedures; however, they are reported because they may be evaluated and /or monitored. ‘A patient is admitted with benign prostatic hypertrophy (BPH) for a transurethral prostatectomy. ‘The anesthesiologist in the preoperative note documents that the patient has mitral valve prolapse and requires antibiotics prior to undergoing dental procedures. The fact that the patient hes mitral valve prolapse and requires antibiotics is a signficent factor for the anesthesiologist. This condition is under clinical evaluation ky the anesthesiologist and is being treated simultaneously. Therefore, both BPH and mitral valve prolapse (MVP) are reported, ‘A patient is admitted with acute appendicitis. The anesthesiologist and the preoperative Consultation incicate that the patient has a history of chronic obstuctiwe pulmonary disease (COPD), The acute appendicitis and the COPD are coded. Refer to Coding Clinic (1992:20: 16-17)°; COPD is 2 chronic condition that affects patients for the rest of their lives. This, in tur, affects the monitoring and evaluation of this patient, Integral Versus Nonintegral Conditions Conditions that are an integral patt of the disease proces are not coded ‘A patient is admitted to the hospital with a cough. After performing a diagnostic evaluation, the physician determines that the patient tas pneumonia. Coughing is a symptom of pneumonia and Is not coded. ‘A patient is admitted to the hospital with hypotension, fever, and an elevated white blood count ‘A blood culture comes back positive, and the physician determines that the patient has sepsis. In this case, only the sepsis and the SIRS are coded; hypotension, fever, and an elevated white blood count aro all cympioms of sapsis and aro therefore not coded. Likewise, conditions that are NOT an integral part of the disease process may be coded. Ber Caling Clinic (9902Q:p15)" “Additional conditions that may net be associated rou- tinely with a disease process shonld be ended when present.”aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.42 | cHapTeR 2 The Health Record as the Foundation of Coding 5. Only the teatmentis documented (without a diggnesis) EXAMPLE “The MAR shows adminisvation of levethyroxine (Synthroid), but no documertation is provided by the provider of a diagnosis. Itis noted that a medication is given, but no diagnosis is documented to correspond with the treatment. 6. Present on admission (POA) indicator satus is unknown or unclear EXAMPLE On the third hospital day, the provider documents that the palfent’s disbetes is uncontroled. & query 's initiated to determine whether the patient's diabetes was uncontrolled at the time of admission, When Not to Initiate a Query Do noi query a prosider’s clinical judgment. It is not the coder’s responsibility to question a provider's clinical judgment because the documentation in the record does not support the condition, EXAMPLE Patient presents to the hospital with a cough and feter. The physician documents pneumonia on the discharge summary. The chest x-ray is negative Who to Query The queryshould be directed to the prosider who supplied the documentation in question, This may mean that the query is direcied © a consultant, aneshesiologist, ar surgeon, among others. Abnormal lab finding queries should be addressed to the attending physi- ‘can. there isconfict ing documentation beaveen a consullant and anaviending physici the attending physician should be queried for clarification Elements of a Query Form A query should contain the following elements: = Dste of query Patient name Medical record number Account number Admission date/daic of service Specific question needing clarification along with etlinieal indicators Identification of the coder asking the question. Contact information for the coder initiating the query “tea for tesponse trom provider Plice for provider signature and date of response Instruction for documentation or any correction or addendum in the body of the record Queries can be forms (Figure 2-13) placed in charts, faxes, and /or electronic commu nications transmitted via secure e-mail or IT messaging. Facility policy will control where queries are maintained, Iti preferable that they become part of the official health record, whether paper or electronic Itis not advised to use sticky notes, scratch paper, or any note that can be removed and, discarded. It isaeceptable to nse a single query form for muliple queries Bahan dengan hak cipiaCHAPTER 2 The Health Record as the Foundation of Coding I 43 PHYSICIAN QUERY FORM Patient Name: Patient Number ‘Amission Date Discharpe Date ‘Query Date: Dear Dr ln order to assign the most appropriate codes that retect the conditions olyour patient, more Froma cosing perspective “urosepsis” is anonspecife tem. Itmay mean thatthe patienthas sopsie localized n the urinary tao, 0: may signify tat tho urinary tact infootion has nowt become generalzed cepsis, Please documentin the space below orwrite an addendum to the patients record the diagnosis that best represents You use of the tem Physisian Respense: Physician signature Date Thank you Coder Name: Contact FIGURE 2-13. Physician query form. Unacceptable Types of Queries Iris unacceptable to lead a provider to document a particular response, The query should not he directing, prodding, probing, or presumpsive, The provider should not be led to make an assumption. AHIMAin the Practice Brie! Managing an Effective Query Provess" bas given the following examples of leading queries.44 1 cuapter 2 The Health Record as the Foundation of Coding EXAMPLE, EXAMPLE, EXAMPLE, EXAMPLE Leading/Unacceptable Dr. Smith Based on your documentation, this patient has anemia and was transfused 2 units of blood, Also, there wa® 10 point dip in hemetocrit following surgery. Please document “Acute Blood Loss Anemia,” as this patient clearly meets the clinical criteria for this diagnosis. Acceptable Dr. Smiths In your progress note on 6/20, you documented anemia and ordered transfusion of 2 unite ff blood. Also, according to the lab work dene on xxix, the patient had a 10 point diop in hematocrit following surgery. Based on these indications, please decurment, in the discharge summary, the type of anemia you were treating. Leading/Unacceptable Dr. Jones: This patient has COPD and is on aaygen every night at home and has been on continuous, fygen since admission. Please decument “Chronic Respiratory Failure.” Acceptable Dr. Jones: This patient has COPD and is on oxygen every night at home and has been on continuous. oxygen since admission. Based on these indications, please indicate if you were treating one of the following diagnose = Chhionic Respiratory Failure Acute Respiratory Failure Acute on Chronic Respiratory Failure Hypoxia Unable to determine Other In both of the unacceptable examples, the cocler was asking for a provider to document a particular diagnosis, No other documentation options were proxided other than the one listed. These queries were already assuming a diagnos, rather than giving the clinical facts and allowing the provider t9 make a clinical determination. The nonleading way to ask is, with open-ended queries or multiple-choice answers with clinically reasonable choices, as, well asan “other” option that allows the provider to input something entirely different from the multiple-choice answers given, It is inappropriate to inoduce new information not previously documented in this record. For example, if on a previous admission the provider documents that the patient is HIV positive, but during this stay that diagnosis is not documented, it would be Inappropriate tw query for “new lnformaton” that 8 noc documented during the encounter Query forms should steer away from “yes” and “no” poses, when a diagnosis has already beens documented, a “yes" or “no Innpact on reimbursement should never be indicated on a query form. answer questions. For POA pur queryis unaccepuatble Qualifications for Individuals Submitting Queries In the Practice Briel Managing an Ejfetioe Query Procas,!! AHIMA suggests that individuals performing queries should be very familiar with the AHIMA Standards of Ethical Coding, aswell as have competencies in the following areas:aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.CHAPTER OUTLINE LEARNING OBJECTIVES ABBREVIATIONS/ ACRONYMS ICD-9-CM Format and Conventions ICD-9-CM Official Guidelines for Coding and Reporting ICD-10-CM Official Guidelines for Coding and Reporting Format of ICD-9-CM and ICD-10-CM Code Books Format of Tabular List of Diseases and Injuries Format of Alphabetic Index to Diseases and Injuries Coding Conventions Abbreviations Punctuation Instructonal Notes Appendices A. Morphology of Neoplasms ©. Classification of Drugs by American Hospital Formulary: Service List Number and Their ICD-9.CM Equivalents D. Classification of Industrial Accidents According to Agency E. List of Three-Digit Categories Chapter Review Exercise Chapter Glossary 1. Identify the format of the ICD-9-CM and ICD-10.CM code book 2. Explain and apply the conventions and guidelines 3. Identify the appendices AHS American Hospital 00-10:CM Intemational NS-DRG Nedicare Severity Formulary Sevice lassication of Diseases, 10th diagnosis-telated groups CPT Curent Procedural Revision, Clinie! Modification NEC aot elseutere clssifiable Terminology IGD-10-PCS Intemational NOS: not otherwise specified AeA eee Glassicaton of Diseases, 10th ye yd Heath Organization ‘Statistical Manua! of Mental Revision, Procedure Coding a Disord, Feurth Editon Sisten ICD-9-CM International {00-0 tnteratonal Clssifeaton Classification of Diseases, th &f Diseases or cology Revision, Cinica! Modcaton 4 Bahan dengan hak cipta48 1 chapter 3 1cD.9-CM Fermat and Conventions Tiassa lose neces Coen Pees ir Ope CS STaNC Section | Conventions, general cofing dens, and chaper-specife guidelines Official |e ctrscessentene cee al ar dt ine arte bie cerca aunatriara endl ea pesitewe celine nies chewed hice! Guidelines for ‘A. Conventions for the ICD-9-CM Coding and" The conventions for the IGD-9.CM are the general rules fer use ofthe etasifeation Reporting independent of the guidelines, These conventions are Incorporated within the Index nd IED he eo ch as (rtd bred il Thee Eat er dpe ae sete 1. Fora The ICD.9-CM uses an indented format for eas in reference 2. Abtreviatone a. Index abbreviations NEG. “Not elsewhere classfabie" ‘This abbreviation inthe index represents “other specified”: when a specifi code is nol avalable fora conditen, the index dicts the coer tothe “other speciied” NEC. “Not elsewhere classifiable” This abbreviation in the tabular represents “other specified”. When a specific code is not available for a condition, the tabular includes an NEC entry under 2 code to identify the code as the “other specified” code. (See Section 1.5.2. “Other” codes) NOS “Not otherwise specified” This abbreviation is the equivalent of unspecified (See Section 1A.5.., “Unspecified” codes) 3. Punctuation 1 Brackets are used in the tabular list to enclose synonyms, alternative wording or xplanatory phrases. Brackets are used in the indox to identily manifestation codes. (See Section LA.6. “Etology/manifesiations”) (2 Parentheses are used in both the index and the tabular to enclose supplementary words that may be present a absent in the statement of a disease or procedure without affecting the code number to which it's assigned. The terms within the parentheses ara raforred to as nonescantial modifiers, Colons are used in the Tabular list after an incomplete term which needs ene or mere of the modifiers following the colon te mate it assignable to a given category. 4, Inclades and Exclutes Hotes and Inclusion terms Inclades: This note appears immediately under a three-digit code title to further define, or give an example of, the content of the category Exclides: An excludes note under a code indicates that the terms excluded from the code are to be coded elsewhere. In some cases the codes for the excluded terms should not be used in conjunction with the cade from which il is excluded. An example of this 1s a congenital condition excluded fram an acquired form of the same condition. The congenital and acauired codes should not be used together. In other cases, the excluded terms may be used together with an excluded cods. An example of this is when fracturos of differant bonas aro coded to different codes. Both codes may be used together if both types of fractures are present. Inclusion terms: List of terms is included under certain four and five digit codes. These terms are the conditions for which that code number is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms aro a list of the \arious conditions assigned to that coe. The inclusion terms are not necessarily exhaustive, Adcitional terms ‘ound only in the index may also be assigned a cade. 5. Other and Unspecified codes 2. “Other” oles Codes titled “other” or “other specified” (usually a code with a 4th digit 8 or a ‘ith-digit 9 for diagnosis coves) are for use when the information in the medicel record provides detall fer which a specific cade does not exist. Index entries with NECCHAPTER 3. ICD-9.CM Format and Conventions 1 49 in the line designate “other” codes in the tabular. These index entries represent specific disease entities for which no specific code exists so the term is included within an “other” code. b. “Unspecified” coves Codes (usually a code with a ath digit 9 or a Sth digit 0 for diagnosis codes) titled “unspecified” are used when the information in the medical record is insufficient to assign a mare specific code. 5. iology/mnifestation convention (‘code fire\" “use ad classified elsewhere” notes) Cortain conditions nave both an underlying etioiogy and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by tho manifestation. Whoravor such a combination exists, there is a “use additional coo" note at the etiology code, and a “code first” note at the manifestation code, These Instructional notes indicate tie proper sequencing arder of the codes, etiology followed by manifestation In mest cases the manifestation codes will have in the code Iitle, “in diseases classified elsewhere.” Codes with this title are a component af the etiologyimanifestation convention. The code title indicates that itis a manifestation code. “In diseases Classified elsewhere” codes are never permitted to be used a first listed or principal Giagnosis codes. They must be used in conjunction with an underlying condition code and they must be listed following the underlying condition There are manifestation codes that do nat have “in diseases classified elsewhere" in the title. For such codes, a "use additional code” note will still be present and the rules. for sequencing apply. In aduition to the notes in the Tabular, these conditions also have a specific Index entry structure, In the Index both conditions are listed together with the etiology coce fist followed by the manifestation codes in brackets. The code in brackets is always to be sequenced second. ‘The most commonly usod stiology/manifestation combinations ara the sod: for Diabetes mellitus, category 250. For each code under category 250 there is a use additonal code note for the manifestation that is specific for that particular diabetic ‘manifestation. Should a patient have more than one manifestation of diabetes, more thar ane code ‘tom category 250 may be used with as many manifestation codes as are needed to fully describe the patient's complete diabetic condition. The category 250 Giabetes cades should be sequenced first, followed by the manifestation codes. “Code first” and “Use additional code” notes are also used as sequencing rules in the classifcation for certain codes thet are not part of an etiologyimanifestation combination See—Seclion 8.9. “Multiple coding for single consition” "nd ‘The word “and” should be interpreted to mean either “and” or “or” when it appears in a title ih The word ‘with” should be interpreted to mean “associated with” of “due to” when it appears a code title, the Alphabetic Index, or note in an instuctional the Tabular List. The word “with” in the elphabetic index ia sequenced immediately following the main term, not in alphabetical order. . "See" and"See Also” The “see” instruction following a main term in the Index indicates that another term should be referenced. It is necessary to go to the main term referenced with the “seo” note to locate the correct code. A *see also” instruction following a main term in the index instructs that there is another main term that may also be referenced that may pravide additonal index entries that may be useful. It is not necessary to follow the “see also” note when the orginal main term provides the necessary code, al cole,” and “in diseasesaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.54 1 CHAPTERS ICD.9.CM Format and Conventions 63.1 Perforation of intestine (nontraumatie) Perforation (nontriumatic) of rectim —| > [Eeciedes 11] perforation (nontraumatish of duodenum (K26-) perforation (nontraumate oF inking ‘with diverticular disease (K370, I72KSTAKEZS) +> perforation (nontraumatc of Sppendis (k350) FIGURE 3-5. Example of Excludes] and Excludes2 notes. 13. Etiology’manifestation conventios (“code fist, “use ad a diseases classified elsewhere” notes) Certain conditions have both an underlying etiology and multiple body system ‘manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has ® coding convention that requires the underlying condition be sequences fire followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the man festation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation In most eases the menifestation codes will have in the coe ttle, “in diseases classified elsewhere.” Codes with this ttle are a component of the etiolegy! ‘manifestation convention. The code title indicates that it is a manifestation code. “In diseases classified elsewhere” codes are never permitted to be used as firstisted or principal diagnosis codes. They must be used in conjunction with an underlying Condition cede and they must be listed following the underlying cordition. See category FO2, Dementia in other diseases classified elsewhere, for en example of this There are manifestation codes that do not have “in diseases classified elsewhere” inthe title. For such codes a ‘use additional code” nate will sill be present and the rules fer sequencing apply In addition to the notes in the Tabular List, these conditions also have 2 specific Alphabetic Index entry structure. In the Alphabetic Index both conditions are listed together with the etiology code first followed by the manifestation codes in brackets, The code in brackets is always to be sequenced second. ‘An example of the etology/manifestation convention is dementia in Parkinson's disease, In the Alphabetic Index, code G20 ‘s listed fist, followed by code FO2,80 or FO2.81 in trackats. Code G20 represents the underlying etiology, Parkinson's disoase, and must be sequenced first, whereas codes FO2.80 and FO2.81 represent the ‘manifestation of dementia n diseases classiied elsewnere, with or withcut behavioral disturbance, “Code frst” and “Use additional code" notes are also used as sequencing rules in the classification for certain cedes that are rot part of an atiolegy/manifestation combination. See Section /.B.7, Multiple coding for @ single condition. 14, “Ana” The word “and” should be interpreted to mean either “ané” or “or” when it appears in a title 45. “with” The word “with” should be interpreted to mean “associated with” or “due to” wher It appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List The word “with” in the Alphabetic index is sequenced immediately following the main term, rot in alphabetical order 16. “See” and “See Also” The “see” instruction following a main term in the Alphabetic Index indicates thet ‘another term should be referenced. It is necessary fo go te the main term referenced with the “see” note to locate the correct code.CHAPTER 3. ICD-9.CM Format and Conventions 1 §5 Failure failed Conta respiration, resptateeyJ969 este 960 swith chronic J962 center G33 ‘Sonic)96. wrth seieJ962 nesborn P85 ‘Petpeecoctwa O51 FIGURE 36. Alphabetic Index default code for respiratory failure. FORMAT OF ICD-9-CM AND ICD-10-CM CODE BOOKS The ICD-9-CM code book contains three volume: = Volume 1 Tabular List of Diseases and Injuries = Volume 2 Alphabetic Index of Diseases and Injuries = Volume 3 Tabular List and Alphabetic Index of Procedures Volume 2 (Alphsbeie Index) is usually fouind st the front of the code book and is folloved by Yolume 1 (Tabular List) and then Volume 3 (Index and Tabular for Procedures). Several publishers have a variety of ICD-GM code hooks available. Cade books are available for use in physician offices that include only Volumes 1 and 2 because ICD-9-CM. procedure codes (Volume 3) are not used by physicians. (Physicians use CPT codes to bill for services and procedures.) Expert versions may contain reimbursement edits, color-coded information, Medicare code edits, and age and sex edits. Some books are updated with replacement pages quarterly and may include references to Coding Clinic articles, At the beginning of a code book, information is usually provided that explains the conventions used in that verson. ‘The ICD-10-CM codebook is also divided into wo parts: an Alphabetic Index and a ‘Tabular List. The Alphabetic Indes lists terms and corresponding codes in alphabetic arder, The main index is the Index to Diseases and Injuries, and there isan additional index 10 External Causes of Injury. There are two tables located in the main index: the Neoplasn table and the Table of Drugs and Chemicals, The Tabular List is an alphanumeric listing oF codes that are divided into chapters based on bady system or conditions, There isan additional book for procedures, which is entitled ICD-10-PES. Bahan dengan hak cipta56 | CHAPTERS ICD.9.CM Format and Conventions Format of Tabular URS ae RUS SLE es Diseases: Tabular List Volume 1 1. Infectious and Parasitic O'seases (091-139) 2. Neoplasms (140-235) 3. Endocrine, Nutritional and Metabolis Diseases, and Immunity Disorders (240-279) 4. Diseases of the Slood and Blaod-Forming Organs (280-289) 5. Menta’ Diserders (290-319) 5. Diseases of the Nervous System and Sense Organs (320-389) 7. Diseases of the Circulatory System (390-459) 8. Diseases of the Respratory System (460-519) 9. Diseasae of the Digestive System (520-570) 10. Diseases of the Senitourirary System (580-629) 11. Gomplications of Pregnancy, Childbith, and the Puerpeium (630-679) 12. Diseases of the Skin and Subcutaneous Tissue (680-709) 13. Diseases of the Musculoskeletal System and Connective Tissue (710-739) 14. Congenital Anomalies (740-759) 15. Cortain Corcitions Originating in the Perinatal Period (760-779) 16. Symptama, Signs, and IlLDefined Conditions |780.799) 17. Injury and Po'soning (800-989) Y Coxes—Suppiementary Clessificaian of Factors Influencing HesIth Status and Contact With Health Senices (VO1-V89) Codes—Supplementary Classiticalion of External Causes of Injury and Peisoning (E800-£999) ih ee RCE eg {¢D-10-CM Tabu List af Diseases and Injuries 1. Certain Infectious and Parasitic Diseases (A00-699) 2. Neoplasms (COC-D49) 3. Diseases of the Blood and Blaod-Forming Organs and Certain Disarders Inveling the Immune Mechanism (050-088), 4, Endocrine, Nutritional, and Metabolic Diseases (E00-E90) 5. Menta) and Behavioral Disordars (FO1-F99) 8. Diseases of the Nervous System (G00-699) 7. Diseases of the Eye and Adnexa (HCO-HE9) 8, Diseases of the Ear and Mastoia Process (H60-H95) 3. Diseases of the Gircuiatory System (100-199) 20. Diseases af the Respratary System (400-199) 1L- Diseases of the Digestive System (K00-K94) 32. Diseases af the Skin and Subcutaneous Tissue (L00-L99) 13. Diseases of the Musculoskeletal System and Connective Tissue (NOO-M99) aA 6 16 V7 18 33 2. Diaeosas of the Genitourirary System (NOO-ND9) Pregnancy, Childbirth, an¢ the Puergerium (000-099) Certain Conditions Originating inthe Perinatal Period (FOO-F96) Congerita! Malformations, Defermations, and Chromosomal Abnormalities (Q00-299) Symptoms, Signs, and Abnormal Cinical and Laberatory Findings (ROD-R9S) Iniury, Poisoning. and Certain Other Consequences of External Causes (SOO-TBE) External Causes of Moraidity (VO1-¥99) 21. Fretars Infuuencing Health Status and Contact with oath Sorvieas (200-738) List of Diseases and Injuries In [CD9-GM, Volume 1, the Tabular List of Discases and Injuries (Table $1) consists of 17 chapters. Most of these chaptersare classified by body system or etiology (cause of disease) ‘Within each chapter, the corles are divided as follows Sections Categories Subcategories Subelassifications Bahan dengan hak cipiaaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.60 1 chapter 3 IcD.9-CM Fermat and Conventions used in Chapter 19. Ifa code in these categories is not six characters in length, a dummy placeholder of x" musi be added before the seventh character EXAMPLE Sprain of ribs, subsequent encounter, $23.41x0. Using Figure 3-9, assign the appropriate fift-digit subclasifications. 1, Pyogenic arthritis left knee 710 2. Localized osteoarthritis rignt wrist 753 3. Traumatic arthropathy, right ankle 716.1 A. Pain shoulder joint n9.4 5. Swelling elbow jcint m0 Supplementary Classifications There are two sections of supplementary classifications in ICD-9-CM: f= Supplementary Classification of Factors Influencing Health Status and Contact With Health Services (VUI-V89) = Supplementary Classification of External Causes of Injury and Poisoning (ESOIES99) Both sipplementary clasifications contsin alphanumeric codes. One of the clasifies tions is found following the Tabular List for Diseases and Injuries ani is entiled Supple mentary Classification of Factors Influencing Health Status and Contact With Health Services (WOI-VRN), ar V codes. V cores are available to code encounters for circumstances other than disease or injury ‘The second supplementis the Supplementary Classification of External Causes of Injury and Poisoning (E8N0-E990), or E codes, These codes are located after the V codes, The E codes are used as a supplement to ICD-2-CM diagnosis codes to provide data on cause, invent, and place ofan iujuty oF poboning, There are no supplementary clasifications in ICD-10M. The wo supplementary cas sifications in [€D-9-CM were moved to the main classification in ICD-LO-CM. Format of Alphabetic Index to Diseases and Injuries ‘The Alphabetic Index contains three sections in ICD.9-CM: Index to Diseases and Injuries fm Table of Drugsand Chemicals & Alphabetic Index to External Causes of Injury and Poisoning (E codes) Two tables are located within the Alphabetic Index, These tables are used for farther clarification of subterms under the main term entries of Hypertension and Neoplasm. These tables are discussed in their respective chapters. ‘The Alphabetic Index in ICD-LUCM contains the following: )-10-CM Index to Diseases and Injuries plasm Table » Table of Drugs and Chemicals = ICD-16-CM Index to External Causes Index to Diseases and Injuries Three levels of indentation are used in the Alphabetic Index. These include the Following: = Main terms = Subcerms Carryover lines Bahan dengan hak cipiaEXAMPLE, EXAMPLE, CHAPTER 3. ICD.9.CM Format and Conventions I 61 ‘Main term +} Cholelithiasis (impacted) multiple) 574.2 Note Use thefollowing ft digit sablossifeation with category 57 1 aethout mention af ebrira 1 with obstruction Sublerm ndentation |_with J cholecystitis 57421 TT cube S740 a ee ca ‘holedecholtiais 5749 — ‘with FIGURE 3-10. Varous levels cholecystits5747 of indentation in the Index. The SOUSA oe bold teren is the main teem, and eae the varios subterms ae sted Delceney deficient Setar dronysterod dehydrogenase a2 -phosphogluconi dchydmgenase (hemi) 28.2 iLbeta hycrnsynse 2552 ‘Zalparhyny lane 255.2 Ib hydrox ptereedekgelrgenaee 2502 ‘Aalydihydronplae 255.2 2hydeosslase 52 2) FeO 10 Wamoical ovis nthe Ape z Index The main terms are identified by bold print and are set flush with the left margin of each column (Figure 3-10), Alphabedzation rules apply in locating main terms and sub- terms in the Alphabetic Index. Numerical entries appear first under the main term or subterm (Figure 9-11). Main terms usually are identified by disease conditions and nouns. ‘The main term is not a body part or site The patient has Eeen admitted with deep vein thrambesis. The main term is “thrombosis. ‘Deep is @ location end “Vein” refers to a body part. The pationt is being teated Tor adhesive bursitis of the shoulder The main term is “bursitis” “Adhesive” describes the type of bursitis and “shoulder” is 2 body part (Figure 3-12). Eee Underline the main terms to be locaied in the Alphabetic Index in the following diagnosis statements. Decubitus ulcer of the hee! Acute anterior wall myccardial infarction Respiratory anthrax Endometriosis of the ovary Gouty arthritis peeps62 1 chapter 3 1cD.9-0M Fermat and Conventions Duplay's7262 FIGURE 3-12. Main term and essential modtiers. ‘Fever7=08 —> witnchits 7805 mela regions oo bo Melati) 846 shortus NEC 0229 ‘den 061 FIGURE 3-13, Connecting term “with” follows the main term, ‘The subterms are indented to the right under the main term. They are not bolded land begin with @ lowercase leuer, Sublerms modify the main wrm and someumes are called essential modifiers. These terms provide greater specificity to the disease or injury. It ispossible fora subterm to be followed by additional subterm|s). These additional subterms are indented even farther to the right than are subterms (refer to Figure 3-10). Some subterms are called “connecting words”. ‘This means that there is a relationship between a maia term of a subterm and an associated condition or etiology. Connecting words “with” and “without” are Iocated before any other subterms (Figure 9-13). Additional connecting words include the following: = Awocisted with, Due to In With With mention of Bowes Using the Alphabetic Index only, assign codes to the following condition Asthma due to detergent Chollithiasis with acute cholecystits Parkinsonism associated with orthostatic hypotension ystocele in pregnancy Lict the eublorme for conyaa. preps Carryover lines are used when an entry vill not fit ona single ine. These are indented to the right even farther than a subterm to avoid confusion (Figure 314) 1 dengan hak ciaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.CHAPTER 3. ICD.9.CM Format and Conventions | 87 FIGURE 3.21. Colon used within “Includes” note. FIGURE 3-22. Braces. Colons Colons are used in the Tabular List afier an incomplete term that needs one or more modi- fiers following the colon to make it assignable to a given category. Colons also are used in both Inclusion and Exelusion notes © invlieate that one of the words [rom the indented list must be present for the note to apply (Figure $21). In Figure 3-21, the term “hypertensive” is used to describe various heart conditions. The colon helps to save space and means the sume as if it was written in this way in bok the ICD9-CM and the ICD-10-CM: Hypertensive cardiomegaly Hypertensive cardiopathy tt Hypertensive cardiovascular disease Hypertensive heart disease or failure Braces ‘The purpose of the brace is 10 sive printing space by reducing the repetition of words. A. brace is used to enclose a series of terms, each of which is modified by a statement that appears to the right of the brace (Figure 5-23) Braces are not used i IGD-10-CM. Instructional Notes Notes with instruetions are foxtnd in sll three volumes of ICDAUCM. General notes may be found in the Alphabetic Index and the Tabular List. These notes provide additional infor~ mation (Figure 23). Other ypes of instructional notes are “Inclusion”; “Exclusion”; "code first’; “use additional code": and ‘code, ifapplicable, any cnussl condition first” Bahan dengan hak cipta68 CHAPTER 3 EXAMPLE, ICD.9.CM Format and Conventions ‘Fracture (abduction) (adduction) {avasion compression] (crush) (Gisdocaton) (oblique) (separation) {elosed) $20.0 Note For fracture of any of thefol- Iowving sites with Fact of other ‘bonesrsee Fracture, multiple “Closed” includes the following de- scriptions of factors, wethor thou slelayee healing, uses they are speci fied ssopen or compound: ‘comminuted depressed clevated Fisssred sreenstick Impacted Tinea simple Slipped epiphysis Spal unspecified “Open inehices the following descrip tons of fracuces with or without delayed hesing: eee infected puncture {ith Foreign body For late effect of racture, Late, ef- fect, rsctre, by site FIGURE 3-23. General notes found in the Alphabetic Index. Inclusion Notes Inclusion” notes in the ICD9-CM are termed “Includes” nots in the ICD-10-CM and are used for the same purpose in both. An Includes note is an instructional note that appears immediately under a three-digit cade title or category. The purpose of the Inclides note is to give examples or further define the content of the category (Figure 3-24) Inclusion Terms According to the guidelines, Inclusion terms are a list of lerms that ate found under some Fourth: and fifth-digit codes (Figure 3:25). These terms may be synonyms or various other conditions that are assigned to the code. Incluson terms de not necessarily constitute a comprehensive list. Additional terms found only in the Alphabetic Index and not in the Tabular List may be assigned a code without mention in the Inclusion terms, In these instances, the Index should be trusied. Inclusion terms are used in the sime manner in both the ICD-8-CM and the [GD-10-0M. Exclusion Notes An Excludes note is ant instructional note that may appear alter any code in the Tabular List. One of the purposes of the Excludes note is to direct the coder to another code. The patient has COPD with asthma. Under category 496, an exclusion note indicates that COPD with asthma is coded to 493.2 (Figure 3-26). Alter verifying 493.2 in the Tabular List, note that fifth digit is nacessary for a valié code assignment. In [CD 10-CM, 144. includes asthma with chronic okatructive pulmonary disease, but there is an instructional note to code also the type of asthma, if applicable (J45..). ak ciptaCHAPTER 3. [CD.9.CM Format and Conventions I 68 FIGURE 3:24. This “Includes” note is found under category 401, Essential hypertension. FIGURE 3:26. Exclusion note. Another purpose of an Exchision note is to instruct the coder that the excluded terms should not be used along with the code that is assigned. The example given in the guidelines is that only one core should be assigned far a condition that has different codes for cone genital and acquired (Figure 8-27) Exclusion notes also are used to instruct the coder that an additional code may be required because this corde is excluded from a particular code. Bahan dengan hak ciptaaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.CHAPTER 3. ICD.9.CM Format and Conventions I 13 Diabetes, diabetie (Continued) Tanceréaur’s (diabetes mellitus with ‘parked emsciation) 2508 [261] dueto secondary diabetes 2498 Dot Intent chemical) - see Diabetes, second ay, complicating pregnancy childbirth, ‘or puerperium 6188. “tpotdosis 2908 127271 ‘lueto secondary dinbetes 2098. wan macula edema 2505 (36207) itueto secondary diets 2495 e207) , _croaneusyms retinal 2905 {362 01) “dueto secondary dnbetes 2495 e201) -mononeurvpathy 2506 (355.2) Mluete sctondary dhbetes 2496 tml 77 ee Diabetic nephropathy ropa 250 [583 81] ———— eee ne eeseren| Emaierad) 158181) FIGURE 2-22. Slanted brackets enclosing manifestation code, Eanes EXAMPLE, Using the Tabular List and instructional notes, assign and requence the following code(s). See category 331 and assign code(s) for 2 patient who has Alzheimer’s disease with behavioral disturoances, See code 484.3 and assign code(s) for a patient with pneumonia due to whooping cough. 3. See code 707.1 and assign code(s) for a patient wth atherosclerosis of the let loner extremities with a toe ulcer. 4. See code 600.91 and essign code(s) for e patient with hyperplasia of the prostate with urinary retention, 5. See code 456.2 and assign codefs) for a patient wth bleeding esophageal varices and cirrhosis of the liver Linking Terms Asin the Index, terms such as “and,” “with,” “due to," and “in” are used to link terms. These terms have special definitions within ICDS-CM and cade assignment ‘The term “and” means “and /or" when it appears ina code title in the Tabular Lis. The code 474.8, Other chronic disease of tonsils and adenoids, could mean any of the followin, fm Chronic disease of tonsils @ Chronic disease of adencids Chronic disease of tonsils and adenoids Theterm “with” (with “mention of,” “associated,” and in") indlicatesthat both elements in the title must be present and documented for this code to be assigned. Viral preumenia with influenza is assigned codes 487.0 and 480.9 (Figure 9-33), Both the pneumonia and the influenza must be present for code 487.0 to be assigned (11.08, J12.9) 1 dengan hi74 1 chapter 3. 1cD-9-0M Format and Conventions FIGURE 2-33. Influenza with paeumonia, FIGURE 3:34. “Due to” indicates a relationship between the cataract and subsequent subterms. ‘The term “due to” indicates a causal relationship between two conditions Its found in both the Alphabetic Index and the Tabular List, [fit is documented that a condition is, due to another condition and there is an Alphabetic Index entry for the subtemt “due 10,” the coder must follow the Index (Figure 331). Cross-References Crossroference termaare used in the Alphabetic Index to instruct coder w lock elsewhere prior to code assignment, These terms include “ss.” “see als,” “see category” and “see condi tion” (Figure 333). “The term “ses” is a mandatory instruction that advises the coder to go to another main tem (Figure $36). ‘The term “see also” nstructsthe coder about the possibility that a better main term may appear elsewhere in the Alphabetic Index. If the specifie diagnosis cannot he completely Bahan dengan hak ciptaCHAPTER 3. ICD.9-CM Format and Conventions | 18 FIGURE 3.95. Uncer the main term *Hereditay,” manéatory instructions are given to "see" contition. FIGURE 2.36. Crore-reference to “see” another main term == |. ‘CROSS REFERENCE 2 ae FIGURE 3-37. “See also” instruction to go to the main term “urticaria. identified by the subserms, it may be necessary to follow the “see also” instruction (Figure 537) If a patient has hives because of use of a medication, in the Alphabetic Index, the only code available for the main term “hives” is 7089. Ifthe “ser als” instruction is not fol lowed, the wrong code would be assigned. When you go to “urticaria in the Index, several subierm selections are available, including 708.0 for “urticaria due to a drug” (ee Figuie 337) A Seode also" nove instructs the coder that two codes may’ be requited to fully describe a condition. “Cade also” notes do not give sequencing inswuction. Default Codes In the ICD-10.CM Alphabetic Index, ifa code is listed next 19 the main term, itis the default code, A default code may represent a condition that is most commonly associated with the muiin term or is the unspecified term for that condition. For example, if pneumonia is Bahan dengan hak ciptaaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.82 | cuapter 4 Basic Stops of Coding should not solely rely on the discharge summary to capture all diagnoses and procedures hat oceurted during this encounter For many reasons, the discharge summary is not the only document from which codes are captured, = Coders may not have a discharge summary at the time of coding, = Ifthe patient is in the hospital for a long stay, often the attending physician will focus, only on those diagnoses that were treated during the latter part of the stay ‘= Physicians list conditions that in the patient’s history = Likewise, physicians describe diagnoses as “history of” when, in fact, they represent conditions that are being currently treated. Most coders start the coding process as they begin their document review, A coder is continually trying tb determine the principal chagnosis during the record review, Clues to determination of the principal diagnosis can be found in dhe ER record or in the admiuins, ‘orders, Physicians, in their admieting orders, give a reason for admitting the patient. When evaluating an ER record, a coder first Jooks for the chief complaint (GG), which is the reason in the patient's own words for presenting to the hospital not currently under treatment and that appear only EXAMPLE “CC: havea bad cough, fever, and heedache, and my throat is so sore | can't even swallow liquids. As the coder continues the review of the ER document, the ER physician provides a diagnosis for admission to the hospital, The admitting diagnosis is the condition that requires the patient 1 be hospitalized. This condition may be a sigh or a symptom that requires testing and evaluation to determine a diagnosis, This may be a known diagnosis ‘ora probable diagnosis, or it may include a differential diagnosis, In the previous example, the ER physician might document, and dehydration.” In this ease, the pneumonia has not yet been confirmed, but the dehy- dration is known, A represent a variety of diag ducted to rule out or contitm the difterential diagnos Admit patient to the hospital for possible pnewmonis, ferential diagnosis occurs when & patient presents with a gmptom that could »ses. During the patient's stay, a variety of studies may be con- EXAMPLE A patient presents with abdominal pain, and the physician suspects that this might represent appendicitis, gastroonteritis, or cholecystitis. Appendicitis, gastroenteritis, and cholecystitis are differential diagnoses. A coder continues on through the health record, reviewing all progressnotes, operative reports, anesthesiology notes, and consults to arrive at all diagneses and procedures that need to be captured o reported. The second most important concept that a coder must remember (alter the definition ‘of principal diagnosis and prineipal procedure) is that once a term has been located in the Alphabetic Index, the code mus then be verified in the Tabular Index. This isnot the ease in ICD-10-PCS, in waich you do not need to refer o the Index before referring to the tables. ALPHABETIC INDEX ‘The Alphabetic Index consists of an Alphabetic Index to Diseases and an Alphabetic Index 10-POS, the purpose of the Alphabetic Index isto locate the appro to Procedures, In ICI priate table. Locate the Main Term in the Index to Diseases Once she coder begins to establish diagnoses and procedures, the first ask in selecting a code is to Jocae the main term, which is always identified by bold type, in the Alphabetic Intex.CHAPTER 4 Bacic Stops of Coding I 83 EXAMPLE Using preumonia as the principal diagnesis, locate this term in the Alphabetic Inéex. The code for pneumonia is 486 (118.9) (Figure 4-1), Using Figure 1, assign codes (9 the follewing diagnoses: Aspiration pneumonia Pneumonia due to Klebsiella pneumeniae Mycoplasma pneumonia Varicella pneu Viral pneumonia geees After the main term, “pneumonia,’ in the Alphabetic Index, ist long list of nonessential modifiers (words in parentheres). Remember that nonessential modifiers have no effect on the main term, They are “take it or leave it” terms, Sometimes, the subt searching for can be found among the nonessential modifiers. ‘m thata coder is EXAMPLE Granulomatous pneumonia is coded to 486 (118.9). Acute pneumonia, 486 (118.9) Fulminant proumonia, 486 (118.9). (Sea Figure 4.1.) In locating the main term, the coder must remember that main terms are usually identi= fied by disease conditions and nouns. They are not body parts or sites, IPa physician docu ments Klebsiella puevenoniee pneumonia, the noun isthe main term and the one to be located in the Alphabetic Index. To find Kletsielle pneumoniaein the Alphabetic Index, the coder goes to “pneumonia” and locks for the subterm, “Klebiella” (Figure 4-2) Subtorms are madifiers of main terms, and in contrast to nonessential modifiers, they do have an effect on the appropriate code assignment. To determine the main term, the coder must decide what condition the patient has (in this case, pneumonia), which is the matin term; subterms are modifiers of the main term, which in this case is Klebsiella prewmoniae EXAMPLE Ifa patient has a diagnosis of hiatal hernia, the main term is “hernia,” and the subterm is lata” The main terms usually are nouns andor disease conditions. The mein terms below are underline. Gastric upset Chronic mast Heroes simplex EXAMPLE The patient has a diagnosis of appendicitis, and the operative report (OR) describes the procedure as a laparoscopic appendectomy. Look up “appendectomy” in the Alprabetic Index and the subterm “laparoscopic,” 47.01 In {CD-10-PCS, look up “appendectomy,” and the Index directs the user to “excision and resection.” Under “resection, appendix,” the user is referred to table ODTJ Sometimes, 4 main term s y he found under mare than one Index entey (Figure 4-3). This is most often true of eponyms (a disease, syndrome, or a procedure, named for a person). Adjectives and anatomic sites do appear as main terms, but they instruct the coder to see the condition (Figure 14) 1 dengan hak cipia84 | cuapter 4 Basic Stops of Coding Main eon Pe ps ee = aes {granalonaioun Oommen agi aoa 48.9 | {ite tbe feminine) | each Se oom Nc ane Seema. ec Pmumia bs Seen. | Bee eee Reni cme od ‘hms oa wr) ‘Shoat os a pce ‘or Pees Some | Seles | cee mae a ae oe a Pees eee ee eee one a, | eebewwn ee ee ea So | | ae ae eee = cee oo Semen | eee Bn | Sete Behe oo =e el ae = ee oe me ‘chcatiodamycais 14.) eo ee ae es Gayo oo ee ee ete a ee Se ee eae = na sees | Gast EOE rn Sas See oe Stems | enaecemee tan emacs Ninian time | puncte Say tl FIGURE 4-1. Alphabetic Index entry for “pneumonia, Bahan dengan hak cipiaCHAPTER 4 Bacio Stop of Coding I 85 rie ue) 70 ee oo ea =e Se aecae sunemot | gmat eas ee 482.84 ie pets oem aS ae Noneseental mmodiier endogenous 3168 FIGURE 4-2. Example of subterm “Alebsiella,” under “pneumonia pe ea ee —___ Tum acute) (multiple) (perforated) || diverticulitis 751.0 Sime teen (euptired) 62.10 eee te Cece eee) swith diverticulitis 562.1 TL ‘aeta (Kommerells) 742.21 spend (nninamaton) $133 ‘ngeal ventricle (congenital) 742.3 |— Nace plat (pertoph) 7310. mathoracic 530.6 FIGURE 4-3. Example of multiple Alphabetic Index entries tor Meckel’s dverticulum. Tschiagia (xe ao Sati) 7283 Techlopagus 7304 Ishin, iehial se condition ‘se2.ls0 Iselin’s disease orosterchondrosis 7325 FIGURE 4.4. Example of an anatomic site instucting coder ‘0 260 condition and an instuction to see also. EXAMPLE Diagnosis of ischial fracture: The Index for “ischial” would direct the coder to go to the condition or, in this case, fracture. Ichi, ischial-—soe condition EXAMPLE Chronic otitis media—look up “chronic” in the Alphabetic Index (Chronic—see condition ‘The term “se” isa mandatory direction to look elsewhere in the Alphabetic Index. Sometimes, the Index will direct the coder to # ala This instruction means that if Uke term cannot be located under the Index ent, the user should go to the see alse suggested Index entry ‘The general rule that main terms identify disease conditions has some exceptions, Some of these exceptions are V/Z codes, which can be found under main terms such as “admis- sion,” “examination,” and “status.” These will be fully covered in Chapter 8 on V/Z codes. Likewise, obstetric conditions ean be found under main terme sveh as “pregnsaney,” “hbo, and “puerperal” and will he covered in Chapter 21 in the section on obsietries and gynecol- ‘ogy. There isalso a main term for late effects that can be used to identify residuals of various, disease conditions and complications. 1 dengan hak cipiaaa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.aa You have either reached a page that is unavailable for viewing or reached your viewing limit for this book.CHAPTER OUTLINE LEARNING. OBJECTIVES ABBREVIATIONS/ ACRONYMS General Coding Guidelines for Diagnosis ICb-9-CM Official Guidelines for Coding and Reporting General Coding Guidelines Late Effects Present on Admission ICb-10-CM Official Guidelines for Coding and Reporting Chapter Review Exe Chapter Glossary Reference 1. Apply ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting 2. Sequence |CD-9-CM and ICD-10-CN diagnosis codes as directed by coding guidelines or ICD-9-CM and ICD-10-CM conventions 3. Determine whether signs, symptoms, or manifestations require separate code assignments, 4, Assign ICD-9-CM and ICD-10-CM diagnosis codes for late effects ABA. Anion Hespita BRA Deft Reductin Act ——_—I0D-10-0M ftertonl Assocation €PO Govemmert Ping Dice OBSSication of sears, lth AHIMA Amtcan Heth AC hospital acquit cordton Revision, iia Moiation Information Maragement ICD-10-PCS Interational HIPAA Health Incurence Association Paral anhceurabiy Cost of Dares, I CABG coronary atery bypass het eg pac ie raft stem 100-9-0M Intemational CNS Center forMedicae end Giasscation af Diseases, sth NOUS. National Center Heath Matlcald Services Revision, Clinical Modification DEHS US, Deparment af Halth POA present on adnission and Human Services ICD-9-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING The ICD-9-CM Official Guidelines for Coding and Reporting were developed by the coop- erating parties to provide further guidance regarding coding and sequencing that is not provided in the ICD-9-CM manual. These guidelines do not cover every situation and have been formatted in a manner that will allow for expansion as new guidelines are developed. The guidelines may be changed each year, and changes may have greater impact in some years than in others. In this chapter, the coder will review the general guidelines and coding examples as cable, The convention guidelines with examples were presented in Chapter $, "ICD- appl 9-CM, Format and Conventions." Chapterspecific guidelines are provided and explained in the respective disease or body system chapter. Bahan dengan hak ciptaCHAPTER 5 General Coding Guidelines for Diagnosis I 91 FSRSRSTYN Pease refer to the companion Evolre website for the most current guidelines. Effective October 1, 2011 Official Narrative changes appear in bold text Guidelines for toms underlined have been moved within the guidelines since October 1, 2010 e The Centers for Medicare and Medicaid Serices (CMS) and the National Center fr Health Coding and —ctetistice (NCHS), two departments within the U.S. Federal Government's Department of Health Reporting and Human Services (DHHS) provice the folowing guidelines for ceding and reporting using, the International Classification of Diseases, sth Hev'sion, Clinical Modification (ICD-9-C¥, ‘These guidelines should be used as a companion document tothe afficial version of the ICD-9-CM as published on CD-ROM by the U.S. Sovernment Piintirg Office (GPO) These guidelines have been aparoved by the four organizations that make up the Cooperating Parties forthe IC0-9-CM: the American Hospital Association (AHA), the American Health Information Management Assocition (AHIMA), CMS, and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for (CD-9-CM" published by the AHA. ‘These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. The instructions and comentions of the clasiiction take precedence over guidelines, These fuidelires are based on the ceding and sequencing instructions in Ylumes I, It and Il of ICD-9-CM, but provide additional instruction. Adhererce to these guidelines nhen assigning ICD-9-CM diagnosis end srocedure codes is requted under the Health Insurance Portability ang Accountabilty Aet (HIPAA). The diagnosis codes (Volumes 1-2) have been agopted under HIPAA for al healtheate setings. Volume 2 procedure codes have been adopted for inpatient precedures reported by hospitals, A joint effort between the healthcare grovicer and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the heattheare provider and the coder in identifying those diagnoses and procedures that are to be reforted. Tho importsnce of consistent, complete documentation in the medal record cannot be overemphasized. Without such cacumentation accurate coding cannot be achieved. The entre record should be reviewed to determine the speciic reason for the encounter and the conditions treated The term encounter is used forall settings, including hospital admissions, n the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accourtable for establishing the patient's Glaghosis. Only tis set of guidelines, approved by the Cooperating Parties, ts offical The guidelines are organized into sections. Section | includes the stucture and conventions ofthe classifeatin and general guidelines that apply fo the entie classification, and chapter specific guidelines thal correspond to the chapters as they are arranged in the Classification. Section Il includes guidelines for selection ef principal diagnosis fr nor- cuipatient settings, Section IIlnclides guidelines for reprting adltional diagnoses in rot-oulpatient settings, Seetion IV is for outpatient eading and reperting GENERAL CODING GUIDELINES General coding guidelines apply 1 all healthcare settings and to the entire ICD9-C) IGD-10-GM classification systems. and Section | Conventions, general coding guidelines and chapter specific guidelines B. General Coding Guielines 1, Use of Both Alphabetic Index and Tabular List Use both the Alphabetic Index and the Tabular List when locating ane assigning a de. Reliance on only the Alphebetic Index or the Tabular List leads to errors in -ade assignments and less speciicty in code selection.92 CHAPTER 5 General Coding Guidelines for Disgnotis EXAMPLE “Threatened ‘orion of miscarriage 640.0 ‘with subsequent abortion (also “Abortion, spontaneous) 6346 affecting fetus 7621 Inbar ott “afcctng fetus or newboen 76.8 premature ot miscarriage 640.0 <<} — “sect Fetus 7621 premature ‘delivery 6442 alfecting fetus or newboen 7618 labor e110 before 22 completed weeks of gesinion 6100 FIGURE 5-1. Alphabetic Index entry for “threatened miscarriage. Patient presents with threatened miscarriage. She is discharged home the naxt day with viable prognency. Threatened miscarriage: Under the main torm “threatened” and the eubtemm “miscarriage” in the Alphabetic Index, code 640.0 is listed. Ii the coder were to assign this cede, tt would be an invalid code. Veriication in the Tabular List reveals thet a hth digit is required. The correct code assignment for “threatened miscarriage” is 640.03, (See Figures 5:1 and 5-2.) 2. Locate each term in the Alphabetic Iniex Locate each term in the Alphabetic index and verity the code selected in the Tabular List. Read and be guided by instructional notations thal appear in both the Alphabetic Index and the Tabular Lt. (See Figures 5-3 and 5:4.) Instructional notes can be found in all three valumes, It is important to review the ‘Tabular code category for notes that may apply © the entire category, These notes can be found at the beginning of a chapter, section, code category, or individual code classification, For additional details on various instructional notes, refer to Chapter 3 in this text 3, Level of Detal in Coding Diagnosis and procedure codes are to be used at their highest rumber of digits available ICD.9.0M diagnosis codos are composed of codes with eithor 3, 4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of coves that may be further subdivided by the use of fourth andior fifth digits, which provide greater detail A three-digit code is to be used only if itis nat further subdivided. Where fourth- Cove frst snerivng onditon, a= 1 Cove frst underiving condition, as | Cave rst ander condition, as 1630 Catnrcia complicals, wnepocited © 366.31 Glancomatous flecks (ubcapstlar) © 346.32 Cataract in inflammatory disorders ‘Ivonieshowsdits(3630-363.2) (© 366.33 Cataract with seovuseularization

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• Principles: Life and Work

  

  From Everand

  Principles: Life and Work

  Ray Dalio

  Rating: 4 out of 5 stars

  4/5 (608)
• The Glass Castle: A Memoir

  

  From Everand

  The Glass Castle: A Memoir

  Jeannette Walls

  Rating: 4.5 out of 5 stars

  4.5/5 (1716)
• Grit: The Power of Passion and Perseverance

  

  From Everand

  Grit: The Power of Passion and Perseverance

  Angela Duckworth

  Rating: 4 out of 5 stars

  4/5 (590)
• Sing, Unburied, Sing: A Novel

  

  From Everand

  Sing, Unburied, Sing: A Novel

  Jesmyn Ward

  Rating: 4 out of 5 stars

  4/5 (1104)
• Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race

  

  From Everand

  Hidden Figures: The American Dream and the Untold Story of the Black Women Mathematicians Who Helped Win the Space Race

  Margot Lee Shetterly

  Rating: 4 out of 5 stars

  4/5 (897)
• Shoe Dog: A Memoir by the Creator of Nike

  

  From Everand

  Shoe Dog: A Memoir by the Creator of Nike

  Phil Knight

  Rating: 4.5 out of 5 stars

  4.5/5 (540)
• The Perks of Being a Wallflower

  

  From Everand

  The Perks of Being a Wallflower

  Stephen Chbosky

  Rating: 4.5 out of 5 stars

  4.5/5 (2104)
• The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers

  

  From Everand

  The Hard Thing About Hard Things: Building a Business When There Are No Easy Answers

  Ben Horowitz

  Rating: 4.5 out of 5 stars

  4.5/5 (348)
• Bad Feminist: Essays

  

  From Everand

  Bad Feminist: Essays

  Roxane Gay

  Rating: 4 out of 5 stars

  4/5 (1018)
• Elon Musk: Tesla, SpaceX, and the Quest for a Fantastic Future

  

  From Everand

  Elon Musk: Tesla, SpaceX, and the Quest for a Fantastic Future

  Ashlee Vance

  Rating: 4.5 out of 5 stars

  4.5/5 (474)
• Her Body and Other Parties: Stories

  

  From Everand

  Her Body and Other Parties: Stories

  Carmen Maria Machado

  Rating: 4 out of 5 stars

  4/5 (822)
• The Outsider: A Novel

  

  From Everand

  The Outsider: A Novel

  Stephen King

  Rating: 4 out of 5 stars

  4/5 (1850)
• The Emperor of All Maladies: A Biography of Cancer

  

  From Everand

  The Emperor of All Maladies: A Biography of Cancer

  Siddhartha Mukherjee

  Rating: 4.5 out of 5 stars

  4.5/5 (271)
• The Sympathizer: A Novel (Pulitzer Prize for Fiction)

  

  From Everand

  The Sympathizer: A Novel (Pulitzer Prize for Fiction)

  Viet Thanh Nguyen

  Rating: 4.5 out of 5 stars

  4.5/5 (122)
• Angela's Ashes: A Memoir

  

  From Everand

  Angela's Ashes: A Memoir

  Frank McCourt

  Rating: 4.5 out of 5 stars

  4.5/5 (441)
• Brooklyn: A Novel

  

  From Everand

  Brooklyn: A Novel

  Colm Tóibín

  Rating: 3.5 out of 5 stars

  3.5/5 (1947)
• The Little Book of Hygge: Danish Secrets to Happy Living

  

  From Everand

  The Little Book of Hygge: Danish Secrets to Happy Living

  Meik Wiking

  Rating: 3.5 out of 5 stars

  3.5/5 (401)
• A Man Called Ove: A Novel

  

  From Everand

  A Man Called Ove: A Novel

  Fredrik Backman

  Rating: 4.5 out of 5 stars

  4.5/5 (4610)
• The Art of Racing in the Rain: A Novel

  

  From Everand

  The Art of Racing in the Rain: A Novel

  Garth Stein

  Rating: 4 out of 5 stars

  4/5 (4203)
• A Tree Grows in Brooklyn

  

  From Everand

  A Tree Grows in Brooklyn

  Betty Smith

  Rating: 4.5 out of 5 stars

  4.5/5 (1929)
• Steve Jobs

  

  From Everand

  Steve Jobs

  Walter Isaacson

  Rating: 4.5 out of 5 stars

  4.5/5 (807)
• The World Is Flat 3.0: A Brief History of the Twenty-first Century

  

  From Everand

  The World Is Flat 3.0: A Brief History of the Twenty-first Century

  Thomas L. Friedman

  Rating: 3.5 out of 5 stars

  3.5/5 (2259)
• The Yellow House: A Memoir (2019 National Book Award Winner)

  

  From Everand

  The Yellow House: A Memoir (2019 National Book Award Winner)

  Sarah M. Broom

  Rating: 4 out of 5 stars

  4/5 (98)
• Devil in the Grove: Thurgood Marshall, the Groveland Boys, and the Dawn of a New America

  

  From Everand

  Devil in the Grove: Thurgood Marshall, the Groveland Boys, and the Dawn of a New America

  Gilbert King

  Rating: 4.5 out of 5 stars

  4.5/5 (266)
• Yes Please

  

  From Everand

  Yes Please

  Amy Poehler

  Rating: 4 out of 5 stars

  4/5 (1898)
• A Heartbreaking Work Of Staggering Genius: A Memoir Based on a True Story

  

  From Everand

  A Heartbreaking Work Of Staggering Genius: A Memoir Based on a True Story

  Dave Eggers

  Rating: 3.5 out of 5 stars

  3.5/5 (231)
• Team of Rivals: The Political Genius of Abraham Lincoln

  

  From Everand

  Team of Rivals: The Political Genius of Abraham Lincoln

  Doris Kearns Goodwin

  Rating: 4.5 out of 5 stars

  4.5/5 (234)
• The Woman in Cabin 10

  

  From Everand

  The Woman in Cabin 10

  Ruth Ware

  Rating: 3.5 out of 5 stars

  3.5/5 (2521)
• Fear: Trump in the White House

  

  From Everand

  Fear: Trump in the White House

  Bob Woodward

  Rating: 3.5 out of 5 stars

  3.5/5 (738)
• Wolf Hall: A Novel

  

  From Everand

  Wolf Hall: A Novel

  Hilary Mantel

  Rating: 4 out of 5 stars

  4/5 (3811)
• John Adams

  

  From Everand

  John Adams

  David McCullough

  Rating: 4.5 out of 5 stars

  4.5/5 (2409)
• On Fire: The (Burning) Case for a Green New Deal

  

  From Everand

  On Fire: The (Burning) Case for a Green New Deal

  Naomi Klein

  Rating: 4 out of 5 stars

  4/5 (74)
• The Light Between Oceans: A Novel

  

  From Everand

  The Light Between Oceans: A Novel

  M.L. Stedman

  Rating: 4.5 out of 5 stars

  4.5/5 (789)
• The Unwinding: An Inner History of the New America

  

  From Everand

  The Unwinding: An Inner History of the New America

  George Packer

  Rating: 4 out of 5 stars

  4/5 (45)
• Manhattan Beach: A Novel

  

  From Everand

  Manhattan Beach: A Novel

  Jennifer Egan

  Rating: 3.5 out of 5 stars

  3.5/5 (792)
• The Constant Gardener: A Novel

  

  From Everand

  The Constant Gardener: A Novel

  John le Carré

  Rating: 3.5 out of 5 stars

  3.5/5 (104)
• Rise of ISIS: A Threat We Can't Ignore

  

  From Everand

  Rise of ISIS: A Threat We Can't Ignore

  Jay Sekulow

  Rating: 3.5 out of 5 stars

  3.5/5 (137)
• Little Women

  

  From Everand

  Little Women

  Louisa May Alcott

  Rating: 4 out of 5 stars

  4/5 (104)