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Chapter XX:

Chapter Title

Chapter 11:

Diagnostic Coding

Learning Outcomes

Cognitive Domain

Note: AAMA/CAAHEP 2015 Standards are italicized.

1. Spell and define the key terms

2. Describe the relationship between coding and reimbursement

3. Name and describe the coding system used to describe diseases, injuries, and other reasons for encounters with a medical provider

4. Explain the format of the ICD-9-CM

5. Give four examples of ways E codes are used

6. Describe how to use the most current diagnostic coding classification system

7. Describe the ICD-10-CM/PCS version and its differences from ICD-9

Learning Outcomes (cont'd.)

Psychomotor Domain

Note: AAMA/CAAHEP 2015 Standards are italicized.

1. Perform diagnostic coding (Procedure 11-1)

2. Utilize medical necessity guidelines (Procedure 11-1)

Learning Outcomes (cont'd.)

Affective Domain

Note: AAMA/CAAHEP 2015 Standards are italicized.

1. Work with physician to achieve the maximum reimbursement

2. Utilize tactful communication skills with medical providers to ensure accurate code selection

Learning Outcomes (cont'd.)

ABHES Competencies

1. Apply third-party guidelines

2. Perform diagnostic and procedural coding

3. Comply with federal, state, and local health laws and regulations

Coding is the assignment of a number to a verbal statement or description. It is used for health insurance claims processing. Correct coding is essential. Incorrect or incomplete information can result in nonpayment of claim and incorrect insurance data can affect a patient’s insurability.

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Introduction

International Classification of

Diseases, Ninth Revision, Clinical Modification (ICD-

9-CM: a system for transforming verbal

descriptions of disease, injuries, conditions, and procedures to numeric code

It is essential that the physician and medical assistant work together to achieve accurate documentation, code assignment, and reporting of diagnoses and procedures.

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Introduction (cont’d.)

advance beneficiary notice (ABN): document that informs covered patients that Medicare may not cover a certain service and the patient will be responsible for the bill

Since Medicare considers certain procedures medically necessary only at certain intervals, having the patient sign an advance beneficiary notice will ensure payment of treatments and procedures that will likely be denied by Medicare.

The third-party payer needs to know why a service was performed to assess medical necessity. And, the diagnosis justifies the procedure.

medical necessity: a determination made by a third party that a certain service or procedure was necessary based on

sound medical practice

Checkpoint Question

What is meant by medical necessity?

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Checkpoint Answer

Medical necessity means a particular service or procedure is reasonable.

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Diagnostic Coding

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ICD-9-CM: statistical classification system based on the WHO

System for changing verbal descriptions into standardized numeric codes

New ICD-10-CM provides more detailed and current information

ICD-9-CM: 13,000 diagnoses codes, < 4,000 procedure codes

ICD-10-CM: 70,000 diagnoses codes, 72,000 procedure codes

Diagnostic Coding (cont’d.)

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Three volumes of ICD-9:

Volume 1 = Tabular list of diseases

Volume 2 = Alphabetical index of diseases

Volume 3 = Tabular list and alphabetical index of procedures

Changes must be approved by WHO

New codes published every October — keep office soft-ware and code books updated

Checkpoint Question

What organization must approve any changes in the disease classification system?

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Checkpoint Answer

The World Health Organization must approve any changes in the coding system.

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Diagnostic Coding (cont’d.)

Inpatient Versus Outpatient Coding

Volumes 1 and 2 are used to justify physician services where services are provided in office or in hospital

Outpatient services provided at:

Health care provider’s office

Hospital clinic

Emergency department

Hospital same-day surgery unit or ambulatory surgical center

Observation status in hospital for short-stay

Inpatient services:

Patient admitted for treatment, staying for 24 hours or more

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outpatient: a medical setting in which patients receive care but are not admitted

inpatient: a medical setting in which patients are admitted for diagnostic, radiographic, or treatment purposes

Diagnostic Coding (cont’d.)

Volume 3 is used by hospitals to report procedures, services, supplies, and reasons for procedures

UB-04 (uniform bill) for inpatient admissions, outpatient procedures, and emergency services:

For nursing services and costs associated with running institution

Does not include physician services

CMS-1500 claim form to report physician services

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Checkpoint Question

Name and give uses for the three volumes of the ICD-9-CM.

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Checkpoint Answer

Volumes 1 and 2 of the ICD-9-CM are used to report the diagnostic code that justifies physician services whether those services are provided in the office or in the hospital. Hospital coders use Volume 3 to report inpatient procedures, services, and supplies, as well as the reasons for the services.

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The Diagnostic Codebook

Coding books available from several publishers:

Ingenix

Medicode

AMA

Classification system available as part of medical software packages

For accuracy—always use most current codes:

Important to update codes on superbills or other forms

Millions of dollars lost due to incorrect code on form not updated

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To become an expert medical coder, you need general knowledge of human anatomy and medical terminology.

Checkpoint Question

How often is the ICD-CM updated?

When is the use of the new codes required?

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Checkpoint Answer

ICD-CM is updated annually, published in late summer and effective every October 1st.

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The Diagnostic Codebook (cont’d.)

Tabular List of Diseases

Classification of conditions and injuries by code number

17 chapters in ICD-9-CM; 21 chapters in ICD-10-CM

Grouped by etiology and body systems

Each chapter is assigned a range of code numbers

Three-digit codes = general disease

Fourth digit = further breaks down category

Fifth digit = highest specificity

Always used to code condition to highest definition

Includes 5 appendices

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Etiology: cause of disease

Truncated coding: diagnosis coding that is not done at the highest level available for a particular diagnosis or problem

The Diagnostic Codebook (cont’d.)

Table of contents from ICD-9-CM, Volume 1, and ICD-10-CM

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The Diagnostic Codebook (cont’d.)

Sample page from ICD-9-CM, Volume 1, showing categories, subheadings, and so on

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The Diagnostic Codebook (cont’d.)

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The Diagnostic Codebook (cont’d.)

Supplementary Classifications

ICD-9-CM

V-codes

E-codes

ICD-10-CM

Chapter 20, External Causes of Morbidity

Chapter 21, Factors Influencing Health Status and Contact with Health Services

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The Diagnostic Codebook (cont’d.)

Factors Influencing Health Status

V01 to V82 in ICD-9-CM

Z00 to Z99 in Chapter 21 in ICD-10-CM

Gives reason for physician or hospital care not due to current illness

History of illness

Immunizations

Live-born infant type of birth

ICD-10-CM gives additional codes to further explain situation include lifestyle problems

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V-codes: codes assigned to patients who receive service but have no illness, injury, or disorder, e.g., a vaccination or a screening mammogram

The Diagnostic Codebook (cont’d.)

External Causes of Injury

E800 to E999 in ICD-9-CM

Chapter 20 in ICD-10-CM

Codes for external causes of injury and poisoning

Used in conjunction with regular codes in chapters 1–17

Do not affect reimbursement — used for statistics in industry, insurance, national safety, public health

ICD-9-CM, Volume 2, Section 3, separate index to access E codes

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E-codes: codes indicating the external cause or reason for an injury or illness

Checkpoint Question

List four reasons for using supplemental codes.

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Checkpoint Answer

Supplemental codes are used to provide information concerning injuries:

Industrial medicine

Insurance underwriters

National safety programs

Public health agencies and others

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The Diagnostic Codebook (cont’d.)

Alphabetic Index of Diseases

Arranged by condition

ICD-9-CM has 3 sections; ICD-10-CM has replaced section 3 with chapter 20

Section 1:

Alphabetic Index to Diseases and Injuries

Main terms along with codes

Must cross-reference or check tabular list to ensure correctness

System of exceptions

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You must not accept a number as the correct code without a cross-reference or check of the tabular list.

cross-reference: notation in a file telling that a record is stored elsewhere and giving the reference; verification to another source; checking the tabular list against the alphabetic list in ICD-9 coding

The Diagnostic Codebook (cont’d.)

Section 2:

Table of Drugs and Chemicals

Includes drugs, toxins, chemical agents

Section 3:

Alphabetic Index to External Causes of Injuries and Poisonings

Accidents, injuries, and violence

Not used for medical diagnoses — supplement the diagnosis to give clearer picture

Should not be used alone

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Checkpoint Question

What are supplemental codes to classify Factors Influencing Health Status used for?

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Checkpoint Answer

Supplementary codes to classify Factors Influencing Health Status are used to report reasons for receiving services other than illness.

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The Diagnostic Codebook (cont’d.)

Inpatient Coding

Tabular List and Alphabetic Index of Procedures

Used for inpatient facilities

Based on anatomy, not to surgical specialty

Includes miscellaneous diagnostic and therapeutic procedures

Two-digit codes with two-decimal digits

Replaced by ICD-10-PCS

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Locating the Appropriate Code

Using the Diagnostic Coding Conventions

Conventions are standardized and must be strictly followed

Main Term

Choose main term within diagnostic notes – often an eponym

Find the condition, not the location

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eponym: word derived from a personal name, e.g., Alzheimer disease

conventions: general notes, symbols, typeface, format, and

punctuation that direct and guide the coder to the most complete and accurate ICD-9 code

main term: words in a multiple-word diagnosis that a coder should locate in the alphabetic listing. They represent the condition (not the location to be coded.

Locating the Appropriate Code (cont’d.)

Conventions used in diagnostic coding

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Locating the Appropriate Code (cont’d.)

Additional Digits

In many cases a fourth digit has been added to provide more specificity

Others also have fifth digit

ICD-9-CM codes requiring a fifth digit are identified in both volumes 1 and 2

ICD-10-CM may have 4 to 7 additional digits

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specificity: relating to a definite result

Locating the Appropriate Code (cont’d.)

Samples of fifth-digit classifications from ICD-9-CM. (A) Volume 1. (B) Volume 2.

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Locating the Appropriate Code (cont’d.)

Samples of seventh-digit classification from ICD-10

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Locating the Appropriate Code (cont’d.)

Primary Codes

Primary diagnosis in outpatient coding

Primary code listed first on the CMS-1500

When More Than One Code Is Used

Necessary to convey accurate picture of the patient’s total condition

If any condition is related to or affects treatment, should be listed as supplementary information

Multiple codes should be sequenced

Allows 12 different diagnostic codes

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primary diagnosis: the condition or chief complaint that brings a person to a medical facility for treatment

When patients have more than one diagnosis, it is necessary to convey an accurate picture of the patient’s total condition.

Locating the Appropriate Code (cont’d.)

Sample CMS-1500 claim form indicating proper sequencing.

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Locating the Appropriate Code (cont’d.)

Late Effects

Code late affects with current complaint first, then original cause second

Key words defining late effects

“late”

“due to an old injury”

“due to a previous illness/injury”

“due to an illness or injury occurring a year or more ago”

“sequela of …”

“as a result of…”

“resulting from …”

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late effects: conditions that result from another condition. For example, left-sided paralysis may be a late effect of a stroke

Locating the Appropriate Code (cont’d.)

Sample section of late effects in ICD-9-CM. (A) Volume 1. (B) Volume 2.

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Locating the Appropriate Code (cont’d.)

Coding Suspected Conditions

Inpatient setting — coders list conditions after testing is complete

Outpatient-coder reports reason for visit as it occurs

First visit is “headache

MRI ordered for:

“Rule out”

“Suspected”

“Probable”

Not accurate to code visit as “brain tumor” before it is confirmed

Symptom code

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In outpatient settings, the coder reports the reason for the patient visit as it occurs.

Checkpoint Question

When coding a visit on a date before a definitive diagnosis is made, what is coded?

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Checkpoint Answer

Before a definitive diagnosis is assigned to a patient, services must be coded with the patient’s symptoms at the time he or she was seen.

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Locating the Appropriate Code (cont’d.)

Documentation Requirements

Code based on patient’s medical documentation

If not in the chart, didn’t happen

Audits compare codes used with patient documentation

Audits ensure compliance and detect fraud

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As discussed throughout this chapter, you should choose the code assigned to any given claim for a service or procedure based on the documentation available in the patient’s record at the time of the service.

audit: a review of an account; inspection of records to

determine compliance and to detect fraud

The Future of Diagnostic Coding: International Classification of Diseases, Clinical Modification, Tenth Revision

Scheduled to be implemented on October 1, 2015

WHO has revised ICD to improve data quality

Includes more codes and will be used by every type of health care provider for all encounters, including hospice and home health care

Codes are alphanumeric

Index similar to that of ICD-9-CM

Two new chapters added:

Disorders of eye

Basic knowledge of ICD-9-CM will prove invaluable

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The Future of Diagnostic Coding: International Classification of Diseases, Clinical Modification, Tenth Revision (cont’d.)

Conventions

Many conventions will not change

One difference is “Excludes” notes — ICD-10 uses two:

“Excludes1” means not coded here and does not allow for exceptions

“Excludes2” indicates that if medical documentation supports both conditions, both may be coded

Placeholder “X”

Some disorders will require a 7th character in ICD-10-CM

Some will have no 5th or 6th, and “X” is used as a placeholder

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The Future of Diagnostic Coding: International Classification of Diseases, Clinical Modification, Tenth Revision (cont’d.)

Special Codes

E-Codes and V-Codes:

No longer located in supplemental listing but are in main classification system

Don’t start with E and V

Used with external cause code + place of occurrence code

Diabetes mellitus codes:

Changing considerably

Provide more detail

Find training opportunities through various coding professional organizations and the CMS

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The Future of Diagnostic Coding: International Classification of Diseases, Clinical Modification, Tenth Revision (cont’d.)

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Checkpoint Question

How will the implementation of ICD-10-CM improve the coding of reasons for services?

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Checkpoint Answer

In ICD-10 CM, the longer combination of numbers and letters allows for expanding of the system as new technologies are discovered and used. The codes will also provide more information which will enhance efficiency and accuracy.

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