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INTRODUCTION TO ICD 9 CODING

INTRODUCTION TO ICD 9 CODING. INTERNATIONAL CLASSIFICATION OF DISEASES, NINTH EDITION CLINICAL MODIFICATIONS. OBJECTIVES. Learn the purpose of ICD coding Explain the features of ICD 9 CM volumes Learn the meaning of cross reference Accurately . INTRODUCTION.

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INTRODUCTION TO ICD 9 CODING

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  1. INTRODUCTION TO ICD 9 CODING INTERNATIONAL CLASSIFICATION OF DISEASES, NINTH EDITION CLINICAL MODIFICATIONS

  2. OBJECTIVES • Learn the purpose of ICD coding • Explain the features of ICD 9 CM volumes • Learn the meaning of cross reference • Accurately

  3. INTRODUCTION • Accurate coding is crucial to reimbursement and the avoidance of fraud and abuse charges. • In order to successfully complete coding the medical assistant must know medical terminology, anatomy, diagnostic tests and disease terminology.

  4. WHAT IS ICD 9 • ICD-9-CM is the medical coding and classification system used in the USA to gather information about diseases and injuries. • ICD-9 is an adaptation of the ICD-9 th revision developed by the World Health Organization. • ICD-9 is a classification system that provides numeric codes for diagnosis and injuries.

  5. STRUCTURE OF ICD 9 • The codes are contained in three volumes. • VOLUME 1 is a numeric tabular list of disease and injury codes • VOLUME 2 is an alphabetic index of diseases and injuries • VOLUME 3 is a combined tabular list and alphabetic index of procedure codes

  6. PURPOSE • The ICD-9-CM codes answer the question • Why did the patient need the services? • CPT codes answer the question • What services did the physician (or health care provider) provide the patient?

  7. STRUCTURE OF ICD 9 • 17 main chapters that classify diseases and injuries by body system or etiology (cause) • Two supplementary classifications called • “Classification of Factors Influencing Health Status and Contact with Health Services,” commonly known as V codes • “Classification of External Causes of Injury and Poisoning,” known as E codes • Four appendices.

  8. TABULAR LIST FORMAT • Each chapter in Volume 1 is organized by: • Sections • Categories • Subcategories • Fifth-digit subclassifications

  9. SECTION • A section is a group of three-digit categories that represent a single disease or a group of closely related diseases. • Example: “Diseases of Esophagus, Stomach, and Duodenum” 530-537

  10. CATEGORY • A category is a three-digit code that represents a single disease or closely related conditions • Example 531 Gastric ulcer

  11. SUBCATEGORY • Subcategories consists of four digits and provide more information about the disease, such as the site, cause , or other characteristics. • A period or coma precedes the forth digit. • 531.0 An acute gastric ulcer with hemorrhage • 531.1 An acute ulcer with perforation • 531.2 An acute gastric ulcer with hemorrhage and perforation

  12. SUBCLASSIFICATION • Subclassifications are represented by fifth digit and allow for even more specific information about the disease. • 531 gastric ulcer • 0-without mention of obstruction but with hemorrhage and 1 / 531.01/ with hemorrhage and obstruction.

  13. REMEMBER!!! • IF THE FOURTH AND FIFTH DIGITS ARE AVAILABLE THEY MUST BE INCLUDED IN THE CLAIM.

  14. SUPPLEMENTARY CLASSIFICATIONS V & E CODES

  15. V CODES • Supplementary classification of factors influencing health status and contact with health services, also called V-codes V 01 – V 82. • V codes provide a mechanism to classify interaction with health care provider when the individual is not sick. • V70.4 Examination for medico-legal reasons- Blood- alcohol test, Blood drug test,…

  16. E CODES • Supplementary classification of external causes of injury and poisoning, also called E-codes • E 800 E 999 • E930- Antibiotics causing adverse effects in therapeutic use.

  17. Alphabetic index of Diseases and Injuries • The alphabetic index contains the following sections: • Alphabetic index to diseases and injuries • Table of drugs and chemicals • Alphabetic index to external causes of injury and poisoning- E codes

  18. GUIDELINES FOR ACCURATE CODING • Locate the main term within the diagnostic statement and underline it. • Locate the main term in the Alphabetic index – volume 2 • Remember to refer to all notes under the main term • Examine any modifiers appearing in parentesis next to the main term

  19. GUIDELINES FOR ACCURATE CODING • Take note of the subterms intended beneat the main term. • Be sure to follow any cross reference instructions such as “see” or “see also” • Confirm the code selection in the tabular list – volume 1

  20. EXAMPLE • URINARY TRACT INFECTION DUE TO E. COLI.

  21. EXAMPLE Underline the main term Locate the main term in the Alphabetic index Review the subterms. There is no mention of due to E.coli Follow the cross match references as see, see also or if there are no such instructions note the code

  22. EXAMPLE • Infection, urinary tract NES 599.0 • Check the code listed in the tabular list • 599.0 is listed as Urinary tract infection, site not specified • Two other terms are listed – bacterial and pyuria and a exclusion note for candidiasis. • Now you are directed to use an additional code to identify the microorganism E. Coli 041.4

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