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The Key to Your Success

Learn essential coding steps & main terms identification in medical coding practice to ensure accurate code selection for diagnoses & procedures.

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The Key to Your Success

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  1. The Key to Your Success Medical Coding 1 Unit 3– Practice Your Skills

  2. Coding Steps - Basics • Identify the main term • Look it up in the Alphabetic Index • Find the code number from the alphabetic index in the Tabular/Numeric List • Fine tune the code to the highest specificity (number) based on information found in the Tabular List.

  3. Coding Steps - Detail 1. Locate the main term within the diagnostic statement. 2. Locate the main term in the Alphabetic Index (Volume 2). Keep in mind that: ---Primary arrangement for main terms is by condition ---Main terms can be referred to in ill-defined lay terms that you must convert to medical terms 3. Refer to all notes under the main term. Check instructions in any notes appearing in a box immediately after the main term. 4. Follow any cross-reference instructions (terms such as “see” or “see also” must be followed to ensure correct codes) 5. Confirm your code selection in the Tabular List (Volume 1) 6. Follow instructional terms in the Tabular List (Volume 1) Watch for exclusion notes as well as the fourth/fifth digit requirements. Be sure to check all the way back to the original heading for that section as the instructional information may be located one or more pages preceding the actual page where the code is located. 7. Assign the code number you have determined correct. Repeat these steps for each diagnostic code selected making certain those integral to another diagnosis are not coded. 8. Place the diagnostic code(s) for each service in the appropriate order.

  4. Diabetes mellitus with iritis • 250.00, 250.50, 364.3 or 364.42 • Delerium tremens due to chronic continuous alcoholism • 291.0, 291.1, 303.90, or 309.91 • Spontaneous delivery of full-term pregnancy with single live born • V27.0, V27.9, 73.5, 73.59, 650, 650.0 • 1st and 2nd degree burns of forearm and 3rd degree burns of back sustained at his warehouse job. • 942.34, 943.11, 943.21, E849.0, E849.3, E899 Who’s on First? Identify which code(s) are correct and which would be primary:

  5. Answers • Diabetes mellitus with iritis • 250.50, 364.42 • Delerium tremens due to chronic continuous alcoholism • 291.0, 309.91 • Spontaneous delivery of full-term pregnancy with single live born • 650, V27.0, 73.59 • 1st and 2nd degree burns of forearm and 3rd degree burns of back sustained at his warehouse job. • 942.34, 943.21, E899 , E849.3 Who’s on First? Identify which code(s) are correct and which would be primary:

  6. Main Terms What is the main term in a diagnosis statement? What is the main term in a procedure? How does that help us find the correct term? What if the main term is not in medical terms or we can’t find it in the coding manual?

  7. Fitting of a cardiac pacemaker • Injury by shotgun, undetermined whether accidental or intentional (shooting) • Medical dislocation of tibia, proximal end, open • Ligation of thyroid vessels • Allogenic bone marrow transplant with purging Let’s Practice More Main Terms Select the main term:

  8. Answers • Fitting of a cardiac pacemaker • Injury by shotgun, undetermined whether accidental or intentional (shooting) • Medical dislocation of tibia, proximal end, open • Ligation of thyroid vessels • Allogenic bone marrow transplant with purging Let’s Practice More Main Terms Select the main term:

  9. Review Coding Practice II Procedures What is the main term? • Allogenic bone marrow transplant with purging • Biopsy, brain (open) • Bunionectomy with soft tissue correction & arthrodesis • Creation of conduit between right ventricle and pulmonary artery • Dilation & curettage for termination of pregnancy

  10. Review Coding Practice II Procedures ANSWERS What is the main term? • Allogenic bone marrow transplant with purging 41.02 • Biopsy, brain (open) 01.14 • Bunionectomywith soft tissue correction & arthrodesis77.52 • Creation of conduit between right ventricle and pulmonary artery 35.92 • Dilation & curettage for termination of pregnancy69.01

  11. ICD-9-CM Coding GuidelinesChapter 4 E-Codes and V-Codes • E-Codes • External Cause of Illness or Injury • Never can be a primary code • V-Codes • Factors influencing Health Status and Contact with Health Services, i.e., seen for other than a disease or injury • Can be primary or secondary code • Examples include vaccinations, recurrent service for a known disease, history of issues that influence health

  12. V-CodesFactors influencing health status and contact with health services You’re not sick  You have a disease that you’re in for a treatment of that disease or injury Your health might be influenced by this Categories Communicable disease exposure Infectious disease carrier Vaccines What else?

  13. ICD-9-CM Coding GuidelinesExercise 4.21 Identify the V-Code main term and code: • Bone marrow donor • Chemotherapy encounter • Examination for summer camp

  14. ICD-9-CM Coding GuidelinesExercise 4.21 ANSWERS Identify the V-Code main term and code: • Bone marrow donorV59.3 • Chemotherapy encounter V58.11 • Examination for summer camp V70.3

  15. E-CodesExternal causes of injury and poisoning You had an accident You have late effects of an accident You were a victim of terrorism You had a reaction, side effect or overdose of a substance What else? How many codes do we assign? For what?

  16. ICD-9-CM Coding GuidelinesExercise 4.20 Identify the E-Code main term and code: 6. Hives resulting from penicillin taken as prescribed 7. Coma due to overdose of barbiturates during an attempted suicide 8. Adverse reaction to pertussis vaccine

  17. ICD-9-CM Coding GuidelinesExercise 4.20 ANSWERS Identify the E-Code main term and code: 6. Hives resulting from penicillin taken as prescribed. E930.0 7. Coma due to overdose of barbiturates during an attempted suicide. E950.1 8. Adverse reaction to pertussis vaccine.E948.6

  18. Let’s Review Conventions • The use of a colon in the tabular: • Indicates that one or more additional terms are to be included in the diagnostic statement to classify a condition or procedure • Means the words following the colon may be present in or absent from the provider’s diagnostic statement • Excludes notes appear in the: • Index to Diseases and Index to Procedures • Tabular List of Procedures and Index to Procedures • Tabular List of Diseases and Tabular List of Procedures • The see also instruction in the Index to Diseases follows a sub-term and refers the coder to another main term that: • May provide additional useful index entries • Contains the code that is to be assigned What are conventions? Where do we find them?

  19. Answers Let’s Review Conventions • The use of a colon in the tabular: • Indicates that one or more additional terms are to be included in the diagnostic statement to classify a condition or procedure • Means the words following the colon may be present in or absent from the provider’s diagnostic statement • Excludes notes appear in the: • Index to Diseases and Index to Procedures • Tabular List of Procedures and Index to Procedures • Tabular List of Diseases and Tabular List of Procedures • The see also instruction in the Index to Diseases follows a sub-term and refers the coder to another main term that: • May provide additional useful index entries • Contains the code that is to be assigned What are conventions? Where do we find them?

  20. Step 1 • Decide if this is a diagnosis or procedure • Identify the main term Let’s Code  Excision of ectopic breast tissue Gram-negative septicemia due to E.coli Multiple personality Personal history of penicillin allergy Postsurgical hypothyroidism Transurethral destruction of prostate tissue using microwave thermotherapy Twin pregnancy with loss of one (delivered)

  21. Answers • Step 1 • Decide if this is a diagnosis or procedure • Identify the main term Let’s Code  Excision of ectopic breast tissue Gram-negative septicemia due to E.coli Multiple personality Personal history of penicillin allergy Postsurgical hypothyroidism Transurethral destruction of prostate tissue using microwave thermotherapy Twin pregnancy with loss of one (delivered)

  22. Step 2 • Assign the appropriate code Let’s Code  Excision of ectopic breast tissue Gram-negative septicemia due to E.coli Multiple personality Personal history of penicillin allergy Postsurgical hypothyroidism Transurethral destruction of prostate tissue using microwave thermotherapy Twin pregnancy with loss of one (delivered)

  23. Answers Let’s Code  Excision of ectopic breast tissue = 85.24 Gram-negative septicemia due to E.coli = 038.42 Multiple personality = 300.14 Personal history of penicillin allergy = V14.0 Postsurgical hypothyroidism = 244.0 Transurethral destruction of prostate tissue using microwave thermotherapy = 60.96 Twin pregnancy with loss of one (delivered) = 651.31, V27.3

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