Chapter 05 Diagnostic Coding

1. Insurance Handbook for the Medical Office 13th edition Chapter 05 Diagnostic Coding

2. Introduction to Diagnostic Coding Explain the reasons and importance of coding diagnoses. Describe the importance of matching the correct diagnostic code to the appropriate procedural code. Differentiate between primary (first listed), principal, and secondary diagnoses. Describe how medical necessity is supported by the diagnosis code. Differentiate between ICD-10-CM and ICD-10-PCS. Lesson 5.1

3. Introduction to Diagnostic Coding (cont’d) Discuss the history of diagnostic coding. Compare the process for locating a code in ICD-9-CM versus ICD-10-CM. Identify the Alphabetic and Tabular Index of the ICD-10-CM coding manual. Define and demonstrate an understanding of diagnostic code conventions, symbols, and terminology. Lesson 5.1

4. Diagnosis Coding for Outpatient Professional Services Guidelines for diagnostic coding must be followed when assigning codes Only diagnoses that currently relate to patient state should be coded Payment for services may be tied into diagnostic coding, due to medical necessity requirements

5. Assigning a Diagnosis Code Diagnostic coding must be accurate because payment for inpatient services rendered to a patient may be based on the diagnosis In the outpatient setting, the diagnosis code must correspond to the treatment or services rendered to the patient or payment may be denied

6. Sequencing of Diagnostic Codes • Primary diagnosis (first-listed) • Related to the chief complaint • Main reason for the encounter • Secondary diagnosis • May contribute to the primary diagnosis • Not the underlying cause (etiology) • Principal diagnosis • Only applicable to inpatient cases/claims • Similar to primary diagnosis for outpatient

7. Medical Necessity • Insurance companies may not cover procedures that are not diagnosis-related • Reference book is helpful in these situations • For cases dealing with CMS: • Consult regional fiscal intermediary’s website for local coverage determinations (LCDs) • Also consult federal government’s website for national coverage determinations (NCDs)

8. International Classifications of Diseases • International Classification of Diseases, Tenth Revision, Clinical Modifications (ICD-10-CM) • Used for diagnosis coding for office and outpatient services • International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) • Used for coding of procedures for inpatient services

9. History • Began in England during 17th century • First official version – 1948 • United States started using ICD – 1950 • Eight revision of ICD (ICDA-8) – 1966 • Ninth revision of ICD (ICD-9-CM) – 1979 • Tenth revision of ICD (ICD-10-CM) – 1992 • Implementation date of October 1, 2014

10. Transition from ICD-9-CM toICD-10-CM • Insurance specialist must be familiar with both ICD-9-CM and ICD-10-CM • Date of service will determine which coding system to use • Noncovered entities are not required to implement ICD-10. • Process of locating a diagnosis code is the same in both coding systems • Coding manuals are organized similarly • Alphabetic index used for locating main term • Tabular index to verify selected code

11. Transition from ICD-9-CM toICD-10-CM • ICD-10-CM exceeds previous systems • Number of concepts and codes provided • Expanded to include health-related conditions • Provides greater specificity • Reporting to sixth-digit level with seventh-digit characters

12. Crosswalks • General equivalence mappings (GEMs) • Used to accurately and effectively translate codes • Used to convert data from ICD-9 to ICD-10 (forward mapping) and vice versa (backward mapping) • Crosswalk publications and software are now available • Are not exact, but can assist in finding appropriate code ranges

13. ICD-10 Diagnosis and Procedure Codes • Benefits to adoption of ICD-10 • Much greater specificity • Includes laterality or ordinality of encounter • Expansion of clinical information • Reduced cross-referencing • Flexibility and easy of expandability • Updated medical terminology and classification of diseases • Ability to compare mortality and morbidity rates • Fewer nonspecific codes than in ICD-9-CM

14. Alphabetic Index to Diseases and Injuries • Contains: • Tables of Drugs and Chemicals • Neoplasm Table • Index to External Causes • Main code descriptor items are in alphabetical order • Indented subterms, applicable additional qualifiers, descriptors, or modifiers are beneath main terms

15. Alphabetic Index to Diseases and Injuries

16. Special Points to Remember in Alphabetic Index Appropriate sites or modifiers listed in alphabetic order under main terms Examine all nonessential modifiers Eponyms appear as both main term entries and modifiers under main terms Look for sub-listed terms in parentheses associated with eponym Locate closely related terms, code categories, and cross-referenced synonyms

17. Tabular List of Diseases and Injuries • Composed of alphanumeric codes that represent diagnoses • ICD-10-CM codes contain up to seven characters with a decimal point after third character • Digit #1 – alpha character • Digits #2 and #3 – numeric characters • Digits #4 to #7 – alpha or numeric characters • “x” used as placeholder • Save a space for future code expansion • Meet requirement of coding to the highest level of specificity

18. Tabular List of Diseases and Injuries

19. Special Points to Remember in the Tabular List Use two more codes when necessary Search for one code when two diagnoses or a diagnosis with an associated secondary process or complication is present Use category codes only if there are no subcategory codes Read all instructional notes provided

20. Diagnostic Code Book Conventions Abbreviations, punctuation, and symbols Placeholder character Seventh characters Other and unspecified codes Includes notes Excludes notes Default code Gender and age codes Selection of a coding manual

21. Practice Diagnostic Coding Apply general coding guidelines to translate written descriptions of conditions into diagnostic codes. Apply chapter-specific coding guidelines to reporting of specific illnesses and conditions. Relate additional coding guidelines specific to reporting of outpatient services. Lesson 5.2

22. Practice Diagnostic Coding (cont’d) Describe methods of becoming more familiar with codes commonly encountered in your office. Demonstrate the ability to abstract medical conditions from the medical record and accurately assign diagnostic codes by completing the problems in the Workbook. Lesson 5.2

23. General Coding Guidelines • Locating a code in the ICD-10-CM • Locate term in Alphabetic Index • Verify term in the Tabular List • Dash (-) at end of Alphabetic Index entry indicates additional character required • Determined by Tabular List

24. General Coding Guidelines • Level of detail in coding • ICD-10-CM codes composed of 3, 4, 5, 6, or 7 characters • Always code to the highest level of specificity

25. General Coding Guidelines • Signs and symptoms • No precise diagnosis can be made • Signs and symptoms are transient, and a specific diagnosis was not made • Provisional diagnosis for a patient who does not return for further care • A patient is referred for treatment before a definite diagnosis is made

26. General Coding Guidelines • Conditions that are an integral part of a disease process • Signs and symptoms should not be assigned as additional codes • Conditions that are not an integral part of a disease process • Signs and symptoms should be reported when documented • Multiple coding for a single condition • “Use additional code” • “Code first”

27. General Coding Guidelines • Acute, subacute, and chronic conditions • Code acute (subacute) sequence first, followed by chronic condition code • Combination code • Single code used to classify two diagnoses, or • Diagnosis with associated secondary process (manifestation) • Diagnosis with associated complication

28. General Coding Guidelines • Sequela • Condition produced after the acute phase of an illness • Also called a “late effect” • Impending or threatened condition • Should be referenced as such in the Alphabetic Index and reported accordingly

29. General Coding Guidelines • Reporting the same diagnosis more than once • Each diagnosis code may be reported only once for an encounter • Laterality • Final character of code should reflect laterality

30. General Coding Guidelines • Documentation for BMI and pressure ulcer stages • Patient’s provider must document associated diagnosis (obesity, pressure ulcer) • Syndromes • Symptom complex • Reported by following Alphabetic Index • Documentation of complications of care • Assigned based on provider’s documentation of relationship between condition and the care or procedure

31. Chapter-Specific Coding Guidelines Human Immunodeficiency Virus Neoplasms Coding of diabetes mellitus Circulatory system conditions Hypertension Myocardial infarctions Pregnancy, delivery, or abortion

32. Chapter-Specific Coding Guidelines Injury, poisoning, and other consequences of external causes Injuries and late effects Burns and corrosions Adverse effects, poisoning, underdosing, and toxic effects External causes of morbidity Factors influencing health status and contact with health services Encounters for reproductive services

33. Diagnostic Coding and Reporting Guidelines for Outpatient Services Outpatient surgery Uncertain diagnosis Chronic disease Code all documented conditions that coexist Patients receiving diagnostic services only Preoperative evaluations General medical examinations with abnormal findings

34. Handy Hints in Diagnostic Coding Identify important references with a colored highlighter Add table to main section of Alphabetic Index, Tabular List, and Drug and Chemical Table Keep a list of diagnostic and CPT procedure codes commonly encountered by your office Consult payer guidelines AMA publishes a list of the most common diagnostic codes at the end of each of their mini-specialty code books Some medical practices develop an encounter form that is an all-encompassing billing document

35. Computer-Assisted Coding • Computer software automatically generates medical codes of review, validation, and use based on clinical documentation provided by health care practitioners • Two technology options: • Structured input • Data entry screens with point-and-click fields, pull-down menus, structure templates, or macros. • NLP • Uses artificial medical intelligence

36. Questions?