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Basic ICD-9-CM Diagnosis Coding Part I Conventions and Process

Basic ICD-9-CM Diagnosis Coding Part I Conventions and Process. March 16, 2007 10 am – 12 noon MST. Irene Mueller, EdD, RHIA Montana Hospital Association MT-NC Tele-Video Spring 2007. 401.9. Part I Objectives. 365.11. 87.49.

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Basic ICD-9-CM Diagnosis Coding Part I Conventions and Process

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  1. Basic ICD-9-CM Diagnosis CodingPart I Conventions and Process March 16, 2007 10 am – 12 noon MST Irene Mueller, EdD, RHIA Montana Hospital Association MT-NC Tele-Video Spring 2007

  2. 401.9 Part I Objectives 365.11 87.49 Ability to understand and apply the; • Basic ICD-9-CM coding conventions • Basic ICD-9-CM coding process.

  3. 3/16/07 Schedule • 10 am – 10:05 • Introductions/Overview of day • 10:05 – 10:50 • History of ICD-9-CM & ICD-10 • Code Books & Codes • Coding Conventions • 10:50 – 11 am Break • 11:00 - 11:45 • Coding Process • 11:45- 12:00 noon • Questions

  4. History of ICD-9-CM & ICD-10 • ICD is universal classification system of illnesses, developed in 1893 • ICD-9-CM in US; used to • report, compile, and compare hc data • evaluate appropriateness & timeliness of medical care, • plan health care delivery systems, • determine patterns of patient care among providers, • analyze payments for healthservice, and • conduct epidemiological & clinical research. • Reimbursement & billing functions added in 1960s (MC, MA then PPS (DRGs)

  5. World Health Organization (WHO) is responsible for maintenance Two Classifications in US ICD-10-CM replaces ICD-9-CM v. 1&2 NCHS maintains ICD-10-PCS replaces ICD-9-CM v. 3 CMS maintains ICD-10-CM planned implementation is no sooner than 2009? 2 years after CMS orders ICD-10 used in US for mortality data since 1/1/1999 (State Depts of Vital Stats) ICD - 10

  6. ICD-10-CM • Uses alphanumeric codes (C81.11, S55.18) • Increases from 7,000 categories (3 digit codes in ICD-9-CM) to 13,000 and 60,000 codes • Additional categories for “problems” • occupational exposure to risk-factors • general exam without complaint or diagnosis • exam for administrative purposes • immunization not carried out • Classifies injuries by site, not type • Trimester specific OB codes • Laterality • Some codes up to six digits

  7. Developed by 3M Health Information Systems entirely free-standing coding system four objectives completeness expandability multi-axial structure standardized terminology Tabular List, Alphabetic Index Modular codes 7 characters, 34 alphanumeric values I & O not used, might confuse with 1 or 0 1st character indicates one of 16 Sections of ICD-10-PCS each character has same meaning in Section, but can have different meaning elsewhere ICD-10-PCS

  8. ICD-9-CM Control & Maintenance • Cooperating Parties CMS - (payers) NCHS - (researchers, etc.) AHA - (providers) AHIMA - (HIM, coders, etc.) • Annual Changes effective immediately • October 1 (Federal Gov’t fiscal year) • April 1, mid-year (no grace period)

  9. ICD-9-CM Code Books • 3 Volumes • AI • Tables (HTN, Neoplasms, Drugs) • V codes indexed in main AI • E code index is sep, last • TL • 17 Chapters (Sections) • E & V codes • Procedures • AI & TL

  10. Appendices • A - Morphology of Neoplasms • Tissue type of neoplasm • Not reported for billing • Are reported to State Ca Registries • Help coder select correct column in Neoplasm Table • C – Drugs by AHFS List • D – Classification of Industrial Accident • Can help coder id equipment category for E codes • Helps in assigning place of occurrence E code • E- List of 3-digit categories

  11. ICD-9-CM Code Structure • Diagnosis XXX Category XXX.X Subcategory XXX.XX Sub-classification • Procedure XX.XX WOW: IF more specific code available, MUST select a code at that level

  12. V Codes • Always Diagnosis! • Report conditions, NOT disease/injury, but that influence patients’ health status • Clarify reason for encounter • Add’l factors for patient receiving care • Some V codes • are Pr Dx Codes (Newborn) • ONLY Secondary codes (History of) • Can be either (Chemotherapy)

  13. E codes • Report external causes of injury, poisoning, or other adverse reactions • Environmental events • Industrial accidents • Injuries due to crimes • Reporting E codes can expedite insurance claims • Place of Occurrence • Indicates which insurance should be billed

  14. AI Coding Conventions • Main term (Nouns, Adjectives, Eponyms) • Problem, Condition, Disease • NOT body part (modifiers, subterms) • Alphabetization • Letter by letter (ignore – and spaces) • “And” - • Exception -“With” sequenced 1st • Numbers • Listed numerically, NOT alphabetically • Main term (nonessential modifiers) • Indented Essential Modifiers (subterms)

  15. AI Coding Conventions • Main term (nonessential modifiers) • Indented Essential Modifiers (subterms) • Nonessential modifier – supplementary words that may be present OR absent from the physician’s statement of a disease or procedure WITHOUT affecting the code number assignment

  16. AI Coding Conventions Qualifier Examples Alt. Site – Fibula vs Tibia Etiology – Diabetic Clin. Status – Acute vs Chronic Main term Subterm (1st qualifier) 2nd Qualifier 3rd Qualifier Effusion pleura, pleurisy, pleuritic pleuropericardial 511.9 traumatic 862.29 with open wound 862.39 WOW: Be Careful! Easy to get lost in indention level when moving from one column to next

  17. AI Coding Conventions • Eponyms • Diseases, syndromes, or procedures named for person. • Listed alphabetically in AI as Main Terms • Listed as subterms under • Disease, Disorder, Syndrome, and • Operation (Proc.) • Ex: Down Syndrome, Graves Disease, Keller Operation, Bankhart Operation

  18. AI Coding Conventions • NEC (Not Elsewhere Classifiable) • only in AI • Means “Other specified” – often .8 codes • Have specific documentation, BUT NO better location in ICD-9-CM • “due to” subterm / “in” subterm • Indicates presence of cause-and-effect relationship between 2 conditions • Physician must make connection in documentation

  19. AI Coding Conventions • Default code (486 for pneumonia) • X references (see, see also) • Boxed Notes • Follow some main terms • Define terms, provide coding instruction, • List 5th digit options or 4th digit (Proc AI) • Ex: Fracture; Diabetes

  20. AI Coding Conventions • Slanted brackets • Used to ID manifestation codes • Manifestation is a condition that occurs because of another condition • Manifestation codes are always add’l codes • Do NOT report the brackets WOW: Slanted Brackets indicate MANDATORY Multiple Coding & SEQUENCING

  21. AI Coding Conventions • Morphology (behavior) codes & Table of Neoplasms • /3 Primary Ca • /6 Metastatic (2ndary) Ca • /2 Ca in Situ • /0 Benign • /1 Uncertain Behavior Unspecified behavior = documentation does not specify the behavior of the neoplasm. WOW: write this info at top of neoplasm table columns

  22. TL Coding conventions • Italic typeface for Code Titles • AND in Code Titles = and/or • Punctuation [ ] enclose synonyms, alternative wording () enclose nonessential modifiers : used after incomplete term one or more add’l terms after the colon MUST be in diagnostic statement to use code • Symbols • vary by codebook publisher

  23. TL Coding conventions • Notes and their locations • Location • Excludes • Direct coder to another location • May need to report both • Includes • Further define or provide examples • Multiple coding • Use Additional instructional note • Code first instructional note

  24. TL Coding Conventions • NOS (not otherwise specified) • = unspecified in documentation • = information cannot be obtained from provider • Review entire record • Labs, radiology reports, operative report, path report for more specific info • Code any confirmed or definitive dx documented in interpretation reports (Pt rec dx services only –outpt guidelines) • Query Dr IF necessary

  25. ICD-9-CM Code Assignment Process • Id ALLmain terms in Dx statement • Id the modifiers in Dx statement • Locatethe main terms in AI • Locate the modifiers in subterms indented under main terms • Check for special instructions or X ref • TENTATIVELY select a code • Verify code category in TL • Check for special instructions or X ref • Assign all required codes

  26. Coding Process Examples • Id ALLmain terms in the Dx • Problem, Condition, Disease • NOT body part • Usually NOUN • Benign prostatic hypertrophy, urinary retention • Urinary Tract Infection, Pseudomonas • Acute Myocardial Infarction • Chronic hypertrophy of tonsils • Perihilar viral pneumonia • Sciatica due to herniated lumbar disk • Left heart failure with benign hypertension

  27. Coding Process Examples • Id the modifiers in the Dx statement • More specificity • Body part/system • Usually adjective (-ic, -al, -ive) • Benign prostatic hypertrophy, urinary retention • Urinary Tract Infection, Pseudomonas • Acute Myocardial Infarction • Chronic hypertrophy of tonsils • Perihilar viral pneumonia • Sciatica due to herniated lumbar disk • Left heart failure with benign hypertension

  28. BPH with urinary retention • Check for special instructions or X ref • TENTATIVELY select a code

  29. BPH with urinary retention • Verify code category in TL • Check for special instructions or X ref • Assign all required codes

  30. Questions ? ? ? imueller@wcu.edu Thank You !

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