Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM Lecture 2

1. 4 Diagnostic Coding: Introduction to ICD-9-CM and ICD-10-CM Lecture 2

2. 4-12 4.4 The Tabular List • The Tabular List: • Diseases and injuries are organized into chapters according to etiology or body system • Supplementary codes and appendices cover other special situations • Each chapter is divided into sections with titles that indicate the types of related diseases or conditions they cover

3. 4-13 4.4 The Tabular List (Continued) • Category—three-digit code that covers a single disease or related condition • Subcategory—four-digit subdivision of a category • Subclassification—five-digit subdivision of a subcategory

4. 4-14 4.4 The Tabular List (Continued) • NOS (not otherwise specified)—indicates the code to use when no information is available for assigning the illness or condition a more specific code • Unspecified—incompletely described condition that must be coded with an unspecified ICD code

5. 4-15 4.4 The Tabular List (Continued) • Ten conventions are used in the Tabular List: • Fifth-digit requirement symbol • Includes and excludes notes • Colons in notes • Parentheses around supplementary terms • Brackets around supplementary synonyms, alternative wording, or explanations • Braces to group related terms • Lozenge for nonWHO codes

6. 4-16 4.4 The Tabular List (Continued) • Ten conventions are used in the Tabular List (continued): • The abbreviation NOS to indicate the code to use when a condition is not completely described, and the abbreviation NEC for the code to use when the diagnosis does not match any other available code • Bullet (●) for new codes or entries, single triangle (►) or facing triangles (►◄) for new or revised descriptions • Phrases for multiple code requirements: codes that are not used as primary appear in italics and are usually followed by an instruction to code first underlying disease or use an additional code

7. 4-17 4.5 Tabular List of Chapters • The Chapters of the Tabular List: • Infectious and Parasitic Diseases—Codes 001–139 • Neoplasms—Codes 140–239 • Endocrine, Nutritional, and Metabolic Diseases, and Immunity Disorders—Codes 240–279 • Diseases of the Blood and Blood-Forming Organs—Codes 280–289 • Mental Disorders—Codes 290–319 • Diseases of the Nervous System and Sense Organs—Codes 320–389 • Diseases of the Circulatory System—Codes 390–459 • Diseases of the Respiratory System—Codes 460–519

8. 4-18 4.5 Tabular List of Chapters (Continued) • The Chapters of the Tabular List (Continued): • Diseases of the Digestive System—Codes 520–579 • Diseases of the Genitourinary System—Codes 580–629 • Complications of Pregnancy, Childbirth, and the Puerperium—Codes 630–677 • Diseases of the Skin and Subcutaneous Tissue—Codes 680–709 • Diseases of the Musculoskeletal System and Connective Tissue—Codes 710–739 • Congenital Anomalies—Codes 740–759

9. 4-19 4.5 Tabular List of Chapters (Continued) • The Chapters of the Tabular List (Continued): • Certain Conditions Originating in the Perinatal Period—Codes 760–779 • Symptoms, Signs, and Ill-Defined Conditions—Codes 780–799 • Injury and Poisoning—Codes 800–999

10. 4-20 4.6 V Codes and E Codes • V Code—alphanumeric ICD code that identifies factors influencing health status and encounters not due to illness or injury • Use for healthy patients to receive routine service, for therapeutic encounters, for a problem that is not currently affecting the patient’s condition, and for preoperative evaluations • E Code—alphanumeric ICD code for an external cause of injury or poisoning • Never used as primary codes

11. 4-21 4.6 V Codes and E Codes (Continued) • Adverse effect—patient’s unintentional, harmful reaction to a proper dosage of a drug • Table of Drugs and Chemicals—reference listing of drugs and chemicals in the ICD-9-CM Alphabetic Index

12. 4-22 4.7 Coding Steps • The correct process for assigning accurate diagnosis codes has five steps: Step 1 – Review complete medical documentation Step 2 – Abstract the medical conditions from the visit documentation Step 3 – Identify the main term for each condition Step 4 – Locate the main terms in the Alphabetic Index Step 5 – Verify the code in the Tabular List

13. 4-23 4.7 Coding Steps (Continued) • Chief complaint (CC)—patient’s description of the symptoms or reasons for seeking medical care • Primary diagnosis—represents the patient’s major illness or condition for an encounter • Coexisting condition—additional illness that either affects the primary illness or is also treated during an encounter