Chapter 4

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied,

duplicated, or posted to a publicly accessible website, in whole or in part.

Michelle Cranney, MBA, RHIT, CCS-P, CPC

Chapter 4

ICD-9-CM with ICD-10 Coding Guidelines



TERM REVIEW

• DIAGNOSIS

• SIGN

• SYMPTOM

• MEDICAL NECESSITY

(continued)



ICD-9 PROVIDES

A CODING SYSTEM THAT PROVIDES

AN ACCURATE WAY TO COLLECT STATISTICS TO:

Keep people healthy Plan for need health care resources Record MORBIDITY (disease) dataRecord MORTALITY (death) data Report patients’ conditions on claims

(continued)



ICD-9 PROVIDES

A CODING SYSTEM THAT PROVIDES A mandated code set for diagnosis under

HIPAA Electronic Health Care Transactions and Code Sets standards. (Codes must be current at the date of the service/patient encounter)

(continued)



SEVEN STEPS TO ACCURATE CODING

• READ SUPERBILL CAREFULLY• REREAD PHYSICIAN NOTES• ASK QUESTIONS• CODE DIAGNOSIS(ES), SIGNS AND

SYMPTOMS• CODE EACH PROCEDURE• LINK EACH PROCEDURE CODE TO AT

LEAST 1 DIAGNOSIS• DOUBLE CHECK YOUR CODES

(continued)



TERMS

• SUPPORTING DOCUMENTATION• UPCODING• UNBUNDLING• DOUBLE BILLING



DETERMINING WHAT TO CODE

Raymond went to see Dr Langston because his throat has been scratchy and sore. After examining the patient and taking a throat culture, Dr Langston determines that Raymond has strep throat and writes him a presciption



Abstracting Physician’s Notes• What are the patient’s signs and

symptoms (chief complaint)?

• What is the diagnosis? (Why is the physician caring/treating or providing services for this patient?)



ICD-9-CM and ICD-10-CM Official Guidelines for Coding and Reporting• Rules developed by cooperating parties for

ICD-9-CM and ICD-10-CM to accompany and complement official conventions and instructions provided within ICD-9-CM and ICD-10-CM

• Companion to ICD-9-CM and ICD-10-CM

(continued)



CASE STUDY

Darlene Jones broke a drinking glass in her hand. After cleaning it, she went to the doctor because it was still hurting. He removed additional pieces of glass from the wound

What is the diagnostic-related key word?(Index/Volume 2)



LOOK A LITTLE FURTHER

IS THE GLASS? A SPLINTER? FOREIGN BODY?

IS THE LOCATION OF THE WOUND IN-HER HAND?IN SOFT TISSUE?



WHAT IS YOUR DIAGNOSIS CODE?



HIPAA Alert!

• HIPAA regulations require providers and third-party payers to adhere to ICD-9-CM Official Guidelines for Coding and Reporting

• Violation of coding guidelines is violation of HIPAA



FUTURE OF ICD-9

• Effective October 1, 2014, ICD-10-CM/PCS replaces ICD-9-CM



ICD-9 Official Guidelines for Coding and Reporting

• Organized in FOUR sections– Section I ( Conventions, General Coding Guidelines, and

Chapter –specific Guidelines)

– Section II (Selection of Principle Diagnosis)

– Section III (Reporting Additional Diagnosis)

– Section IV- (Diagnostic Coding and Reporting Guidelines for Outpatient Services)



GUIDELINES FOR CODING AND REPORTING

• Contain rules that accompany and complement the official conventions and instructions provided within icd-9

• Based on coding and sequencing instructions in the coding manual



GUIDELINES FOR CODING AND REPORTING

• Assists the physician and coder to accurately code patient visit (achieve complete and accurate documentation, code assignment, and reporting of diagnosis and procedures




PAGES 1-2 (ICD-9)

-Section I ( Conventions, General Coding Guidelines, and Chapter –specific Guidelines)

– Section II (Selection of Principle Diagnosis (OP SETTINGS))

– Section III (Reporting Additional Diagnosis (NON-OP SETTINGS))

– Section IV- (Diagnostic Coding and Reporting Guidelines for Outpatient Services)




PAGES 3-31 (ICD-9)

APPENDIX 1- (PRESENT ON ADMISSION REPORTING GUIDELINES)



General Guidelines

• Use both Index to Diseases and Tabular List of Diseases

• Locate term in Index to Diseases first and verify code in Tabular List of Diseases

• Assign highest level of digits available



GuidelinesSigns and symptoms integral to disease should

not be assigned as additional codes

EXAMPLE 1:

Hearing loss, fever, swollen axillary lymph nodes, and infective otitis externa, left ear

What is the SYMPTOM?

SIGN?

What does axillary lymph nodes have to do with the other symptoms?

(continued)



EXAMPLE 1 (CON’T)Signs and symptoms integral to disease should

not be assigned as additional codes

What ICD-9 codes are assigned to this patient visit?

(continued)



Guidelines

Etiology and manifestation convention requires two codes to be reported to completely describe a single condition

EXAMPLE:

Peripheral neuropathy DUE TO type 2 diabetes mellitus

1)What is the main term found in the index?

2) What is the subterm?

(continued)



Example: Peripheral neuropathy DUE TO type 2 diabetes mellitusWhat are the codes chosen?

Why are they in a certain order?

Which code points to the manifestation of the disease?

Etiology and manifestation convention requires two codes to be reported to completely describe a single condition

(continued)



Guidelines

• Multiple coding– Use additional code

– Code first

– If applicable, code any causal condition first

• Acute (or subacute) and chronic conditions

• Combination code versus multiple code



Late Effect

• Residual condition that develops after acute phase of illness or injury has ended– No time limit on reporting

EXAMPLE:

Osteoarthritis of left hand due to previous crush injury

1) What is the residual condition?

2) What is the late effect condition?

3) How is this example coded?



Chapter 2: Neoplasms

• ICD-9-CM: 140-239

• ICD-10-CM: C00-D499

• Neoplasm– “New growths or tumors in which cell reproduction is

out of control”• Benign

• Malignant

(continued)



Revisiting Neoplasms

• Six classifications:– Primary malignancy

– Secondary malignancy

– Carcinoma (CA) in situ

– Benign

– Uncertain behavior

– Unspecified nature

(continued)




• How to use the Neoplasm Table

• Review example

• Assigning code(s) from the neoplasm table

• Primary and secondary malignancies

• Sequencing the neoplasm codes

(continued)




Cancer described as, “metastatic to a site” is considered SECONDARY to the site.

Assign one code to the secondary site and a second code to the specified primary site or unknown primary site

(continued)




EXAMPLE 1:

Metastatic carcinoma from breast to lung

Code (s)?

EXAMPLE 2:

Metastatic carcinoma from breast

Code (s)?

(continued)



Chapter 2: Neoplasms

• When anatomic sites are documented as metastatic, assign secondary neoplasm code(s) to those sites and assign an unspecified site code to the primary malignant site

EXAMPLE 1:

Primary renal cell carcinoma of lung. Code(s)?

EXAMPLE 2:

Metastic osteosarcoma of brain. Code(s)?



Chapter 2: NeoplasmsIf the diagnostic statement does not specify

whether the neoplasm site is primary or secondary, consider the site as PRIMARY, except for the following sites which are considered secondary sites (unless the physician states it is a primary site):

Bone Brain Diaphragm Heart Liver

Lymph Nodes Mediastinum MeningesPleura (NOT LUNG) Neoplasms (Category 195)

Retroperitoneum Spinal cord



Chapter 2: NeoplasmsIf the cancer diagnosis does not contain

documentation of the anatomic site but the term metastatic is documented, assign the codes for “unspecified site” for both the primary and the secondary sites

Example 1:

Metastatic chromophobe adenocarcinoma Code(s)?



Chapter 2: NeoplasmsIf the primary site of malignancy is no longer

present and no further treatment is directed to the site, DO NOT assign the code for primary of unspecified site.

Classify the previous primary site by assigning the appropriate code from Category V10

Example 1:

Metastatic carcinoma to right lung from right breast (left radical mastectomy performed last year) Code(s)?



Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders

• ICD-9-CM: 240-279

• ICD-10-CM: D50-D89

• Diabetes mellitus (5th digit needed to determine)– Type 1

• Patient’s body unable to produce insulin

– Type 2• Patient’s body unable to properly use insulin produce

• Controlled/uncontrolled?

• Manifestations?




Complete (Textbook)

Exercise 4.5




Homework examples:

Premature menopause

Code?

Postsurgical testicular hypofunction

Code?



Chapter 4: Diseases of the Blood and Blood-Forming Organs

• ICD-9-CM: 280-289

• ICD-10-CM: D50-D89

• Hematopoiesis

• Anemia

• Red cell volume

• Hemoglobin content

(continued)



Chapter 4: Diseases of the Blood and Blood-Forming Organs

• Shape (morphology)

• Purpura

• Homework :

• Pancytopenia, congenital



Chapter 5: Mental Disorders

• ICD-9-CM: 290-319

• ICD-10-CM: F01-F99

• WHO guidelines– When classifying behavioral disorders, organically based

illnesses reported before functional illnesses

– Within functional group, classify disorders as psychoses, neuroses, personality disorders, and others

(continued)



Chapter 5: Mental Disorders

• WHO guidelines– When coding mental illnesses associated with physical

conditions, assign as many codes as necessary to fully describe clinical picture

• New for ICD-10-CM– Pain disorders in psychological factors



Chapter 6: Nervous System and Sense Organs

• ICD-9-CM: 320-389

• ICD-10-CM: G00-G99, H00-H95

• Nervous system, including meninges

• Central nervous system– Brain

– Spinal cord

• Peripheral nervous system



Chapter 7: Circulatory System

• ICD-9-CM: 390-459• ICD-10-CM: I00-I99• Hypertension, hypertensive table

– Malignant (accelerated)

– Benign

– Unspecified

COMPLETE Exercise 4.9 (textbook page 162)

HOMEWORK-

Right heart failure

Benign hypertension

(continued)



Chapter 7: Circulatory System

• Cerebral infarction, stroke, CVA

• Late effects of cerebrovascular disease

• Myocardial infarction



Chapter 8: Respiratory System

• ICD-9-CM: 460-519

• ICD-10-CM: J00-J99

• Nose, sinuses, pharynx, larynx, trachea, bronchi, and lungs

• Chronic obstructive pulmonary disease– Refer to main term “obstruction”

(continued)



Chapter 8: Respiratory System

• Pneumonia

• Asthma (status asthmaticus)

• Acute exacerbation



Chapter 9: Digestive System

• ICD-9-CM: 520-579

• ICD-10-CM: K00-K94

• Major digestive organs include pharynx, esophagus, stomach, and intestines

• Accessory (secondary) organs include salivary and parotid glands, jaw, and teeth

(continued)



Chapter 9: Digestive System

• Structures that support digestive process are gallbladder, pancreas, and liver

HOMEWORK

Reacurring femoral hernia, with gangrene, unilateral



Chapter 10: Genitourinary System

• ICD-9-CM: 580-629

• ICD-10-CM: N00-N99

• Chronic kidney disease (CKD)

• Kidney transplant status– ICD-9-CM: V42.0

– ICD-10-CM: Z94.0

• CKD with other conditions



Chapter 11: Pregnancy, Childbirth, and Puerperium

• ICD-9-CM: 630-677

• ICD-10-CM: O00-O9A

• Conditions occurring during pregnancy, childbirth, and six weeks immediately following childbirth

• Never report these codes on baby’s record

(continued)




• Outcome of delivery– ICD-9-CM: V27.0-V27.9

– ICD-10-CM: Z37.1-Z37.9

(continued)




• ICD-9-CM: 630-633 (ectopic or molar pregnancy)

• ICD-10-CM: O00-O02

(continued)




• ICD-9-CM: 639 (complications following abortion and ectopic or molar pregnancy)

• ICD-10-CM: O08

• Fifth digits to identify abortive stage– Unspecified (0)

– Incomplete (1)

– Complete (2)

(continued)




• ICD-9-CM: 640-648 (complications related to pregnancy)

(continued)




• ICD-9-CM: 650 (normal delivery)

• ICD-10-CM: O80– Minimal or no assistance

– Episiotomy permitted

– Fetal manipulation not permitted• e.g., use of forceps

(continued)




• Except for ICD-10-CM, fifth digit required for current episode of care– Unspecified as to episode of care (0)

– Delivered with or without mention of antepartum condition (1)

– Delivered with mention of postpartum complication (2)

– Antepartum condition or complication (3)

– Postpartum condition or complication (4)



Chapter 12: Skin and Subcutaneous Tissue

• ICD-9-CM: 680-709

• ICD-10-CM: L00-L99

• Epidermis, dermis, subcutaneous tissue, nails, sebaceous glands, sweat glands, hair, and hair follicles



Chapter 13: Musculoskeletal System and Connective Tissue

• ICD-9-CM: 710-739

• ICD-10-CM: M00-M99

• Bones, muscles, cartilage, fascia, ligaments, synovia, tendons, and bursa

(continued)



Chapter 13: Musculoskeletal System and Connective Tissue

• Localized osteoarthrosis– Primary

• Unknown etiology

– Secondary• Caused by external or internal injury



Chapter 14: Congenital Anomalies

• ICD-9-CM: 740-759

• ICD-10-CM: Q00-Q99

• Classifies all conditions according to principal or defining defect rather than cause– Except for chromosome abnormalities

(continued)



Chapter 14: Congenital Anomalies

• May be apparent at birth or hidden and identified sometime after birth

• Codes may used throughout patient’s life



Chapter 15: Conditions Originating in Perinatal Period

• ICD-9-CM: 760-779

• ICD-10-CM: P00-P96

• Perinatal period– Interval of time before, during, and up to 28 days

following birth

• Never report these codes for mother’s episode of care



Chapter 16: Symptoms, Signs, and Ill-Defined Conditions

• ICD-9-CM: 780-799

• ICD-10-CM: R00-R99

• Includes symptoms, signs, and abnormal results of laboratory or other investigative procedures

(continued)



Chapter 16: Symptoms, Signs, and Ill-Defined Conditions

• Key terms– Abnormal, abnormality

– Decrease, decreased

– Elevation

– Findings, abnormal, without diagnosis



Chapter 17: Injury and Poisoning

• ICD-9-CM: 800-999

• ICD-10-CM: S00-T98

• Injuries

• Fractures

• Burns

• Adverse effects, poisonings, and toxic effects



Fractures

• Open/compound fracture

• Closed/simple fracture– Comminuted

– Depressed

– Fissured

– Greenstick

– Impacted

(continued)



Fractures

• Closed/simple fracture– Linear

– Slipped epiphysis

– Spiral fracture

• Complicated

• Malunion (late effect)



Burns

• ICD-9-CM: 940-949

• ICD-10-CM: T20-T32

• Classified according to:– Depth

• First degree (erythema)

• Second degree (blistering)

• Third degree (full thickness)

(continued)



Burns

• Classified according to:– Extent

• Percentage of body surface

– Agent (e.g., chemicals, fire, sun)• E codes assigned



Adverse Effects

• Also known as adverse reactions– Appearance of pathologic condition caused by ingestion

or exposure to chemical substance properly administered or taken

• e.g., allergic rash due to penicillin

– Table of Drugs and Chemicals



Poisonings

• Occur as result of overdose

• Wrong substance administered/taken or intoxication that involves combining prescribed drugs with nonprescribed drugs or alcohol– e.g., coma due to overdose of codeine

(continued)



Poisonings

• ICD-9-CM: 960-979

• ICD-10-CM: T36-T65

• Manifestation of poisoning



Toxic Effects

• ICD-9-CM: 980-989

• ICD-10-CM: T51-T65

• When someone ingests or comes into contact with harmful substance



V Codes

• ICD-9-CM: V01-V85

• ICD-10-CM: A00-Y99

• Supplementary Classification of Factors Influencing Health Status and Contact with Health Services

(continued)



V Codes

• Classifies occasions when circumstances other than disease or injury recorded as diagnoses or problems

(continued)



V Codes

• Categories:– Contact/exposure

– Inoculations and vaccinations

– Status

– History (of)

– Screening

– Observation

– Aftercare

(continued)



V Codes

• Categories:– Follow-up

– Donor

– Counseling

– Obstetrics and related conditions

– Newborn, infant, and child

• Routine and administrative examinations

• Miscellaneous



E Codes

• ICD-9-CM: E800-E999

• ICD-10-CM: V00-Y99

• Supplemental Classification of External Causes of Injury and Poisoning

• Classifies environmental events, circumstances, and conditions as cause of injury, poisoning, or other adverse effect

(continued)



E Codes

• Reported in addition to code from Chapters 1-17 to indicate nature of condition

Chapter 4

Documents

Transcript of Chapter 4