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Coding Principles

ICD-9 Cpt-4 HCPCS

QuestionAnswer
ICD-9-CM international classification of diseases 9th revision clinical modification
ICD-9-cm published by WHO world health organization
ICD-9-cm codes have 3 to 5 digits the more digits the more specific
The category first 3 digits of icd-9-cm code
the sub category 4th digit of icd-9-cm code
sub classification 5th digit of icd-9-cm code
primary dx first listed diagnosis chief complaint reason pt was seen
qualified dx working diagnosis qualifying symptoms
adverse effect unfavorable reaction (to a medication)
benign noncancerous no properties of cancer
malignant cancerous having properties of cancer
CA in situ cancer is still at site of origin has not spread
morbidity a diseased condition of the body
mortality the death rate number of deaths in a given time
comorbidity an underlying disease or condition contributes to the pt's present condition
familial inherited from ones family
acute a condition that runs a short but severe course
NOS not otherwise specified
NEC not elsewhere classifiable
chronic "recurrent" condition that runs over a longer period of time
eponym a procedure or disease named after the physician who discovered it
V codes non sickness or injury codes
E codes external causes of injury never used as primary dx
slanted brackets indicate the need for a second code listed as dx in the same order
italicized codes never used as primary dx
main terms appear in bold
icd-9 volume 2 alphabetical guide code listed by pts condition
icd-9 volume 1 numerical real deal codes
icd-9 volume 2 section 2 table of drugs and chemicals
icd-9 volume 2 section 3 index to external causes of injury
cogenital born with, present at birth
volume 1 v codes located after the systems
volume 1 e codes located after the v codes
sub terms indented 2 spaces
sub sub terms indented 4 spaces
non-essential modifiers in parenthesis after main terms included with main term
personal history a pt's history
family history a pt's family history
fitting of equipment
history of icd-9 vol 2 codes for family and personal history
hypertension section of icd-9 vol2
neoplasm new growth section of icd-9 vol2 benign malignant or unspecified
connecting words with, without,due to associated with, in with mention of
colon : needs one or more of the following modifiers
brace } modifies all in bracket
excludes indicative that terms are to be coded elsewhere
ICD-9-cm volume 3 procedure codes located here used in hospital setting for inpatients not used in dr offices
see explicit directions to look elsewhere
see also directs coder to look under another term for specifics
see category directs coder to look in volume 1
notes define and give instruction
modifiers added to codes to supply more specific information
and means and or
with 2 conditions must be present to use code
brackets ] enclose synonyms or alternate words
italics exclusion notes or diagnosis not to be used as primary
includes further defines or explains content
parenthesis supplementary words that do not change the code
X used during guide to remember that code needs a 5th digit
late effect residual effect from previous injury or surgery
combination code use 1 code to diagnose 2 separate dx
burns needs 2 codes (at least) first code is site and degree 2nd code is % of body surface
primary neoplasms first site of cancer
secondary neoplasms another site (other than 1st) that cancer has spread to
uncertain behavior the pathology report must state this in order to use these codes
unspecified code used when neoplasm destroyed while biopsy report still pending
metastasis spread of a tumor from one site to other sites
morphology tissue typing of a neoplasm could be benign or malignant
CPT-4 current procedural terminology 4th edition published by the ama American medical association
CPT-4 six sections : E&M ,anesthesiology surgery, radiology, pathology & laboratory, and medicine
anesthesia all codes require a physical status modifier
consultation one physician asking another physician for advice in writing
+ add on codes these codes are not to be used without another code in front of them
review of systems inventory of the body obtained thru a mini-exam series of questions
history of present illness information about a pt's condition from onset to present
past family social history questions used to get clear understanding of pt's background
convert inches to cm 2.54 x # of inches
chief complaint (cc) reason for the visit reason pt is being seen
integumentary system 3 types of closures simple , intermediate, complex
modifiers 2 digits used after the 5 digit code
open fractures bones stick out of skin
closed fractures bones do not stick out of skin
manipulation attempted reduction maneuvering the bone back into place
radiology when coding for xray look in xray
pathology panels a whole series of tests on a specific subject
principle diagnosis reason to admit pt in hospital
principle procedure performed for definitive treatment not diagnostic or exploratory
outpatient coding if no dx code for signs and symptoms
inpatient coding if no dx code as if dx was present
cpt-4 level 1
hcpcs level 2
hcpcs healthcare common procedural codes dme injections transportation
dme durable medical equiptment
Created by: 100001078761258
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