Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
ICD-10-CM {CPC}
ICD-10-CM Guidelines & Coding Concepts
| Definition | Term |
|---|---|
| appears below a manifestation code that must not be used as a first-listed code | Code First Underlying Disease |
| these codes are for symptoms only, never for causes | Code First Underlying Disease |
| known as the "Official Guidelines" | ICD-10-CM Official Guidelines for Coding and Reporting |
| these rules are developed by a group known as the four cooperating parties made up of CMS advisers, AHA, AHIMA, and NCHS | ICD-10-CM Official Guidelines for Coding and Reporting |
| has sections for general rules, inpatient (hospital) coding, and outpatient (physician office/clinic) coding | Official Guidelines |
| Conventions, general coding guidelines, and chapter specific guidelines | Official Guidelines: Section 1 |
| Selection of Principal Diagnosis: explains the guidelines for establishing the diagnosis or diagnoses for inpatient cases | Official Guidelines: Section 2 |
| Reporting Additional Diagnoses: explains the guidelines for establishing the diagnosis or diagnoses for inpatient cases | Official Guidelines: Section 3 |
| Diagnostic coding and Reporting Guidelines for Outpatient Services: explains the guidelines for establishing the diagnosis or diagnoses for all outpatient encounters | Official Guidelines: Section 4 |
| 1. Code the PRIMARY (first-listed) DIAGNOSIS first 2. Code to the highest level of certainty 3. Code to the highest level of specificity | Key points of Official Guidelines: Section 4 |
| the term "first-listed diagnosis" is used in lieu of "principal diagnosis" | In the OUTPATIENT SETTING |
| code the REASON for the surgery as the first-listed diagnosis, even if the surgery is not performed due to a contraindication | OUTPATIENT SURGERY coding guidelines (Same Day) |
| assign a code for the MEDICAL CONDITION as the first-listed diagnosis | OUTPATIENT SURGERY coding guidelines (Observation Stay) |
| code the REASON for the surgery as the first reported diagnosis, followed by codes for the complications as SECONDARY diagnoses | OUTPATIENT SURGERY coding guidelines (Observation due to complications) |
| DO NOT code diagnoses documented using terms of uncertainty. Rather code the condition(s) to the highest degree of certainty for that encounter, such as: symptoms, signs, abnormal test results, or other reason for the visit | Uncertain diagnosis |
| may be coded and reported as many times as the patient receives treatment and care for the condition(s) | Chronic diseases |
| sequence FIRST the diagnosis, condition, problem shown in the medical record. codes for other diagnoses may be sequenced as additional diagnoses | Diagnostic services |
| in the absence of any signs, symptoms, or associated, assign: Z01.89, Encounter for other specified special examinations | Routine laboratory/radiology testing |
| it is appropriate to assign both the Z code and the code describing the reason for the non-routine test | Routine laboratory/radiology testing (sign, symptom, or diagnosis evaluation) |
| code any confirmed or definitive diagnosis(es) | Diagnostic tests (OUTPATIENT encounters) |
| sequence first the diagnosis shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter | Therapeutic services |
| when the primary reason for the admission/encounter is CHEMOTHERAPY or RADIATION therapy the appropriate Z code service is listed FIRST, and the diagnosis for which the service is being performed listed second | Therapeutic services (RULE EXCEPTION) |
| sequence first a code from subcategory Z01.81, to describe the pre-op consultations. assign a code for the condition to describe the reason for the surgery as an ADDITIONAL diagnosis. code also any findings related to the pre-op eval | Pre-Operative evaluations |
| code the diagnosis for which the surgery was performed. if the post-op diagnosis is different from the pre-op diagnosis, select the POST-OP diagnosis for coding, since it is the most definitive | Ambulatory surgery |
| the code should be assigned as the FIRST-listed diagnosis | General medical examination (with abnormal finding) |
| encounters for general medical examinations (provides codes for with and without abnormal findings) | Z00.0- |
| encounters for routine child health examinations (provides codes for with and without abnormal findings) | Z00.12- |
| if both the acute and chronic illnesses have codes, this code is listed first | Acute code |
| TWO codes are usually required: code for the SPECIFIC effect, followed by the code for the CAUSE | Sequelae |
| this code that led to the sequela, is NEVER used with a code for the late effect itself | Acute Illness |
| these codes contain the letter M followed by four digits, a slash, and a final digit | M codes (morphology codes) |
| these codes are not used in physician (outpatient) practices | M codes (morphology codes) |
| A = initial, D = subsequent, S = sequela | External cause codes: The Encounter |
| category Y92 | External cause codes: The place of occurrence |
| category Y93 | External cause codes: The activity |
| category Y99 | External cause codes: The status |
| Z code: TWO chief types | 1. Reporting visits with healthy (or ill) patients who receive services other than treatments 2. Reporting encounters in which a problem NOT currently affecting the patient's health status needs to be noted |
| these codes describe Social Determinants of Health | Z codes from Z55 to Z65 |
| Assignment of these codes is permitted to be based on documents from clinicians who are not the patient's provider (social workers and nurses) | Z codes from Z55 to Z65 |
| Review complete medical documentation | Coding Step 1 |
| Abstract the medical conditions from the visit documentation | Coding Step 2 |
| Identify the main term for each condition | Coding Step 3 |
| Locate the main term in the Alphabetic Index | Coding Step 4 |
| Verify the code in the Tabular List | Coding Step 5 |
| Check compliance with any applicable Official Guidelines and list codes in appropriate order | Coding Step 6 |
| Principal Dx = Inpatient settings | I-10 GUIDELINES : FIRSTLISTED DIAGNOSIS |
| First-Listed Dx = outpatient settings | I-10 GUIDELINES : FIRSTLISTED DIAGNOSIS |
| in the OUTPATIENT setting, the term "FIRST-DIAGNOSIS [primary]" is used instead of "PRINCIPAL DIAGNOSIS" | I-10 GUIDELINES : FIRSTLISTED DIAGNOSIS |
| in the OUTPATIENT setting, may take several encounters to confirm diagnosis | I-10 GUIDELINES : UNCONFIRMED DIAGNOSIS |
| Sign/Symptoms are reported: Pt presents with complaint of frequent heartburn [REPORT: frequent heartburn] | I-10 GUIDELINES : UNCONFIRMED DIAGNOSIS |
| code the REASON for the surgery first: EVEN IF THE SURGERY IS NOT PERFORMED. FOLLOW BY CODE to report reason procedure IS NOT performed | I-10 GUIDELINES : OUTPATIENT SURGERY |
| report circumstances other than disease or injury | I-10 GUIDELINES : Z CODES |
| are INFORMATIVE codes | I-10 GUIDELINES : Z CODES |
| may be FIRST or ADDITIONALLY listed : depending on circumstances | I-10 GUIDELINES : Z CODES |
| reports encounters for inoculations and vaccinations | Z23 |
| procedure codes identifies administration | I-10 GUIDELINES : Z CODES |
| located after the I-10 Table of Drugs and Chemicals | I-10 GUIDELINES : EXTERNAL CAUSE INDEX |
| Type or form of the condition that is NOT LISTED | the coder chooses "OTHER" because a type is indicated but not found |
| No type is mentioned | the documentation is not complete enough to assign a more specific code, so the least-specific choice "UNSPECIFIED" is assigned |
| No "OTHER" vs. "UNSPECIFIED" coding option | select the "OTHER SPECIFIED" coding option, which in this situation represents both |
| never first-listed Dx / clarify injury or adverse effects | I-10 GUIDELINES : EXTERNAL CAUSE CODES |
| Categories Z03 & Z04 | I-10 GUIDELINES : OBSERVATION STAY |
| Patient admitted to OBSERVATION STATUS: Report Z code as FIRSTLISTED for Dx stated as suspected/rule out conditions | I-10 GUIDELINES : OBSERVATION STAY |
| Report the reason for the surgery as the first-listed diagnosis (reason for the encounter) | I-10 GUIDELINES : OUTPATIENT SURGERY |
| Code terms describe the external circumstances under which an accident, injury, or act of violence occurred | I-10 GUIDELINES : EXTERNAL CAUSE CODES |
| These codes have their own Index in I-10 | I-10 GUIDELINES : EXTERNAL CAUSE CODES |
| Patient admitted to OBSERVATION STATUS: if Dx has been made, report Dx as FIRST-LISTED | I-10 GUIDELINES : OBSERVATION STAY |
| Other codes may be reported in addition to observation codes | I-10 GUIDELINES : OBSERVATION STAY |
| If these conditions are present and affect patient care or is treated— report as this | I-10 GUIDELINES : COEXISTING CONDITIONS |
| Example, patient presents with SOB due to asthma. Patient is morbidly obese making examination and treatment more complex. First-listed: (asthma) / Coexisting Condition: (obesity) | I-10 GUIDELINES : COEXISTING CONDITIONS |
| INPATIENT: report diagnosis as if exists [ Probable, suspected, questionable, rule out, working Dx, etc.] | I-10 GUIDELINES : UNCERTAIN DIAGNOSIS |
| OUTPATIENT: report symptoms, signs, abnormal test results, or other reason for encounter | I-10 GUIDELINES : UNCERTAIN DIAGNOSIS |
| Code the condition to the highest degree of certainty, such as symptoms, signs, abnormal results, or reason for encounter | I-10 GUIDELINES : UNCERTAIN DIAGNOSIS |
| are treated on ongoing basis | I-10 GUIDELINES : CHRONIC DISEASES |
| Report condition as many times as patient receives care or treatment for condition | I-10 GUIDELINES : CHRONIC DISEASES |
| Do not report conditions that were previously treated and no longer exist | I-10 GUIDELINES : CHRONIC DISEASES |
| Report history codes (Z80-Z87) as secondary Dx if condition impacts current condition or affects treatment | I-10 GUIDELINES : CHRONIC DISEASES |
| if only these types of services are provided, report REASON FOR SERVICE first | I-10 GUIDELINES : DIAGNOSTIC SERVICES |
| Example: Pt presents for routine, periodic gynecological exam, report Z01.419 [No signs, symptoms, or associated diagnosis] | I-10 GUIDELINES : DIAGNOSTIC SERVICES |
| Example: Pt presents for diagnostic imaging for left breast mass, subareolar. Report N63.42, unspecified lump in left breast, subareolar | I-10 GUIDELINES : DIAGNOSTIC SERVICES |
| Patient receiving only this type of service, report reason for encounter | I-10 GUIDELINES : THERAPEUTIC SERVICES |
| Example: Outpatient chemotherapy for right breast cancer, report Z51.11 (chemo) and C50.911 (malignant neoplasm, right breast) | I-10 GUIDELINES : THERAPEUTIC SERVICES |
| First-listed code is pre-operative exam | I-10 GUIDELINES : PREOPERATIVE EVALUATION |
| Subcategory Z01.81 code (encounter for preprocedural exam) | I-10 GUIDELINES : PREOPERATIVE EVALUATION |
| Additional code, reason for surgery. Also code any additional findings related to the pre-op evaluation. | I-10 GUIDELINES : PREOPERATIVE EVALUATION |
| Report most definitive Dx / Usually postoperative Dx | I-10 GUIDELINES : PRE/POSTOPERATIVE DX |
| When the report indicates a different pre- and postoperative diagnosis, which would you report? | I-10 GUIDELINES : POSTOPERATIVE DX |
| Routine outpatient prenatal encounters with no complications, report category Z34, supervision of routine pregnancy | I-10 GUIDELINES : PRENATAL ENCOUNTERS |
| Example: 19-year-old female presents for initial prenatal exam, first pregnancy, Z34.00 | I-10 GUIDELINES : PRENATAL ENCOUNTERS |
| Prenatal encounters for high-risk patients report as first-listed, O09 (supervision of high-risk pregnancy) | I-10 GUIDELINES : PRENATAL ENCOUNTERS |
| Example: 29-year-old first trimester female patient presents for prenatal encounter with varicose veins of legs, O22.01 | I-10 GUIDELINES : PRENATAL ENCOUNTERS |
| should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List | Section I.A. : WITH or IN |
| presumes a casual relationship between the two conditions linked by these in the Alphabetic Index or Tabular List | Section I.A. : WITH or IN |
| in the Alphabetic Index is sequenced immediately following the main term or subterm, not in alphabetical order | Section I.A. : WITH or IN |
| an exception to this is the circumstance when the two conditions are unrelated to each other | Section I.A. : EXCLUDES 1 |
| if it is not clear whether the two conditions involving this note related or not, query the provider | Section I.A. : EXCLUDES 1 |
| a code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default | Section I.A. : DEFAULT CODES |
| represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition | Section I.A. : DEFAULT CODES |
| is based on the provider's diagnostic statement that the condition exists | Section I.A. : CODE ASSIGNMENT & CLINICAL CRITERIA |
| is not based on clinical criteria used by the provider to establish the diagnosis | Section I.A. : CODE ASSIGNMENT & CLINICAL CRITERIA |
| I23 {I23.1 Atrial septal defect as current complication following acute myocardial infarction} | Complications within 28 days of initial MI |
| I22.- {Subsequent ST elevation (STEMI) myocardial infarction of inferior wall} | Subsequent STEMI or NSTEMI |
| Anemia, D50-D64 | Coagulation Defects, D65-D69 | Other Disorders of Blood and Blood-Forming Organs, D70-D77 | Frequently reported codes |
Created by:
VA_MedCod3r