MCII-Mod 1
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| ICD-9-CM | International Classification of Diseases, Ninth Revision, Clinical Modification
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| ICD-9-CM was developed and updated | by the World Health Organization (WHO)
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| ICD-9-CM was developed for | statistical collection, not reimbursement
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| ICD-9-CM is updated every year w/changes effective | October 1 of that year.
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| Cooperating parties | four agencies responsible for maintaining and updating ICD-9-CM
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| Who are the 4 cooperating agencies | AHA (American Hospital Association), (NCHS) the National Center for Health Statistics, (HCFA) The Health Care Financing Administration, and the (AHIMA) American Health Information Association
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| Coding Clinic for ICD-9-CM | a quarterly publication published by the AHA, considered to be the official publication for ICD-9-CM
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| Sequencing | refers to the selection of the appropriate first diagnosis for the patient’s encounter. This is known as the PRINCIPAL DIAGNOSIS in the hospital inpatient setting.
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| First diagnosis | the condition, after study that caused the patient to seek treatment for that visit (aka principal diagnosis in hospital outpatient settings)
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| ICD-9-CM consists of how many volumes | three
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| Volume one | includes a tabular numerical listing of diagnosis codes
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| Volume two | contains the alphabetic listing of diagnoses
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| Volume three | includes a tabular and alphabetic listing of procedures primarily used in the hospital patient setting
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| What is the first step in coding | locate the diagnostic term in the alphabetic index in Vol Two of ICD-9-CM
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| Main Term | printed in bold type at the left margin and is the main thing (disease, injury etc) wrong w/the patient
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| In Volume 1 Anatomic terms such as kidney, shoulder, etc. | are never main terms
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| The alphabetic index | is cross-referenced extremely well to allow the coder to locate the correct code using several different terms.
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| Once a coder has identified a code in the alphabetical index | it must be verified in the tabular list
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| V codes | can be used to describe the main reason for the patient’s visit in cases where the patient is not ‘sick’ or used as a secondary diagnosis to provide further information about the patient’s medical condition
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| E codes | are external causes of injury and poisoning, most are optional presently but may be required in the future
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| M (morphology codes) | found in the alphabetic index and are used primarily by cancer registries
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| The Tabular List of ICD-9-CM is set up in | categories, subcategories and fifth-digit subclassifications
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| Categories | groups of three-digit codes made up of similar diseases or a single disease
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| Subcategories | consist of four digits and provide more information such as site of the illness cause or other characteristics of the disease
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| Fifth-digit sub-classifications are available in many categories to provide even greater specificity |
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| If there is a fifth-digit subclassification available | it must be used
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| Many of the fifth-digit subclassification are not shown in the alphabetic index | this is the reason the coder must take the time to review and verify the code in the tabular list
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| When the coder has a limited amount of information | a ‘residual’ subcategory may be used
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| Residual subcategories include ‘other’ and ‘unspecified’ categories | these generally end in digits .8 for other and .9 for unspecified
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| If the code ends in .8 or .9 | this should serve as a flag for the coder, while these residual codes are used appropriately in many cases, it may mean a more specific code can be found
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| Due to space restraints, sometimes a term listed in the alphabetic index will not be repeated in the tabular list | in these cases the coder must trust the alphabetic index use the code listed
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| Braces } | are used in the tabular list to reduce repetitive wording by connecting a series of terms on the left with a statement on the right
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| Brackets [] | are used in the tabular list to enclose synonyms, alternative wordings and explanatory phrases
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| Slanted Square Brackets [] | are used only in the alphabetic index to enclose a second code number that must be used with the first, and is always sequenced second
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| Codes in brackets in the Alphabetic Index | can never be sequenced as principal diagnosis
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| Section Marks § | indicate a footnote that normally means that a fifth digit is needed in that category
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| See | a cross reference that requires the coder to look up a different term
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| See Also | cross reference directs the coder to look under another main term if there is not enough information under the first term to identify the proper code
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| If a condition is found under the excludes box | it means the condition must be coded elsewhere or needs further codes to complete the description
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| Code also | means the coder must use a second code to fully describe the condition
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| Sometimes the code book will instruct the coder to ‘use additional code, if desired’ , the words ‘if desired’ should be | ignored
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| Code also underlying disease | assign the codes for both the manifestation and the underlying cause
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| Use additional code, if desired, to identify manifestation as… | assign also the code that identifies the manifestation
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| NEC | Not Elsewhere Classified
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| NOS | Not Otherwise Specified
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| Combination code | a single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or an associated complication
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| To code an operative report | the coder should first read through the entire report and make notes (or underline) any possible diagnoses or abnormalities noted and any procedure performed
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| If preoperative and postoperative diagnoses are different | the coder should use the postoperative diagnoses which was determined following the surgery
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| If a past condition may affect the current treatment | V code can be used as a secondary diagnosis
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| Certain V codes are so nonspecific or potentially redundant w/other codes that there can be little justification for the use in the INPATIENT setting. There Outpatient use should be limited. They are | V11, V13.4, V13.6, V15.7, V23.2, V40, V41, V47-V49, V51, V58.2, V72.5, V72.6
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| V Codes/categories/subcategories that are only acceptable as first listed , never as secondary | V22.2, V66.7, V09, V10, V12, V13, V14, V15,V16-V19, V21, V27, V42-V46, V49.6X, V49.7X, V60, V62-V64
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| The section that gives coders the most problems | Obstetric Coding
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| Conditions that complicate or are associated w/pregnancy are normally listed under the main terms | Pregnancy, labor, delivery, puerperium
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| When determining the correct fifth digit to use for OB | the coder should review the patient’s medical record to determine if the patient delivered during this episode of care
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| When a patient is admitted b/c of a condition that is either a complication of pregnancy or that is complicating the pregnancy | the code for the obstetric complication is the principal diagnosis
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| Code 650 | is for delivery in a completely normal case & cannot be used in conjunction w/any other code in the pregnancy chapter
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| Code 650 can only be used when | 1-live birth, 2-term (37wks-42wks), 3-single birth, 4-No complications, 5-No instrumentation except episiotomy or artificial rupture of membranes, 6-Cephalic or vertex presentation, 7-No fetal manipulation
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| Procedures having to do w/labor or delivery are commonly located under the main term | delivery
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| All deliveries should be coded w/a | procedure code
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| Abortion | is any loss of the fetus prior to 22wks completed weeks of gestation whether spontaneous or induced
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| The V codes for newborns are included in the | V30-V39 codes, these are not for use on the mother’s chart
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| If a newborn is transferred to another institution | the V30 series is not used by the receiving facility
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| The newborn period is | defined as beginning at birth and lasting through the 28th day following birth
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| Codes from categories 760-763, Maternal causes of perinatal morbidity & mortality | are only assigned when the maternal condition has actually affected the fetus or newborn
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| Assign an appropriate code from categories 740-759, Congenital Anomalies | when a specific abnormality is diagnosed for an infant
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| Spina Bifida | a defective closure of the vertebral column and is categorized according to the level of severity
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| Ventricular septal defect | an opening in the ventricular septum allowing the blood to go from the left ot right ventricle
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| Patent ductus arteriosus | condition where the fetal blood vessel connecting the aorta and pulmonary artery that allows blood to bypass the fetal lungs remains open (patent)
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| Categories 764 and 765 | show slow fetal growth and low birthweight
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| Neoplasm | new growth
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| The final coding of a suspect mass or tumor | should not be completed until after review of the pathology report
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| A common coding mistake made by coders in reference to neoplasms | is checking the neoplasm table and not begin by looking up the histological site
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| If a malignant neoplasm has been removed, but has recurred at the primary site | code the recurrence as a primary site
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| Metastic can be used to describe both | a primary and secondary site
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| If the patient has had a malignancy removed and is back for follow up to look for further signs of cancer | If there are no further signs of cancer then a ‘history of malignant neoplasm’ code is used from the V10 section
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| If the patient has had a malignancy removed and is still in the initial stage of treatment such as chemotherapy or radiation therapy | the cancer should be coded as if it was still present
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| If the patient is undergoing testing b/c a family member has or previously had cancer | a V16 code can be used to show ‘family history of malignant neoplasm
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| If treatment is directed at the malignancy | designate the malignancy as the principal diagnoses, except for the purpose of the encounter is for radiotherapy or chemotherapy sessions
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| E Codes (external codes) | used as secondary codes to show the cause of the injury whenever it is known
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| E codes | are never assigned as principal diagnoses
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| If two or more events cause separate injuries | an E code should be assigned for each cause
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| E codes for child and adult abuse | take priority over all other E codes
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| E codes for cataclysmic events | take priority over all E codes except child and adult abuse
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| E codes for transport accidents | take priority over all other E codes except cataclysmic events and child and adult abuse
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| When the intent of an injury or poisoning is know but the cause is unknown | use codes E928.9, Unspecified accident, E 958.9, suicide and self-inflicted injury by unspecified means and E968.9, Assault by unspecified means
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| When multiple injuries exist | the code for the most sever injury as determined by the attending physician is sequenced first
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| Superficial injuries such as abrasion or contusions | are not coded when associated with more severe injuries of the same site
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| When the primary injury is to the blood vessels or nerves | that injury should be sequenced first
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| When a primary injury results in minor damage to peripheral nerves or blood vessels | the primary injury is sequenced first with additional codes from categories 950-957, injury to nerves & spinal cord and/or 900-904 injury to blood vessels
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| Fractures are classified according | to whether they are open or closed
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| A closed fracture | is one where there is no open wound into the skin
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| If the diagnostic statement does not identify whether the fracture is open or closed | it is coded as closed
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| Examples of closed fractures are | comminuted, greenstick, simple and impacted
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| Examples of open fracture are | compound, infected, puncture and w/foreign body
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| Pathological fractures | occur due to a disease rather than a trauma
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| If the fracture is stated to be ‘pathological, spontaneous or due to disease’ | it is coded as a pathological fracture w/a fifth digit indicating the site of the fracture. It is also necessary to also code the underlying disease of the fracture
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| A burn is classified | to whether it is first, second or third degree
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| For two degrees of burn in the same location | the coder should only code to the highest degree
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| In relation to burns | the fourth digit indicates the percent of body surface burned and the fifth indicates the degree of the burn
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| Non-healing burns are coded | as acute burns
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| Necrosis of burned skin | should be coded as a non-healed burn
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| When coding multiple burns | assign separate codes for each burn site
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| When coding a poisoning or reaction to the improper use of a medication | the poisoning code is sequenced first, followed by a code for the manifestation
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| If the patient’s reason for admission was treatment of the complication | the complication is listed first
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| The late effect is often identified in the documentation by such statements as | ‘residual of, sequela of, due to previous illness’
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| There is no time limit on when a residual can occur | but is considered a residual if the initial (acute) illness or injury has resolved or healed
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| Coding of late effects requires | two codes; the residual condition or nature of the late effect and the cause of the late effect. The residual or nature of the late effect is sequenced first
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| There are only a limited number of late effect codes for use | these can be located under the main term ‘late’
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| All diagnoses that affect the current encounter | must be coded
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| Previous or history of illnesses or injuries should not be coded unless | they affect the patient’s current treatment
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