MCII-Mod 1
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| show | International Classification of Diseases, Ninth Revision, Clinical Modification
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| show | by the World Health Organization (WHO)
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| show | statistical collection, not reimbursement
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| ICD-9-CM is updated every year w/changes effective | show 🗑
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| Cooperating parties | show 🗑
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| Who are the 4 cooperating agencies | show 🗑
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| Coding Clinic for ICD-9-CM | show 🗑
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| Sequencing | show 🗑
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| show | 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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| show | three
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| Volume one | show 🗑
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| show | contains the alphabetic listing of diagnoses
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| Volume three | show 🗑
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| show | locate the diagnostic term in the alphabetic index in Vol Two of ICD-9-CM
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| show | printed in bold type at the left margin and is the main thing (disease, injury etc) wrong w/the patient
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| show | are never main terms
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| The alphabetic index | show 🗑
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| Once a coder has identified a code in the alphabetical index | show 🗑
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| V codes | show 🗑
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| E codes | show 🗑
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| show | found in the alphabetic index and are used primarily by cancer registries
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| show | categories, subcategories and fifth-digit subclassifications
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| Categories | show 🗑
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| show | 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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| show |
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| If there is a fifth-digit subclassification available | show 🗑
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| show | 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 | show 🗑
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| show | these generally end in digits .8 for other and .9 for unspecified
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| If the code ends in .8 or .9 | show 🗑
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| show | in these cases the coder must trust the alphabetic index use the code listed
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| show | 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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| show | are used in the tabular list to enclose synonyms, alternative wordings and explanatory phrases
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| show | 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 | show 🗑
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| Section Marks § | show 🗑
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| See | show 🗑
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| See Also | show 🗑
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| show | it means the condition must be coded elsewhere or needs further codes to complete the description
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| Code also | show 🗑
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| Sometimes the code book will instruct the coder to ‘use additional code, if desired’ , the words ‘if desired’ should be | show 🗑
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| Code also underlying disease | show 🗑
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| show | assign also the code that identifies the manifestation
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| NEC | show 🗑
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| show | Not Otherwise Specified
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| show | 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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| show | 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 | show 🗑
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| If a past condition may affect the current treatment | show 🗑
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| show | 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 | show 🗑
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| The section that gives coders the most problems | show 🗑
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| Conditions that complicate or are associated w/pregnancy are normally listed under the main terms | show 🗑
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| When determining the correct fifth digit to use for OB | show 🗑
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| show | the code for the obstetric complication is the principal diagnosis
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| Code 650 | show 🗑
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| show | 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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| show | delivery
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| show | procedure code
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| Abortion | show 🗑
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| show | 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 | show 🗑
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| The newborn period is | show 🗑
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| Codes from categories 760-763, Maternal causes of perinatal morbidity & mortality | show 🗑
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| Assign an appropriate code from categories 740-759, Congenital Anomalies | show 🗑
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| Spina Bifida | show 🗑
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| show | an opening in the ventricular septum allowing the blood to go from the left ot right ventricle
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| Patent ductus arteriosus | show 🗑
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| show | show slow fetal growth and low birthweight
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| Neoplasm | show 🗑
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| show | 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 | show 🗑
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| show | code the recurrence as a primary site
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| show | a primary and secondary site
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| show | 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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| show | the cancer should be coded as if it was still present
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| show | a V16 code can be used to show ‘family history of malignant neoplasm
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| If treatment is directed at the malignancy | show 🗑
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| show | used as secondary codes to show the cause of the injury whenever it is known
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| E codes | show 🗑
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| show | an E code should be assigned for each cause
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| show | take priority over all other E codes
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| show | take priority over all E codes except child and adult abuse
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| show | 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 | show 🗑
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| show | the code for the most sever injury as determined by the attending physician is sequenced first
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| show | 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 | show 🗑
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| show | 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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| show | to whether they are open or closed
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| show | 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 | show 🗑
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| Examples of closed fractures are | show 🗑
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| show | compound, infected, puncture and w/foreign body
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| Pathological fractures | show 🗑
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| If the fracture is stated to be ‘pathological, spontaneous or due to disease’ | show 🗑
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| show | to whether it is first, second or third degree
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| show | the coder should only code to the highest degree
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| In relation to burns | show 🗑
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| show | as acute burns
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| show | should be coded as a non-healed burn
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| show | assign separate codes for each burn site
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| show | 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 | show 🗑
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| The late effect is often identified in the documentation by such statements as | show 🗑
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| There is no time limit on when a residual can occur | show 🗑
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| Coding of late effects requires | show 🗑
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| There are only a limited number of late effect codes for use | show 🗑
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| show | must be coded
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| show | they affect the patient’s current treatment
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Created by:
RobynTerry1977