MCII-Mod 1 Word Scramble

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

Question	Answer
ICD-9-CM	International Classification of Diseases, Ninth Revision, Clinical Modification
ICD-9-CM was developed and updated	by the World Health Organization (WHO)
ICD-9-CM was developed for	statistical collection, not reimbursement
ICD-9-CM is updated every year w/changes effective	October 1 of that year.
Cooperating parties	four agencies responsible for maintaining and updating ICD-9-CM
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
Coding Clinic for ICD-9-CM	a quarterly publication published by the AHA, considered to be the official publication for ICD-9-CM
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.
First diagnosis	the condition, after study that caused the patient to seek treatment for that visit (aka principal diagnosis in hospital outpatient settings)
ICD-9-CM consists of how many volumes	three
Volume one	includes a tabular numerical listing of diagnosis codes
Volume two	contains the alphabetic listing of diagnoses
Volume three	includes a tabular and alphabetic listing of procedures primarily used in the hospital patient setting
What is the first step in coding	locate the diagnostic term in the alphabetic index in Vol Two of ICD-9-CM
Main Term	printed in bold type at the left margin and is the main thing (disease, injury etc) wrong w/the patient
In Volume 1 Anatomic terms such as kidney, shoulder, etc.	are never main terms
The alphabetic index	is cross-referenced extremely well to allow the coder to locate the correct code using several different terms.
Once a coder has identified a code in the alphabetical index	it must be verified in the tabular list
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
E codes	are external causes of injury and poisoning, most are optional presently but may be required in the future
M (morphology codes)	found in the alphabetic index and are used primarily by cancer registries
The Tabular List of ICD-9-CM is set up in	categories, subcategories and fifth-digit subclassifications
Categories	groups of three-digit codes made up of similar diseases or a single disease
Subcategories	consist of four digits and provide more information such as site of the illness cause or other characteristics of the disease
Fifth-digit sub-classifications are available in many categories to provide even greater specificity
If there is a fifth-digit subclassification available	it must be used
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
When the coder has a limited amount of information	a ‘residual’ subcategory may be used
Residual subcategories include ‘other’ and ‘unspecified’ categories	these generally end in digits .8 for other and .9 for unspecified
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
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
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
Brackets []	are used in the tabular list to enclose synonyms, alternative wordings and explanatory phrases
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
Codes in brackets in the Alphabetic Index	can never be sequenced as principal diagnosis
Section Marks §	indicate a footnote that normally means that a fifth digit is needed in that category
See	a cross reference that requires the coder to look up a different term
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
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
Code also	means the coder must use a second code to fully describe the condition
Sometimes the code book will instruct the coder to ‘use additional code, if desired’ , the words ‘if desired’ should be	ignored
Code also underlying disease	assign the codes for both the manifestation and the underlying cause
Use additional code, if desired, to identify manifestation as…	assign also the code that identifies the manifestation
NEC	Not Elsewhere Classified
NOS	Not Otherwise Specified
Combination code	a single code used to classify two diagnoses or a diagnosis with an associated secondary process (manifestation) or an associated complication
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
If preoperative and postoperative diagnoses are different	the coder should use the postoperative diagnoses which was determined following the surgery
If a past condition may affect the current treatment	V code can be used as a secondary diagnosis
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
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
The section that gives coders the most problems	Obstetric Coding
Conditions that complicate or are associated w/pregnancy are normally listed under the main terms	Pregnancy, labor, delivery, puerperium
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
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
Code 650	is for delivery in a completely normal case & cannot be used in conjunction w/any other code in the pregnancy chapter
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
Procedures having to do w/labor or delivery are commonly located under the main term	delivery
All deliveries should be coded w/a	procedure code
Abortion	is any loss of the fetus prior to 22wks completed weeks of gestation whether spontaneous or induced
The V codes for newborns are included in the	V30-V39 codes, these are not for use on the mother’s chart
If a newborn is transferred to another institution	the V30 series is not used by the receiving facility
The newborn period is	defined as beginning at birth and lasting through the 28th day following birth
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
Assign an appropriate code from categories 740-759, Congenital Anomalies	when a specific abnormality is diagnosed for an infant
Spina Bifida	a defective closure of the vertebral column and is categorized according to the level of severity
Ventricular septal defect	an opening in the ventricular septum allowing the blood to go from the left ot right ventricle
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)
Categories 764 and 765	show slow fetal growth and low birthweight
Neoplasm	new growth
The final coding of a suspect mass or tumor	should not be completed until after review of the pathology report
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
If a malignant neoplasm has been removed, but has recurred at the primary site	code the recurrence as a primary site
Metastic can be used to describe both	a primary and secondary site
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
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
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
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
E Codes (external codes)	used as secondary codes to show the cause of the injury whenever it is known
E codes	are never assigned as principal diagnoses
If two or more events cause separate injuries	an E code should be assigned for each cause
E codes for child and adult abuse	take priority over all other E codes
E codes for cataclysmic events	take priority over all E codes except child and adult abuse
E codes for transport accidents	take priority over all other E codes except cataclysmic events and child and adult abuse
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
When multiple injuries exist	the code for the most sever injury as determined by the attending physician is sequenced first
Superficial injuries such as abrasion or contusions	are not coded when associated with more severe injuries of the same site
When the primary injury is to the blood vessels or nerves	that injury should be sequenced first
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
Fractures are classified according	to whether they are open or closed
A closed fracture	is one where there is no open wound into the skin
If the diagnostic statement does not identify whether the fracture is open or closed	it is coded as closed
Examples of closed fractures are	comminuted, greenstick, simple and impacted
Examples of open fracture are	compound, infected, puncture and w/foreign body
Pathological fractures	occur due to a disease rather than a trauma
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
A burn is classified	to whether it is first, second or third degree
For two degrees of burn in the same location	the coder should only code to the highest degree
In relation to burns	the fourth digit indicates the percent of body surface burned and the fifth indicates the degree of the burn
Non-healing burns are coded	as acute burns
Necrosis of burned skin	should be coded as a non-healed burn
When coding multiple burns	assign separate codes for each burn site
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
If the patient’s reason for admission was treatment of the complication	the complication is listed first
The late effect is often identified in the documentation by such statements as	‘residual of, sequela of, due to previous illness’
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
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
There are only a limited number of late effect codes for use	these can be located under the main term ‘late’
All diagnoses that affect the current encounter	must be coded
Previous or history of illnesses or injuries should not be coded unless	they affect the patient’s current treatment

Created by: RobynTerry1977