Transcript Chapter 1 Becoming a Successful Student

Copyright, 1996 © Dale Carnegie & Associates, Inc.
Getting to know the ICD-9-CM
 International Classification of Diseases, Ninth
Revision, Clinical Modification
 Intention is to describe the clinical picture of
the patient more precisely
 Used in medical records, medical and
ambulatory care, and review
Updates to the ICD-9
 New books published yearly
 ICD-10-M is used to code and classify
mortality data from death certificates
Why Use ICD Codes?
 Data storage and retrieval
 Maximize reimbursement by accurate coding
 Shorten claims processing time
 Facilitate measurement of compliance with
clinical guidelines
Format and Conventions of ICD-9-CM
 Volume 1, Tabular List
 Classifies diseases and injuries according to
etiology and organ systems, dividing them
into groups:
 Anatomical system type of condition
 Related groups of codes
 Three-digit codes (category codes)
 Fourth-digit codes (subcategory codes)
 Fifth-digit codes (subclassification codes)
Format and Conventions of ICD-9-CM
Cont.
 Classifications of Sections and Structures of
Chapters 1 thru 17
 Subdivided as follows:
 Section: group of three-digit code numbers
describing a general disease category
 Category: three-digit code representing a
specific disease within the section
 Subcategory: further breakdown of the
category, assigning a fourth digit
 Subclassification: five-digit code giving the
highest level of specificity to the disease state
Example of Chapter Structure
 Chapter: Diseases of the Circulatory System
Chapter Seven (390-459)
 Section: Hypertensive Disease (401-405)
 Category: Hypertensive Heart Disease (402)
 Subcategory: Malignant (402.0)
 Subclassification: Without heart failure
(402.00)
 Malignant hypertensive heart disease without
heart failure = 402.00
Format and Conventions of ICD-9-CM
Cont.
 Volume 2, Alphabetic Index
 Alphabetic Index of disease and injury
 Divided into three sections:
 index of diseases
 poison and external causes of adverse affects
of drugs and other chemical structures
 Alphabetic index of external causes of injury
and poisoning
Format and Conventions of ICD-9-CM
Cont.
 Volume 3, Procedures: Tabular List and
Alphabetic Index
 Primarily used in hospital facilities to code
procedures
Symbols, Abbreviations, Punctuations
and Notations
 Instructions for use
 READ CAREFULLY
 NEC - not elsewhere classifiable and NOS not otherwise specified - only use these
codes when you don’t have more information
to be more specific
Steps in ICD Coding
 Identify the key terms in the diagnostic
statement
 check documentation for preexisting
conditions to ensure they are still being
treated
 Never code conditions described as “rule
out”, “suspected”, “probable”, or
“questionable” - code symptoms until
diagnosis is confirmed
 Cannot use codes just because they will get
the service covered by insurance
Steps in ICD Coding Cont.
 Locate the diagnosis in the Alphabetic Index
(Volume 2)
 Read any footnotes, symbols or instructions
 Locate the code in the Tabular List
 Read inclusions and exclusions
 Include fourth and fifth digits when available
 Assign the code
Special Codes
 V Codes - used for preventive visits when
patient is not currently ill (physical exams)
 Example: Exposure to rabies by rabid
skunk, Code as V01.5
 E Codes - used to classify environmental
causes of injury, poisoning, or other
adverse effect
 Example: Accident caused by explosive
material, explosive gases, Butane Code,
Code as E923.2
Special Codes Cont.
 Symptoms, Signs and Ill-defined
Conditions, Chapter 16 - use when definite
diagnosis is unknown
 Example: Rule out myocarial infarction,
Code as “CC chest pain” 786.50
Appendices
 5 appendices in Volume 1
 Morphology of Neoplasms - all cancer
codes by histology, location, and behavior
 Glossary of Mental Disorders - psychiatric
terminology
 Classification of Drugs - adverse effect of
drugs
 Classification of Industrial Accidents injuries categorized by industrial agency
 List of Three-digit Categories - breakdown
of chapter categories
Coding tips and hints
 Always have a good medical dictionary
 Use the most recent ICD manual
 Make notes in your books
 Don’t code only from the Alphabetic Index
 Diagnoses are listed by first word, by a key
word in a phrase, or by anatomical site
involved
Coding tips and hints Cont.
 Avoid nonspecific codes
 Be careful when coding preexisting
conditions
 Documentation must support the diagnosis
 Inaccurate coding can lead to accusations of
fraud and abuse