A single code used to classify two diagnoses
Indicates that a diagosis is still possible
Indicates that a diagnosis once considered likely is no longer possible.
1.) Use both alphabetic Indexes (to locate code) and Tabular Lists (to verify code)
2.) Assign codes to the highest possible level of detail.
3.) Assign combination codes when available.
4.) Only use NEC/NOS codes when no further detail is possible.
5.) Assign multiple codes when required (usually coder will be guided to do this by additional instructional notes in the ICD-9. If this is not the case and coder feels more detail is needed - ask supervisior)
5 very basic (beginning) rules of coding:
Manditory multiple coding
terms used to describe the required assignment of two codes
Instructional notes following the code:
"use additional" (after the underlying condition code)
"code first underlying condition" (after the manifestation code)
Manditory multiple coding is deignated in the Tabular List by __________?
undelying condition code listed first followed by manifestation code in italicized brackets
In the alphabetic index, manditory multiple coding is designated by _________?
True/False manifestation codes cannot be designated as the principle diagnosis
1.) underlying condition = Mumps (072.79)
2.) manifestation = Arthritis (711.50)
correct sequence for manditory multiple coding of a manifestation and its undelying condition?
e.g. Arthritis (711.50) due to mumps (072.79)
Multiple codes should only be assigned if the causal condition is documented as being present. If causal contion is documented then it should be assigned as the first listed code or principle diagnosis.
"Code if applicable, any causal condition first" means.
1.) (first listed or principle dx.) postphlebetic syndrome with ulcer" - 459.11
2.) Ulcer of lower limbs, except pressure ulcer" (unspecified), - 707.10
The category containing "Ulcer of lower limbs, except pressure ulcer" (unspecified), - 707.10 includes a "code if applicaple any causal condition first:" Indented under this note is a list of conditions which includes "postphlebetic syndrome with ulcer" - 459.11.Diagnostic statement indicates ulcer of the lower limbs due to postphlebetic syndrome. What is the correct coding/sequencing?
the conditioned mentioned is documented as being present.
In situations when associated conditions may or may not be documented, the instruction to "use additional code" indicates that multiple codes should be assigned only if_________?
1.) "UTI, site not specified" - 599.0
2.) "Escherichia coli [E. coli]" E.- 041.49
Diagnostic statement indicates urinary tract infection (UTI) due to e-coli. "UTI, site not specified" listed as 599.0 includes the note "Use additional code to identify organism, such as Escherichia coli [E. coli] (E. coli code = 041.49) What is the correct coding/sequencing?
1.) Sypmtoms or signs integral to diagnosis.
2.) Codes based soley on dx tests - labs, x-ray, etc. (unless dx is confirmed by a physician)
3.) dx that do not meet UHDDS criteria e.g. conditions mentioned in report with no further documentation to support conditions relevence to current episode of care.
4.) codes designated as "unspecified" when a more specific code for condition also exists.
Name four rules regarding indisciminate (multiple) coding - These should NOT be assigned:
Report unconfirmed diagnosies as if established except in:
1.) Coding of HIV infection/ AIDS, cancer
3.) Outpatient coding
In an inpatient setting, what is the appropriate coding for unconfimed diagnoses ? i.e. when diagnostic statement lists diagnoses: "possible", "probable", "suspected" "likely", "quest-ionable", "?" , "rule out","consistent with", "compatable with", "indicative of", "suggestive of", "appears to be", and "comparable with" 2 exceptions?
Physician clarification is required for confirmation of disease. If a condition is not confirmed after clarification of record, a code for abnormal findings may be appropriate.
True/False - In inpatient or outpatient coding,"borderline" diagnoses are covered under the "possible/probable" rule and coded as if confirmed.
Both codes are assigned with acute (subacute) as first listed. e.g. "Acute and chronic Bronchitis." -
1.) 466.0 - Bronchitis - acute (subacute)
2.) 491.9 - Bronchitis - chronic
Codes for diagnoses listed as both acute (subacute) and chonic when both subterms appear at the same indentation level e.g
acute or subacute ... 466.0
are assigned and sequenced?
Only one code is assigned in this case. e.g. "Acute and chronic poliomyelitis"
=> 335.21 chronic poliomyelitis.
Codes for diagnoses listed as both acute (subacute) and chonic when when only one term is indented as a subterm with the other subterm in parenthases as a non-essential modifier. e.g.
Poliomyelitis (acute) (anterior) (epidemic) 045.9
Use the combination code. e.g. chronic and acute respiratory failure => 518.84
Codes for diagnoses listed as both acute (subacute) and chonic when a combination code has been provided for use when a condition is described as both acute (subacute and chronic. e.g.
518.84 includes both acute and chronic respiratory failue.
disregard "acute/subacute, chronic" modifiers and just use the regular code.
Appropriate coding for when a diagnosis has no subentries listed for "acute/subacute" or "chronic".
The condition is coded as a confirmed diagnosis. e.g. code 644.21 - "early onset of labor delivered".
Code assignment for "impending" or "threatened" conditions that did occur? e.g. medical record indicates a diagnosis of threatened premature labor at 28 weeks gestation. Review of medical record indicates that a stillborn was delivered during the hospital stay?
1.) Assign code for "threatened" or "impending" condition. e.g. Pt is admitted with dx. of "threatened abortion" but abortion is averted. Assign code 640.0x for "threatened abortion".
2.) Precursor condition that actually existed is coded. e.g. Pt. admitted with a dx of "impending gangrene" but gangrene is averted with prompt tx.
Code is then assigned for the presenting situation that suggested the possibility of gangrene - "redness or swelling"
Code assignment for impending or threatened conditions that did not occur? 2 possibilities:
1.) Code for "threatened" or "impending" condition exists (either under main term, or condition is indented under terms "threatened" or "impending":
2.) No code for "threatened" or "impending" condition is indexed.
False - There is no set period of time that must elapse before a condition can be considered a late effect. Certain conditions due to trauma including "Malunion", "Nonunion", and "Scarring" are inherent late effects no matter how early they occur.
True/False - Set period of time must elapse before a condition can be considered a late effect.
Generally two codes are required:
1.) Residual condition - e.g. "Paralysis" - 344.40,
2.) Late effect code for causal condition (indexed under "Late" in most cases) e.g. "Late, effects, poliomyelitis" - 138
3.) If causal condition was an injury then a late effect E code would be assigned last. In the revious example an E code would not be assigned because poliomyelitis is not an injury.
Generally, what is the appropriate coding/sequencing for late effects - e.g. "paralysis of left leg due to old poliomyelitis"?
1.) When the residual effect is not clearly stated the late effect of the causal condition is is used alone.
e.g. "Sequela of old crush injuy to foot" = 906.4 - "late effect of crushing"
2.) When no late effect code is provided in the ICD-9, but the description in the medical record indicates that condition is a late effect, only the residual condition is coded. (do not code complications from previous surgeries as late effects)
3.) Late effect code has been expanded at the 4th and 5th digit to include residual conditions, then only the combination late effect code is assigned. - (only 438 codes - "late effects of CVA" have been expanded this way)
What are three exceptions to the general guideline for coding of late effects?
False - A late effect code is generally not used with a code for a current illness or injury of the same type, but there is one exception: 438 codes "late effects of cerebrovascular disease (CVA) are assigned as additional code when a pt. with residual effects from a previous CVA is seen for a current CVA. e.g.
434.00 cerebral thrombosis, w/o mention of infarction also gets additional code of: 438.11 - late effects of CVA, with speech, language deficits/aphasia.
True/False a late effect code is never used with a code for a current illness or injury of the same type
all significant procedures must be reported
UHDDS requirements for reporting of procedures?
1.) Is surgical in nature
2.) Carries an anesthetic risk
3.) Carries a procedural risk
4.) Requires specialized training
A significant procedure is defined as meeting any of the following four conditions?
Any procedure that affects payment whether or not it meets the definition of a significant procedure.
Medicare requirements for reporting of procedures?
Standard format for reporting procedures for inpatients?
AMA's "Current Procedural Teminology" (CPT) and
"Health Care Procedure Coding System (HCPCS) level II
Standard format for procedures for outpatients and physician reporting?
Principle procedure = one that is performed for definitive treatment rather than diagnostic or exploratory purposes or one that is necessary to care for a complication.
Definition of Principle procedure?
1.) Assign as principle the procedure most related to the principle diagnosis.
2.) If two or more procedures are equally related to the principle diagnosis, assign as the most resource intensive or complex procedure as principle.
Two coding guidelines for assigning principle procedure when two or more procedures fit the criteria for principle?
Chapters - 00, 13, 16, 17
13= obstetrical procedures
16 = diagnostic and therapeutic procedures not considered to be surgical in nature
00, 17 = overflow chapters - diverse groups of procedures applying to all body systems
Most chapters in volume III (Tabular) deal with specific body systems with the following 4 exceptions:
1.) to advise coder that individual components of a procedure, or two procedures that might be considered as a unit must be coded. Expressed as "code also any synchronous ...."
2.) to advise the coder that an additional code is to be assigned when certain adjunct procedures are performed, or certain equipment is used.
Note - The need to use two codes is sometimes indicated by slanted brackets enclosing the second code to be sequenced as indicated.
"Code also" note in volume III (procedures) indicates additional code is needed for one of the following two reasons?
1.) Type of procedure e.g. "removal, resection, excision, incision, graft, shunt etc."
2.) common name e.g. "hysterectomy"
3.) Eponym e.g. "Davis operation"
Main terms for finding procedures in the alphabetic index of volume III of the ICD-9-CM are usually listed by?
1.) "excision" or "resection"
2.) "excision, lesion, subterm for specific site"
1.) Removal of an organ is usually indexed under?
2.) Removal of a lesion of an organ is found under?
2 codes are needed if both sides receive procedure.
Note: This rule is primarily for joint replacements and dual bilateral joint replacements rarely if ever happen during the same hospital stay.
If code does not make a distinction between bilateral and unilateral what is the appropriate coding for a bilateral procedure during the same episode of care?
1.) Operative approaches, openings, closures that are an integral part of the of the procedure are not coded.
2.) Operative approaches are coded when opening of body cavity is followed solely by a diagnostic procedure such as a biopsy. In this case approach such as laparotomy is sequenced first followed by a code for the biopsy.
What is the appropriate coding for operative approaches and closures.
1.) Codes have been developed to include these techniques for most procedures (combination codes) No additional code needed.
2.) When conversion to an open procedure is necessary, only code the open procedure followed by a V64.xx code to indicate the conversion.
1.) What is the appropriate coding for laparoscopic, thoracoscopic, and arthroscopic approaches?
2.) What is the appropriate coding for conversion from a laparoscopic, thoracoscopic, or arthroscopic approach to an open approach?
1.) Procedure code + code for endoscopic approach (unless directed otherwise by ICD-9, or endoscopic approach is included as part of the procedure codes description)
2.) When the endoscope is passed through more than one body cavity, the endoscopy code should indicate the most distant site.
How are other (non-laparoscopic, thoracoscopic, and arthroscopic) endoscopic approaches to procedures coded (2 guidelines)?
When a lesion removed for therapeutic/treatment purposes is sent to the lab for examination, a biopsy code is not assigned.
When should a biopsy code not be assigned even if a record uses the term "biopsy" in reporting the procedure?
Biopsies performed via needle, brush, or aspiration?
1.) If endoscopy is not included in the biopsy code,
code as: 1st endoscopy code + 2nd biopsy code.
2.) and 3.)
only code "closed biopsy" for brush and aspiration biopsies
How should closed biopsies of the following types be coded?
1.) Closed - endoscopic
2.) Closed - brush
3.) closed - aspiration
1.) no additional code required - "open" biopsy implies incision.
2.) both procedure and biopsy are coded as:
1st = definitive procedure + 2nd biopsy
3.) "needle" is a closed biopsy. In this case, the terms "open"/"closed" refer to the biopsy itself not the surgical procedure. Coded as:
1st = definitive procedure + 2nd "closed" biopsy
4.) 1st = definitive procedure + 2nd = biopsy
How should open biopsies of the following types be coded?
1.) open (by way of incision) biopsy only.
2.) biopsy is incidental to removal of other tissue during a procedure.
3.) needle (closed) biopsy during an open surgical procedure.
4.) biopsy immediately before a surgical procedure begins (i.e. rapid-frozen-section exam)
an associated diagnostic code e.g. "retinal detachment"
A report with a code for a diagnosis-related procedure e.g. "repair of retinal detachment" must also contain__________?
1.) V64.xx codes
2.) Code to the extent to which procedure was actually performed. In examples code only for: incision, endoscopy, or exploration of site, respectively.
3.) Procedure is still coded as performed.
What are the guidelines for coding the following:
1.) Cancelled procedures?
2.) Incomplete procedures - e.g. not completed because:
incision only, endoscopic approach unable to reach site,
cavity or space entered but procedure not competed?
3.) Procedure failed e.g. completed but goal of procedure not achieved?
"Creation", "Formation", or "Shunt"
Shunt procedures are indexed under?
Coder must determine which site is involved in the revision. e.g. if peritoneal only, then code 54.95 "incision of the peritoneum", if ventricular site revised, then code 02.42 "replacement of ventricular shunt", if both sites are involved, then both codes should be assigned.
Appropriate coding for ventriculoperitoneal shunt?
Code for the following:
1.) stent insertion (if stent insertion is part of a coronary angioplasty, code the angioplasty 1st.)
2.) number of vessels treated
3.) number of stents inserted
4.) procedure on vessel bifurcation (if vessel bifurcation present)
Required types of codes for stent insertion?
1.) 92.3x = stereotactic radiosurgery
2.) 93.59 = immobilization
Required coding for stereotactic radiosurgery?
1.) code for specific procedure performed
2.) code from subcategory 00.3x to indicate CAS.
Required coding for computer assisted surgery (CAS)?
1.) code for specific procedure performed
2.) code from subcategory 17.4x to indicate robotic assisted surgery.
Required coding for robotic assisted procedures?
Objective evidence of a disease that can be observed by a physician.
A subjective observation reported by the patient but not confirmed objectively by the physician.
Codes for signs, symptoms, and ill defined conditions are in chapter________ of the ICD-9-CM?
False. For outpatient visits when there is no established diagnosis, only whatever signs or symptoms are available at the highest level of certainty are assigned.
True/False? Words such as "probable", "possible" etc. in a diagnostic report can be coded as confirmed for outpatient visits.
1.) diagnostic statement lists the symptom first followed by contrasting/comparative conditions.
2.) no related condition is present and the symptom is the reason for the encounter.
3.) Signs or symptoms are transient and no definitive diagnosis can be made.
4.) pt. is referred elsewhere for further study before a diagnosis can be made.
Situations when codes from chapter 16 may be designated as principle/first listed diagnoses? (8 possible) (two cards)
5.) a more precise diagnosis can not be made for other reasons.
6.) Symptoms are treated in an outpatient setting without further workup.
7.) a provisional diagnosis of a sign or symptom is made and the patient fails to return for further evaluation.
8.) A residua;l late effect is the reason for admission and the Alphabetic Index directs the coder to an alternative sequencing.
Situations when codes from chapter 16 may be designated as principle/first listed diagnoses? (8 possible) (continued).
highest level of certainty
For outpatients the reason for the encounter is reported to the_____________? which often means that symptom codes are reported as the reason for the encounter with these patients.
Not integral to the underlying condition.
Codes form chapter 16 are only assigned as secondary codes when the signs or symptoms are ___________?
1.) physician has not been able to arrive at a more definitive related diagnosis and lists the abnormal finding itself as the diagnosis.
2.) The condition meets the UHDDS criteria for reporting other diagnoses.
For inpatients, it is rarely appropriate to assign chapter 16 "abnormal findings" codes unless the following two criteria are met:
Review the medical record to determine if additional relevant tests or consultations were carried out or additional care was given. If so a query may be appropriate.
If the coder notes clinical findings outside the normal range but no related diagnosis is stated, the coder should________?
True/False? Codes for ill-defined conditions or unknown causes of morbidity and mortality should never be used when a more definitive diagnosis is available.