ICD 9 Coding: Basic Guidelines and Characteristics of Coding

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International Classification of Diseases 9th Revision Clinical Modification

What does ICD 9 CM stand for?

United States

The CM in ICD 9 means it can only be used in _____.

diagnoses

ICD 10 CM is used for

procedures

ICD 10 PCS is used for

National Center for Health Statistics

Who is responsible for maintaining volumes 1 & 2 of ICD 9?

CMS

Who is responsible for maintaining volume 3 of ICD 9?

tabular list of diseases and injuries

What does volume 1 contain?

index of disease and injuries

What does volume 2 contain?

index and tabular list of procedures

What does volume 3 contain?

classification of diseases and injuries, supplementary classifications, appendices

What are the subdivisions of volume 1?

colon

Used in both exclusion/inclusion notes to indicate that one of the modifiers from the list below must be present in order for statement to apply.

slanted brackets

This is used in volume 2 to enclose a code number that must be used with the code preceding it.

bold

Typeface that is used for all codes and titles in volume 1.

NEC

This is used when documentation indicates a specific condition but there is no separate code for the condition.

brace

This encloses a series of terms that are modified by the statement to the right or left.

brackets

This encloses synonyms, alternative words, abbreviations or explanatory phrases.

NOS

This is used when the diagnostic statement and medical record does not provide specific information that would permit classification to a specific code.

italics

Typeface used for all exclusion notes.

squiggly mark

This indicates a footnote or instructional note.

includes

This further defines or provides examples of a category or section.

parentheses

This encloses supplementary words and does not affect the code.

excludes

This indicates conditions that are to be coded/listed elsewhere.

subterms

These are indented under main term and affects code selection

nonessential modifiers

Terms in parentheses that are nonessential

see

Mandatory instruction, indicates that the coder must refer to alternative term.

notes

Follows terms to define and give further instructions.

NOS

Means unspecified

see also

Directs coder to look under another term if all information is not found under the first term

see category

Directs coder to consult specific category in volume 1.

eponym

Disease/syndrome named for a person.

NEC

Means "other"

chapter, section, category, subcategory, subclassfication

List the order in which codes are organized.

v codes, e codes

What are the two supplementary classifications to the ICD 9 system?

main terms

Terms listed in the alphabetic index in boldface type all the way to the left are known as

april 1, october 1

New ICD 9 codes can go into effect on which dates?

documentation, specific condition

Codes containing the abbreviation NOS are to be used when _____ doesn't provide enough information to point you to a ______

October 1, 2014

What is the scheduled date for implementation of ICD 10 in the U.S.?

ancient Greece

Notion of classification originated at the time of

London Bills of Mortality

This was the first documentation of the proportion of children who died before age six.

WHO

Which organization assumed responsibility for revising ICD every 10 years?

more specific, more codes, alphanumeric, up to 7 characters

What 4 changes were made with ICD 10?

Final Rule of the HIPAA Administrative Simplification Modifications

Implementation of ICD 10 was established in the

ICD 9, CPT, HCPCS, CDT, NDC

What are the five medical code sets under HIPAA?

Medicare Prescription Drug Improvement and Modernization Act

Which act included the possibility that code changes could occur twice a year?

NCHS, CMS

The ICD 9 coordination and maintenance committee is composed of representatives from

yearly

All ICD 9 coding book must be updated

yearly

All coding software must be updated

October 1

New ICD 9 codes are effective

17

Number of chapters for ICD 9 Diseases and Injuries

subcategories

These have 4 digits and provide more specificity of information regarding etiology, site, and manifestations.

chapter, section, category, subcategory

5 digit assignments and instructions appear at the beginning of a ______, _____, _____, or _____.

highest level of specificity

You must code to the ______.

subcategory, subclassification

3 digit codes are only used when there is no ______ or ______.

other

.8 codes are equivalent to

unspecified, other and unspecified

.9 codes are equivalent to _____ or _____.

other

This is a type of specific condition that is not otherwise classified to preceding fourth digits in same category.

unspecified

This describes a condition that has not been described as specific enough to assign it to another 4th digit in same category.

v codes

Supplementary classification of factor influencing health status and contact with health services.

e codes

Supplementary classification of external causes of injury and poisoning.

index to diseases and injuries, table of drugs and chemicals, index to e codes

Three major sections of the alphabetic index (volume 2).

diseases, conditions, nouns, adjectives

Main terms in volume 2 index represent (4) _____.

anatomic site, cause, clinical type

Subterms in volume 2 index describe (3) _____.

hypertension, neoplasm

Which areas of disease in volume 2 are arranged in tables?

associated condition, present

For exclusion notes, codes under consideration cannot be assigned if the _______ specified in the exclusion note is _____.

elsewhere

Exclusion notes may indicate that a condition may have to be coded ____.

additional code, explain the condition

Exclusion notes may indicate that an ______ may be required to fully _____.

5th digit, additional coding instructions, definition of terms

ICD 9 Notes describe needed ______, provide ______, and provide _____.

underlying condition, manifestation

Mandatory multiple coding indicates the need for two codes. One for _____ and the other for _____.

underlying condition, manifestation

When multiple coding is needed, the first code is the _____ and the second code is the _____.

irrelevant information

Multiple codes should note be used to code ______.

once the cause is identified

Signs and symptoms that are characteristic of an illness are not coded _____.

not confirmed by physician

Conditions listed in diagnostic test reports should be avoided if _____.

sections

groups of three digit categories

categories

three digit code numbers

subcategories

four digit code numbers

subterms

Terms indented directly under main terms.

carryover lines

These are indented two standard indentations from level of preceding line and used only when the complete entry cannot fit on a single line

main term, subterm

Subterms preceded by "with" or "without" are not listed in alpha order but appear immediately below ____ or appropriate _____ entries.

inclusion

These notes list synonym or conditions similar enough to be classified to the same code.

exclusion

These notes indicate that a particular condition is not assigned to the code to which the note applies.

code first underlying condition

This identifies a code for a condition that is a manifestation of an underlying disease and that a specific condition must be sequenced first.

use additional code

Indicates that another code may be needed to complete the condition.

code any causal condition first

Indicate that if a causal condition were present, it would be sequenced before the code.

and

This term should be interpreted as "and" or "or".

due to

Indicates that a causal relationship between two conditions exists.

with

Indicates that both elements in the title must be present in the diagnostic or procedural statement. Do not indicate cause/effect relationship, but may occur together frequently.

index, tabular list

The condition or procedure to be coded must first be located in the _____ and the code provided must then be verified in the _____.

residual codes

NEC and NOS codes are also known as ____.

specific code

NOS code should never be assigned when a ______ is available.

combination code

A single code to classify either two diagnoses, or a diagnosis with a secondary condition.

multiple codes

When no combination code is provided, _____ should be assigned as needed to fully code condition.

dual classification

The required assignment of two codes to provide information about both a manifestation and underlying disease.

brackets

Mandatory multiple coding is identified in index by use of second code in ____.

use additional code, code first underlying condition

Dual coding is indicated by _____ or _____.

inpatient, outpatient

Probable or rule out conditions may be coded on _____ side but not _____ side.

HIV

Probable or rule out cases related to _____ may never be coded.

physician documentation

When it comes to HIV, confirm only cases confirmed by ______.

symptoms, signs, abnormalities

For patients seen in an outpatient setting, only ____, ____, and ______ may be reported to the highest degree of certainty.

personal consequences, unconfirmed diagnoses

Incorrect reporting of epilepsy, AIDS, and MS can have serious _______ and therefore caution should be used in coding _____.

possible, not possible

Rule out indicates that a diagnosis is considered ______. Ruled out indicates that a diagnosis is ______.

provider clarification

If the physician indicates a borderline condition, the coder should ask for _____.

abnormal findings

With a borderline condition, if the disease is not clarified by provider, code for _____.

both codes, indentation level, acute

If a condition is described as acute and chronic, _____ are assigned, if they are at the same ______, with the code for the ____ condition listed first.

acute

For acute and chronic conditions, if "acute" is following by "chronic" in parentheses, code only ____.

combination code

A _____ may be available for acute and chronic conditions.

impending or threatening condition

If an impending or threatening condition actually occurs, code _______.

impending, threatened, subterm, impending, threatened

If neither the threatened/impending condition nor a related condition occurred, the coder must answer whether: (1) the condition is indexed under ______ or _____; (2) and if there is a _____ for _____ or ____ under main term.

precursor condition, impending, threatened

When neither threatened or impending terms are indexed, ______ is coded. Code is not assigned for _____ or _____ condition.

late effect

A residual condition that remains after the termination of the acute phase of illness or injury.

residual condition, cause of late effect

Late effects require two codes: ____ and ___.

residual condition, cause of late effect

With late effects, _____ is sequenced first followed by ____.

e code

If a late effect is due to an injury, ____ is assigned.

cause of late effect

In the case of late effect, when the residual effect is not stated, ______ is used alone.

residual condition

In the case of late effect, when no late effect code is provided in ICD 9, but the condition is described as being a late effect, only _____ is coded.

history, complication of previous surgery

Conditions described as due to previous surgery are coded as ____ or _____ rather than late effects.

cause of late effect code

When the late effect code has been expanded at the fourth or fifth digit level to include the residual condition, only _____ code is assigned.

residual effects, current

The only time late effects are coded with a current illness is when a patient with _____ from earlier cerebrovascular disease is seen because of ______ cerebrovascular disease.

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