Insurance Handbook, Chapter 5

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Chapter 5, diagnostic Coding

adverse effect

An unfavorable , detrimental, or pathologic reaction to a drug that occurs when appropriate doses are given to humans for prophylaxis (prevention of disease), diagnosis, and therapy

benign tumor

An abnormal growth that does not have the properties of invasion and metastasis and is usually surrounded by a fibrous capsule, also called a neoplasm.

chief complaint (CC)

A patient's statement describing symptoms, problems, or conditions as the reason for seeking health care services from a physician.

combination code

A combination code is:
- a situation in which a single code is used to classify two diagnoses or
- a diagnosis with an associated secondary process (manifestation) or
- a diagnosis with an associated complication.

Identify a combination code by referring to subterm entries in the Alphabetic Index and by reading the inclusion and exclusion notes in the Tabular List. If the combination code does not specifically describe the manifestation or complications, then use a secondary code.

complication

A disease or condition arising during the course of, or as a result of, another disease modifying medical care requirements;

for DRGs, a condition that arises during the hospital stay that prolongs the length of stay by a least 1 day in approximately 75% of cases. Also known as substantial complication.

computer-assisted coding

Use of computer software that automatically generates a set of medical codes for review, validation, and use based on clinical documentation provided by health care.

conventions

Rules or principles for determining a diagnostic code when using diagnostic code books such as each space, typefaces, indentations, punctuation marks, instructional notes, abbreviations, cross-reference notes, and specific usage of the words "and", "with", and "due to".

These rules assist in the selection of correct codes for the diagnoses encountered.

E codes

A classification of ICD-9-CM coding used to describe environmental events, circumstances, and conditions as the external cause of injury, poisoning and other adverse effects. E-codes are also used in coding adverse reactions to medications.

aponym

a person after whom a place, people, disease, etc. is named

etiology

The cause of a disease; the study of the cause of a disease.

in sito

A description applied to a malignant growth confined to the site of origin without invasion of neighboring tissues.

International Classification of Diseases, 9th Revision, Clinical Modification

A diagnostic code book that uses a system for classifying diseases and operations to assist collection of uniform and comparable health information. A code system to replace this is ICD-10 which is being modified for use in the United States.

International Classification of Diseases, 10th Revision, Clinical Modification

Diagnostic code book that uses a system for classifying diseases and operations to assist collection of uniform and comparable health information. It has been modified, will be implemented on October 1, 2014, and will replace ICD-9-CM volumes 1 and 2 when submitting insurance claims for billing hospital and physician office medical services.

International Classification of Diseases, 10th Revision, Procedural Coding System

Procedural code system developed by 3M Health Information Systems (HIS) under contract with the Centers for Medicare and Medicaid Services (CMS).

When implemented on October 1, 2014, it will replace ICD-9-CM Volume 3 for hospital inpatient procedure reporting in the United States.

Intoxication

A diagnostic coding term that relates to an adverse effect rather than a poisoning when drugs such as digitalis, steroid agents, and so on are involved.

italiacized code

A diagnostic code in ICD-9-CM, volume 1, tabular List, that MAY NEVER BE SEQUENCED AS THE PRINCIPAL DIAGNOSIS.

late effect

An inactive residual effect or condition produced after the acute phase of an illness or injury has ended.

malignant tumor

An abnormal growth that has the properties of invasion and metastasis (e.g., transfer of diseases from one organ to another). The word carcinoma (CA) refers to a cancerous or malignant tumor

metastasis

Process in which tumor cells spread and transfer from one organ to another side.

neoplasm

benign or malignant tumor.

not elsewhere classificable

NEC, This term is used in the ICD-9-CM numeric code system when the code lacks the information necessary to code the term in a more specific category.

not otherwise specified

NOS Unspecified. Used in ICD-9-CM numeric code system for coding diagnoses.

physician's fee profile

A compilation of each physician's charges and the payments made to him or her over a given period of time for each specific professional service rendered to a patient.

poisoning

A condition resulting from an overdose of drugs or chemical substances or from the wrong drug or agent given, or taken in error.

primary diagnosis

Initial identification of the condition or chief complaint for which the patient is treated for outpatient medical care.

principal diagnosis

CONDITION RESPONSIBLE FOR HOSPITAL ADMISSION L-A condition established after study that is chiefly responsible for the admission of the patient to the hospital.

secondary diagnosis

SUBSEQUENT CONDITION THAT MAY CONTRIBUTE TO NEED FOR HIGHER LEVEL OF CARE BUT IS NOT THE UNDERLYING CAUSE.
A reason subsequent to the primary diagnosis for an office or hospital encounter that may contribute to the condition or define the need for a higher level of care but is not the underlying cause. There may be more than one secondary diagnosis.

*slanted brackets

Slanted brackets are used in Index to Diseases to identify "manifestation" codes.

A symbol used with a diagnostic code in ICD-9-CM Volume 2, Alphabetic index, INDICATING THE CODE MAY NEVER be sequenced as the PRINCIPAL DIAGNOSIS.

syndrome

Another name for a symptom complex (a set of complex signs, symptoms, or other manifestations resulting from a common cause or appearing in combination, presenting a distinct clinical picture of a disease or inherited abnormality).

V Codes

A subclassification of ICD-9-CM coding used to IDENTIFY HEALTH CARE ENCOUNTERS THAT OCCUR FOR REASONS OTHER THAN ILLNESS OR INJURY and to identify patients whose injury or illness is influenced by special circumstances or problems.

AHA

American Hospital Association

AHIMA

American Health Information Management

ASCVD

arteriosclerotic cardiovascular disease

ASHD

arteriosclerotic heart disease

CAC

computer-assisted coding

CC

chief complaint

CM

clinical modification

CPT

Current Procedural Terminology

DRG

diagnosis related group

DSM-IV

Diagnostic and statistical manual or mental disorders 4TH Edition

E codes

...

ICD-9-CM

International Classification of Diseases 9th Revision (Clinical Modification)

ICD-10-CM

International Classification of Diseases 10th Revision (Clinical Modification)

ICD-10-PCS

International Classification of Disease 10th Revision (Procedural Coding System)

IDDM (type 1 diabetes)

...

MRI

magnetic resonance imaging

NCHS

National Center for Health Standards.

NEC

Not elsewhere classifiable

NIDDM (type II diabetes)

?

NOS

Not otherwise specified

SNOMED

Systemized Nomenclature of Human and Veterinary Medicine

Two basic principles of diagnostic coding:

1. Diagnostic coding must be accurate because payment for inpatient services rendered to a patient may be based on the diagnosis.
2. In the outpatient setting, the diagnosis code must correspond to the treatment or services rendered to the patient or payment may be denied.

Oct. 2014

ICD-9-CM transition to ICD-10-CM

Proper coding can mean the financial success or failure of a medical practice.

- knowledge of current approved diagnostic coding guidelines,
- a working knowledge of medical terminology including familiarization of anatomy and physiology,
- clinical disease processes, and
- pharmacology is essential to becoming a top-notch coder of diagnoses.

Outpatient coding

payment for outpatient services is related to the procedure codes, but must be supported and justified by the diagnosis and and the medical necessity of the service or treatment provided

Inpatient coding

Payment for services is based on diagnostic coding

Assigning diagnostic codes

All documented diagnoses that affect the current status of the patient may be assigned a code, including condition that exist at the time of the patient's initial contact with physician, as well as conditions that develop subsequently, and affect the treatment received.

Sequencing of Diagnostic Codes

order of codes listed on insurance claim forms in order of diagnosis that most contributed to reason for visit?

primary diagnosis (first listed condition) used when submitted claims for outpatient or office visits
secondary diagnosis (may contribute to condition or define need for higher level of care

primary diagnosis

(first listed condition) main reason for the encounter, in an office setting, this is related to the chief complaint (CC)

chief complaint (CC)

main reason for visit

secondary diagnosis

listed subsequently, may contribute to the condition or define the need for a higher level of care but is not the underlying cause

etiology

underlying cause of a disease

principal diagnosis

used in inpatient hospital coding, is the diagnosis obtained after study that prompted the hospitalization. Possible to be same as primary and principal diagnosis codes to be the same.

number of diagnosis lines on electronic vs paper claims

MAC may accept and process up to a maximum of eight diagnoses on an electronic claim, while paper claims have only four lines for listing diagnosis code

Reason for the development and use of diagnostic codes:

1. tracking of disease processes
2. classification of causes of mortality
3. medical research
4. evaluation of hospital service utilization

Standard transaction code sets

HIPAA Compliance Alert

code set

any set of codes with their descriptions used to encode data elements such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes.
Each transaction mus tinclude the use of medical and other code sets.

ICD-9-CM

official guideline for coding and reporting is the standard code set outlined under HIAA and must be used when assigning diagnostic codes.

Insurance payers cannot reject an insurance claim because it includes a valid HIPAA standard code and that the payer system does not yet recognize.

True

Knowing diagnosis related procedures and exactly which diagnosis relates to the procedure being billed.

"This procedure or item is not payable for the diagnosis as reported for lack of medical necessity."

procedures that are diagnosis related

include most imaging services (radiography, computed tomography, or MRI), cardivascular services (e.g., electrocardiograms, Holter moniters, echocardiography, Doppler imaging, or stress testing), neurologic services (e.g. electroencephalography, noninvasive ultrasonography), many laboratory services, and Vitamin B12 injections,

Physician's Fee profile

compilation of each physician's charges and the payments made to him or her over a given period of time for each specific professional service rendered to a patient.

compiled physician data

fees charged, procedure and diagnostic codes maybe used in the future as the basis for the physician's fee profile.

Insurance billing specialist should code all diagnosis to the highest degree of specificity on a routine basis.

true

Two types of profiles:

1. individual customary profile
2. prevailing profile

History of coding diseases

1869 - AMA American Nomenclature of Diseases
1903 - Bellevue Hospital Nomenclaure of Diseases published
replaced by Standard Nomenclature of Diseases and Operations
1960 - AMA Current Medical Information and Terminology
SNOMED-CT systematized nomenclature of medicine for clinical terminology
1992 - WHO publishes ICD-10, it was clinically modified by the National Center for Health Statistics (NCHS) before code adoption.

mapping

process of linking content from one terminology or classification scheme to another

crosswalk

...

Computer-assisted coding (CAC)

computer software that automatically generates a set of medical codes for review, validation, and use based on clinical documentation provided by health care practitioners.

Factors for physicians adopting CAC

- shortage of coders throughout the US
- financial need to reduce the cost of filing insurance claims
- increased complexity of coding systems, such as implementation of ICD-10-CM by 2014
- adoption of electronic health records (EHR)
- advancement in natural language processing (NLP) technology
- constant changes in code numbers and coding rules and regulations
- compliance liability for increased erroneous claims

CAC uses two options:

1. structured input
2. NLP (natural language processing)

Structured input

physician inputs information on a data entry screen that has point-and-click fields, pull-down menus, structured templates, or macros. System prompts physician for detailed information, words and phrases selected are linked to diagnostic and procedure codes that are automatically generated when all the fields are completed. Input of the detailed information results in a completed documen twith the appropriate level of detail. Coder then checked and/or edits diagnosis and procedure codes

NLP system

National language process, uses artifical medical intelligence.

Physician dictates a report, hand writes a note, or inputs a picture file. The document is sent to an NLP engine that scans the health record and chooses important, relevant words and converts them into suggested codes.

A coder searches and validates the diagnostic and procedural codes and makes any changes, and the codes are transmitted to billing.

NLP system must be regularly updated to address new medical terminology and conform to changes in coding guidelines

TRUE

International Classification of Diseases

began in England during 17th century. US began using ICD to report causes of death and prepare mortality statistics at end of 19th century.

WHO

World Health Organization, the 9th revision of the ICD-9, published, is currently being used by state health departments and the U.S. Public Health Service (USPHS) for mortality reporting.

Organization and Form

ICD-9-CM published by US Dept of Health Services in 1979, updated annually and has three volumes.
Vol 1: Tabular List of Diseases, each having assigned number
Vol 2: Alphabetic Index of Diseases
Vol 3: Tabular List and Alphabetic Index of Procedures used primarily in hospital setting.

ICD-9-CM Volume 1 and 2

used in physicians' office and other outpatient settings to complete insurance claims,

ICD-9-CM published in 3 publications:

"coding clinic", published by AHA must be in place and in use by Oct. 1 each year.
no longer 3 month grace period to implement changes and revsions.

Diagnostic and Statistical Manual of Mental Disorders, Foruth Ediiton (DSM-IV)

psychiatric disorders

Appendices of ICD-9-CM

A. Morphology of Neoplasms
C. Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM Equivalents
D. Classification of Industrial Accidents According to Agency
E. List of three-digit categories

ICD-9-CM Volume 2

Section 1 Index to Diseases, alphabetic
Section 2 Table of Drugs and Chemicals
Section 3 Alphabetic Index to External Causes of Injuries and Poisoning (E Code)

ICD-9-CM Supplementary Classifications

Classification of Factors Influencing Health Status and Contact with Health Service - Codes V01-V89
Classification of External causes of Injury and Poisoning (Coes E000-E999)

ICD-9-CM Chapter Headings

1. Infections and Parasitic Diseases (001-139)
2. Neoplasms (140-239)
3. Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279)
4. Diseases of Blood and Blood-Forming Organs (280-289)
5. Mental Disorders (290-319)
6. Diseases of the Nervous System and Sense Organs (320-389)
7. Diseases of Circulatory System (390-459)
8. Diseases of the Respiratory System (460-519)
9. Diseases of the Digestive System ((520-579)
10. Diseases of the Genitourinary System (580-629)
11. Complications of Pregnancy, childbirth, and the Puerperium (630-677)
12. Diseases of the skin and subcutaneous Tissue (680-709)
13. Diseases of the Musculoskeletal System and Connective Tissue ((710-739)
14. Congenital anomalies (740-759)
15. Certain conditions originating in the perinatal period (760-779)
16. Symptoms, signs, and ill-defined conditions (780-799)
17. Injury and Poisoning (800-999)

Diagnostic code book conventions

rules or principles for determining a diagnostic code when using diagnostic code books such as each space, typefaces, indentations, punctuation marks, symbols, instrucdtional notes, abbreviations, cross-reference notes, and specific usuage of the words and , with and due to.

slanted brackets (//)

In Volume 2, the Alphabetic Index for disease classification, the symbol of SLANTED BRACKET (//) is USED TO INDICATE the NEED FOR ANOTHER CODE.

Italicized code

In Tabular List may never be sequenced as principal or primary diagnoses

General Coding Guidelines

Always use Volume 2, the Alphabetic Index, and second go to the Volume 1, the Tabular (numerical) List before assigning a code. Never use just one volume and never code from the index. Using a medical dictionary aids in coding

Organization and Format of Volume 2

- main terms are classifications of diseases and injuries and appear as headings in bold type.
- subterms are listing under main terms and are indented two spaces to the right under main terms
- modifiers (often referred to as nonessential modifiers because their presence or absence does not affect the code assigned) provide additional description and are enclosed in parentheses.
- carryover lines continue the text and are indented more than two spaces from the level of the preceding line
- subterms of subterms are additional listings and are indented two spaces to the right under the subterm

Fifth-digit codes can appear as follows:

see page 134

Official ICD-9-CM code book Conventions

see page 135 - 136

*Non-essential modifiers

Parenthesis are used to enclosed non-essential modifiers.

NON-ESSENTIAL MODIFIERS: supplementary words that may be present in or absent from the physician's statement of a disease or procedure without affecting the code number to which it is assigned.

*from 3-2-1- code It!

Fourth and fifth digits (tabular list)

...

Handy Hints in Diagnostic Coding

1. always code the underlying disease first
refer to the end of this chapter for trhe step-by-step procedures for locating and selecting diagnostic codes

time saver suggestions

Keep list of commonly encountered CPT procedure codes, making sure to include fourth and fith digit specificity.

consult payer guidelines by calling insurance co. or managed care plan to determin whether certain procedures are a covered benefit for certain diagnoses and if not; have the patient sign a waiver.

reference books that show codes that lilnk between diagnostic and procedure codes are available

AMA publishes a list of most common diagnostic codes at end of their mini specialty code books

update on regular basis
Jan. 1 for procedure codes
April and Oct for diagnostic codes

V Codes - Supplemntary classification of factors influencing health status and contact with heatlh serviceds

supplementary classification of coding located in a separate section at the end of Volume 1, tabular list
Volume 2, Alphabetic index, V-does are included in mjaor sedtion Index of Dises

V Codes consist of 4 primary circumstances

1. person who is not current sick encouters health services for some specific purpose
2. when a person with a resolving disease or injury, such as a chronic, long-term condition that needs continous care, seeks aftercare.
3. when a circumstance influences an individual's health status, but the illness is not current.
4. When it is necessary to indicate the birth status of a newborn.

V code indicators key words

exposure, routine annual examination, admission, history of, encounter, and vaccination

Rejections by 3-party payer

A good health diagnosis code will trigger a rejection by the 3rd party payer unless it is mandated by the insurance company.

admission (encounter)

see pg

health patient examination

V codes V70-V70.9 should be sequenced as primary diagnosies over all other diagnoses.

Post operative medical examination as an inpatient or outpatient negative for chronic or current illness

Good health diagnosis will be rejected. Use an admission (encounter) code from the V72.X code series for "other specified examination" instead of a treatmen tcode. The term "admission (encounter)" is equivalent to encounter for an ddoes not refer to an admission to the hospital.

V codes to Medicare for healthy patient exams

medicare will automatically reject the claim, as well as insurance company that adopts Medicare guidelines as well.

E codes - Index to External Causes of Injury and Poisoning

you look for external causes of injury rather than disease. Code description refers to the circumstances that caused an injury rather than the nature of the injury.

E codes used to code adverse reactions to medications

True, see page 139

Adverse effects, poisoning, intoxification

page 140
The following situations occur and are documented in the medical record to indicate poisoning:
- Taking the wrong medicine.
- Receiving the wrong medication.
- Taking the wrong dose of the right medication.
- Receiving the wrong dose of the right medication
- Ingesting a chemical substance not intended for human
consumption
- Overdose of a chemical substance (drug)
- Prescription drug taken with alcohol
- Mixing prescription drugs and over-the-counter medications without the physician's advice or consent.

Rules for coding

see page 141

Signs, symptoms and ill-defined condtions, Chapter 16 of ICD-9-CM

1. use Chapter 16 codes when following key words in diagnosis: apparent, likely, might, possible, probable, probably, questionable, rule out, suspected or suspicious of.

*DO NOT CODE THESE CONDITIONS AS IF THEY EXISTED OR WERE ESTABLISHED. INSTEAD, DOCUMENT THE CONDITION TO THE HIGHEST DEGREE OF CERTAINTY FOR EACH ENCOUNTER OR VISIT (e.g. signs, symptoms, abnormal test results, or other reason for the visit) and code the chief complaint, sign, or symptom.

* contrary to hospital health information management dept. for coding dx of hospital inpatients.

Instances in which signs and symptoms codes can be used:

1. no precise dx can be made (ex. 5-9 and 5-10)
2. signs or symptoms are transient, and a specific dx was not made (ex. 5-11)
3. provisional dx for a patient who does not return for further care (ex. 5-12)
4. A patient is referred for treatment before a definite dx is made (ex. 5-13)

Sterilization (elective) for contraception

when major purpose of contraception, rather than incidental result of the treatment of a disease.
single code for dx. V25.2

if performed during a current admission for obstetric delivery, sequence code V25.2 in second position

If sterililzation is the end result of a hysterectomy due to injury or damage to uterus during delivery, do not use V25.2, instead code condition or procedure and dx that precipitated the hysterectomy

NEOPLASMS

spontaneous new growth of tissue forming an abnormal mass also known as a tumor.

Coding for neoplasms

columns as follows in "neoplasms" Vol. 2 (see 5-3)
malignant primary
malignant secondary
malignant CA in situ
benign
uncertain behavior
unspecified

neoplasm code numbers usually based on descripton of the neoplasm

coded by anatomic site,and for each site there are 6 possible code numbers (see table 5-3)

if dx does not mention metastasis, then code the case as primary neoplasm

lymphomas / leukemias not classified using primary and secondary terminology

When coding a neoplasm:

1. what is it now?
2. Where did it start?
3. What happened to it?

primary malignancy

the original neoplastic (malignant) site

secondary neoplasm or malignancy

site or location to which the oroginal malignancy has spread or mestastasized

"metastatic from"

indicates primary stage carcinoma

"metastatic to"

indicates secondary stage carcinoma

"Malignant neoplasm spread to"

code it as primary site spread to the secondary site

"recurring malignancy"

new and coded as primary neoplasm

Anatomic sites marked with asterisk*

always considered to be neoplasms of the skin

M Codes (Morphology of Neoplasms)

Appendix A of Tabular List of Neoplasms, NOT USED FOR BILLING INSURANCE CLAIMS BY PHYSICIANS' OFFICES

Circulatory System Conditions difficult to code because of variety and lack of specific terminology used in physician dx.

carefully read all inclusion, exclusion, and "use additional code" notations contained in the Tabular List of Volume I.

Hypertension

high blood pressure

malignant hypertension

condition of very high blood pressure with poor prognosis, malignant means life threatening in this instance

benign hypertension

high blood pressure runs a relatively long and symptomless course.

402.0X - 402.9X

dx statement indicates a cause by stating heart condition due to hypertension or hyeprtensive heart disease

dx statement reads "with hypertension" or "cardiomegaly and hypertension"

need two separate codes

myocardial infarctions (412 / 410 / 414 codes)

separate 3-digit category provided:
- old myocardial infarction
- healed myocardial infarction
- myocardial infarction dx on EEC

myocardial infarction of 8 weeks' duration or less, considered acute, if not specified otherwise

coded 410.xx

myocardial infarction of more than 8 weeks' duration

coded 414.8, other forms of chronic ischemic heart disease

Chronic rheumatic heart disease

some conditions are presumed to be caused by rheumatic fever:
- mitral valve of unspecified etiology 394.9
- mitral valve insufficiency 394.1
- mitral valve and aortic valve disorders of unspecified etiology 396.6
- mitral stenosis 394.0

arteriosclerotic cardiovascular disease (ASCVD)

429.2

440.9 excludes ASCVD because it isn conflict with the note give in 429.2,429.2 is primary when the additional code 440.9 is necessary

arteriosclerotic heart disase (ASHD)

means acute and chronic heart diseability resulting from an insufficient supply of oxygenated blood to the heart

414.0X
(in your Vol 1 copy, write in at 429.2, "see code 440" after "use additional code to identify, if desired the presence of arteriosclerosis"

DIABETES MELLITUS, Type I

patient's pancreas does not function and produce necessary insulin, patient is insulin dependent.

Diabetes Mellitus, Type II

patient's pancreas produces some insulin, but insulin ineffective in removing sugar from bloodstream, contolled with diet, oral medication, or insulin

coding diabetes

always requires five digits because of types and complications that may accompany this disease.
If code is not documented, select code for type II

Do not assume patient is insulin dependent when coding.
if dx unclear, ask physician to clarify:
example: routine taking insulin "V58.67 which is different than coding for temporary use of insulin to control blood sugar.

996.7 if underdose because of pump failure and secondary code of 962.3

Complications related to diabetes, (see pg. 144)

250.50, diabetes with opthalmic manifestions
366.41 cataract related to diabetes
do not use 250.0X if complication of pregnancy, use code 648.01

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