Medical Coding 3

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ICD-9 CM coding conventions

are general rules used in the classification and they are independent of the coding guidelines. format, eponyms, abbrev, punct & symbols, boxed notes, tables, includes and excludes notes and inclusion terms, other, other specified, and unspecified codes, etiology and manifestations rules, and, due to, with, cross-references, including see, see also, see category and see condition

format

for ease in reference- indented 2 spaces, 2 and 4 spaces, additional text is printed on the next line and indented five spacesl

eponyms

diseases or syndromes that are named for people

abbreviations

save space- NEC- not elsewhere classifiable NOS- not otherwise specified

punctuation

slanted brackets, square brackets, parentheses, colons

manifestation

condition that occurs as a result of another condition and are always reported as secondary codes. slanted backets in the Index of Diseases.

synonyms, alternative wording or explanatory phrases

square brackets in Tabular List of Diseases and Tabular List of Procedures to enclose --- [COPD]

parentheses

used in both the ICD-9-CM indexes and tabular lists to enclose nonessential modifiers, which are supplementary words that may be present in or absent from the physician's statement or a disease or procedure without affecting the code number to which it is assigned.

colon

used after an incomplete term in the Tabular List of Diseases and Tabular List of Procedures when one or more additional terms (called modifiers) included after the colon are to be included in the diagnostic statement to classify a condition or procedure.

boxed notes

define terms, provide coding instruction, and list fifth-digit subclassifications for those categories that use the same fifth digits.-- found in certain main terms in the Index to Diseases.

ICD-9 diagnosis category codes

contain 3 digits and subcategory codes contain 4 digits

ICD-9 procedure codes

contain 2 digits and subcategory codes contain just 3 digits

tables- hypertension, neoplasm, drugs & chemicals

Index to Diseases in ICD-9-CM contain tables that organize subterms, 2nd qualifiers, and 3rd qualifiers and their codes in columns and rows to mak it easier to select the proper code.

includes notes

appers immediately below ICD-9-CM Tabular List of Diseases or Tabular List of Procedures codes to further define or provide examples.

excludes notes

appears below an ICD-9-CM Tabular List of Diseases or Tabular List of Procedures that are excluded from the code.

inclusion terms

are listed below certain 4 or 5 digit ICD-9_CM codes in the Tabular List of Diseases and the Tabular List of Procedures.

Trust the Index

concept that inclusion terms listed in the Tabular List of Diseases are not meant to be exhaustive and that additional terms found only in the Index to Diseases (but not in the Tabular List of Diseases) may also be assigned to a code.

other and other specified codes

are assigned when patient record documentation provides detail for which a specific code does not exist in ICD-9-CM

unspecified codes

are assigned because patient record documentation is insufficient to assign a more specific code.

etiology and manifestation rules

to classify certain conditions completely, codes must be assigned to the underlying etiology and multiple body system manifestations due to the underlying etiology.

use additonal code, code first underly disease

combination of codes exists, theTabular List of Diseases etiology contains a... note and the manifestation code contains a ...note.

in diseases classified elsewhere

indicates that the manifestation codes are a component of the etiology/manifestation coding convention.

code, if applicable, any causal condition first

requires the causal condition to be sequenced first if present.

and

appears in category titles and code descriptions int the Tabular List of Diseases and Tabular List of Procedures (and/or)

due to

located in the Index of Diseases as a subterm 9n alpha order and indicates the presence of a cause-and-effect or causal relationship between 2 conditions.

in

appears in the Index of Diseases located in alpha order below the main term.

with

appears in the Index of Diseases or Index to Procedures, located immediately below the main term, not in alpha order.

crosss-references

instruct the coder to refer to another entry in the index or to the tabular list to assign the correct code. see, see also, see category, see condition.

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