Used to report diagnosis, diseases, conditions on the CMS-1500 by physicians.
Tabular list of diseases: contains the disease and condition codes and the descriptions also contains the V codes and E codes
Alphabetic Index of Diseases: this is a alphabetic index of Volume I
What are Volume I & II used for?
Used for inpatient and outpatient settings.
Tabular list and Alphabetic index of Procedures: contains codes for surgical, therapeutic, and diagnostic procedures used primarily by hospitals.
Supplementary Classification of Codes describing factors influencing health status ( family history, birth status ) and contact with health services for other than illness, injury (vaccinations, organ donor, dialysis).
Supplememtary Classification of codes describing reason or external causes fo injury, poisoning and other adverse effects. Found in volume I and II. These codes capture how the injury or poisioning happened, the intent and the place.
VOLULME I TABULAR LIST
Consists of 17 chapters based on either body system or cause or type of disease. Codes range from 001-999
The main division of volume I divided into sections; endocrine,Nutritional, Immunity disorders.
are composed of a group of three-digit codes representing a group of conditions or related conditions.
are composed of three digit codes representing a single disease or condition.
provide a four digit code (one digit after the decimal point) which is more specific than caregory code(3-digit)in terms of cause, site,or manifistation of the condition.
provides a five-digit code which gives the highest specificity of description to a condition.
VOLUME II ALPHABETIC INDEX
contains three sections:
Section 1; Index to diseases
Section 2: Table of Drugs and Chemicals
Section 3: Index to External causes (E codes)
VOLUME II TABLES
Hypertension table: contains a list of conditions that are due to or associated with hypertension.
Neoplasm Table: organized by anatomic site, has six columns for six possible codes malignant, benign, uncertain behavior, in situ, secondary, unspecified nature.
LEVELS OF DETAIL IN CODING
A category code is used only if it is not further subdivided. Where subcategory and subclassification codes are provided , their assignment is mandatory. A code is invalid if it has not been coded to the level of specificity required for that code.
SEQUENCING THE DIAGNOSIS
The diagnosis, condition, or other reason for the encounter shown in the medical record to be chiefly responsible for the services provided is listed first. Coexisting condition that were treated or medically managed or influenced the treatment are listed as additional codes. Conditions that previously treated and no longer exit are not coded. Personal or family history impact current care are assigned a secondary code.