Understanding Health Insurance - week 6

Created by AnnamariePearson 

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ICD-9-CM Coding

Advance Beneficiary Notice (ABN)

acknowledges patient responsibility for payent if Medicare denies the claim

adverse effect, or adverse reaction

the appearance of a pathologic condition caused by ingestion of exposure to a chemical substance properly administered or taken

adverse reaction, or adverse effect

the appearance of a pathologic condition caused by ingestion of exposure to a chemical substance properly administered or taken

axis of classification

(organizing entities, diseases, and other conditions according to etiology, anatomy, or severity)

benign

not cancerous

carcinoma (Ca) IN SITU

a malignant tumor that is localized, circumscribed, encapsulated, and nonevasive (has not spread to deeper or adjacent tissues or organs)

Classification of Drugs by AHFS List

(found in Appendix C of ICDM-9-CM) contains the American Hospital Formulary Services List number and its ICD-9-CM equivalent code number, organized in numerical order according to AHFS List number

Classification of Industrial Accidents According to Agency

(found in Appendix D of ICD-9-CM) is based on employment injury statistics adopted by the Tenth International Conference of Labor Statisticians

coding conventions

rules that apply to the assignment of ICD-9-CM codes

comorbidity

...

complication

a condition that develops after outpatient care has been provided (e.g. ruptured sutures after office surgery)

congenital anomany

disorders diagnosed in infants at birth

contiguous site, or overlapping site

occur when the origin of the tumor involves two adjacent sites

diagnostic coding and report guidelines for outpatient services, hospital-based and physician office

...

E-codes

are located in Tabular List, describe external causes of injury, poisoning, or other adverse reactions affecting a patient's health

encoder

automates the coding process using computerized or web-based software; instead of manually looking up conditions (or procedures) in the coding manual index, the coder uses the software's search features to locate and verify diagnosis and procedure codes.

first-listed diagnosis

...

glossary of mental disorders

(previously found in Appendix B of ICD-9-CM) consisted of an alphabetic listing of terms and definitions based on those contained in ICD-9-CM and input from the American Psychiatric Association's Task Force on Nomenclature and Statistics

iatrogenic illness

results from medical intervention (e.g. adverse reaction to contrast material injected prior to a scan)

Index to Disease ICD-9-CM(
coding conventions,
code in slanted brackets,
eponym,
essential modifier,
main term

...

NEC (not elsewhere classifiable)

identifies codes to be assigned when information needed to assign a more specific code cannot be located in the ICD-9-CM coding book

nonessential modifier

subterms that are enclosed in parentheses following the main term. They clarify the code selection, but they do not have to be present in the provider's diagnostic statement

notes

are contained in boxes to define terms, clarify index entries, and list choices for additional digits

see also

refers the code to an index entry that may provide additional information to assign the code

see also condition

refers the coder directly to the Tabular List category (three-digit code) for code assignment

subterm

...

Index to Disease (Volume 2)

contains three sections
alphabetical index of diseases and injuries
table of drugs and chemicals, and
index to external causes of injury & poisoning (E codes)

Index to Procedures and Tabular List (ICD-9-CM), coding conventions
code also any synchronous
procedures
omit code

...

Index to Procedures and Tabular List (Volume 3)

is included in the hospitaql version of commercial ICD-9-CM books. A combined alphabetical index and numerical listing of all inpatient procedures

indexing

...

injury

traumatic wound or some other damage to an organ

late effect

a residual effect or sequela of a previous acute illness, injury, or surgery

lesion

any discontinuity of tissue (e.g. skin or organ) that may or may nnot be malignant.

List of Three-Digit Categories

(found in Appendix E of ICD-9-CM) contains a breakdown of three-digit category codes organized beneath section headings

malignant

cancerous

metastasize

secondary malignancies are metastic and indicate that a primary cancer has spread to another part of the body

metastatic

indicate that a primary cancer has spread

morphology

indicates the tissue type of a neoplasm

Morphology of Neoplasm (M codes)

Appendix A of ICd-9-CM; contains a reference to the World Health Organization publication entitled International Classification of Diseases for Oncology ICD-O

National Center for Health Statistics (NCS)

and CMS are U.S. Departments of Health and Human Services agencies responsibole for overseeing all changes and modifications to the ICD-9CM.

neoplasm

new growths, tumors, in which cell reproduction is out of control

outpatient

person treated in one of three settings, ambulatoryo surgery where the patient is released prior to a 24 hr. stay, health care providers office, hospital clinic, emergency department, outpatient department, same-day surgery unit (length of stay must be less than 23 hrs. 59 minutes and 59 seconds), and hospital observation where the patient's length of stay is 23 hrs, 59 min. and 59 seconds or less (unless documentation for additional observartion is medically justified)

overlapping site, or contiguous

occur when the origin of the tumor (primary site) involves two adjacent sites

perinatal condition

occurs before birth, during birth, or within the first 28 days of life

perinatal period

the first 28 days of life

poisoning

occur as a result of an overdose, wrong substance administered or taken, or intoxication

preadmission testing (PAT)

completed prior to an in-patient admission or outpatient surgery to facilitate the patient's treatment and reduce the length of stay

primary malignancy

the original tumor site

principal procedure

a procedure performed for definitive treatment rather than diagnostic purposes, or one performed to treat a complication, or one that is most closely related to the principal diagnosis

qualified diagnosis

a working diagnosis that is not yet proven or established

re-exision

occurs when the pathology report recommends that the surgeon perform a second excision to widen the margins of the original tumor site

secondary diagnosis

also called concurrent condition or comorbidity; coexists with the primary condition; has the potential to affect treatment of the primary condition, and is an active condition for which the patient is being treated

secondary malignancy

the tumor has metastasized (spread) to a secondary site, either adjacent to the primary site or to a remote region of the body

secondary procedure

additional procedures performed during the same encounter as the principal procedures

sequetae

late effects of injury or illness

Tabular list (ICD-9-CM) coding conventions
and


bold type

braces

brackets

category

code first underlying disease

colon

Excludes

format

fourth and fith digits

Includes

major topic heading

not otherwise specified (NOS)

parentheses

subcategory

subclassification

use additional code

with

When 2 disorders are separated by the word "and," it is interpreted as "and/or" and indicates that either of the 2 disorders is associated with the code number.

All category and subcategory codes and descriptions

Enclose a series of terms, each of which modifies the statement located to the right of the brace.
Encloses synonyms, alternate wording, or explanatory phrases

printed in bold upper and lowercase type and are preceded by a three-digit code

Tabular List (Volumne 1)

contains 17 chapters that classify diseases and injuries, two supplemental classifications, and five appendices

uncertain behavior

it is not possible to predict subsequent morphology or behavior from the submitted specimen. In order to assign a code fro the column, the pathology report must specifically indicate the "uncertain behavior" of the neoplasm

unspecified nature

a neoplasm is identified, but no further indication of the histology or nature of the tumor is reflected in the documented diagnosis. Assign a code from this column when the neoplasm was destroyed or removed and a tissue biopsy was performed and results are pending

V codes

are located in the Tabular List and are assigned for patient encounters when a circumstance other than a disease or injury is present

mortality

pertaining to death

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