Chapter 12 - Diagnostic Coding
Terms in this set (40)
International Classifications of Disease, Ninth Revision, CM
Assigning numbers to a verbal statement or description.
WHAT ARE THE THREE VOLUMES?
Volume 1 - Tabular list of Diseases
Volume 2 - Alphabetic Index of Diseases
Volume 3 - Tabular list and Alphabetic Index of Procedures
Vol 1 & Vol 2 are used in physician offices for diagnosis; Vol 3 is used in hospitals for procedures - NOT for physicians
VOLUME 2: ALPHABETIC INDEX OF DISEASE
Usually found in the front of the book; List the main terms (in boldface type)
Called essential modifiers
May follow main term, and affect the selection of the code; indented under the main term and listed in alphabetical order
VOL 1 - SUPPLEMENTAL CLASSIFICATIONS
V-CODES - V01 TO V89.09
Explain the reason for the visit, when the patient is not currently III (Ex. Immunizations, History of Illness, Live born infants)
Main terms: Examination; Admission (Encounter) for; Aftercare; Therapy; Observation test; Screening (for) Care (of); Problem with
V-codes also show problems or situations that influence a patient's health status but are not a current illness or injury
E CODES - E800 TO E999
Classify external causes of injury or poisoning (Ex. Bicycle accident, fell off a ladder, injured at the park)
Category codes are used only if there are no decimal digits listed in that category.
Sub-category codes are used only if 5th subclassifications are provided
Highest level of specificity; it's also known as sub-classification for more specifics
Rules applied to assigning ICD-9-CM codes; found in Vol 1 and Vol 2; listed in the front of the ICD-9 with definitions
Procedures or services performed for appropriate reasons
ABN (ADVANCE BENEFICIARY NOTICE)
Signed by the patient in advance of receiving services because Medicare will not pay for the services
Sign or symptom of the disease
Cause or origins of the disease
Presence of illness or disease
Deaths that occur from a disease
Disease, procedure, or syndrome named after the individual who discovered it
Term for high blood pressure
Determination of the nature of cause of disease, or the art of distinguish one disease from another.
A single code is used to describe conditions that frequently occur together.
First of several pages of the ICD-9 manual
Transformation of verbal descriptions of a diagnosis into numbers or a combination of alphanumeric characters.
Terms in parentheses, following the main terms
SIGN OR SYMPTOMS
Patient's condition had not been specifically diagnosed, the health insurance must code
Codes in the tabular list (Vol 1) are arranged:
Under HIPAA, any set of codes used for encoding data elements, such as tables of terms, medical concepts, medical diagnosis codes, or medical procedure codes
Use of ICD-9 began in the United States when the U.S. National Center for Health Services (NCHS) modified the system.
V codes can never be used alone on the CMS-1500 claim form
V codes are used when circumstances other than a disease or injury are recorded as diagnosis or problem
Anatomic sites are often listed as main terms in ICD-CM
LARGEST SECTION IN VOL. 2, THE INDEX TO DISEASES IS ORGANIZED
Alphabetically by main term
A diagnosis should never be coded from the Alphabetic list alone
See or see also tells the coder to continue the search under another main term
You can show only one diagnosis code in Block 23 on the CMS 1500 claim form.
A colon is used in the tabular list after an incomplete term that needs one or more modifiers to make it a complete statement
The abbreviation NOS is the equivalent of 'unspecified'
If the healthcare provider inadvertently omits a diagnosis in the patient's chart health record, an experienced health insurance professional may abstract the correct diagnosis for coding purposes without consulting the physician
An alphabetic filing of diagnosis is contained