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117 terms

ICD 9 Coding: Basic Guidelines and Characteristics of Coding

International Classification of Diseases 9th Revision Clinical Modification
What does ICD 9 CM stand for?
United States
The CM in ICD 9 means it can only be used in _____.
ICD 10 CM is used for
ICD 10 PCS is used for
National Center for Health Statistics
Who is responsible for maintaining volumes 1 & 2 of ICD 9?
Who is responsible for maintaining volume 3 of ICD 9?
tabular list of diseases and injuries
What does volume 1 contain?
index of disease and injuries
What does volume 2 contain?
index and tabular list of procedures
What does volume 3 contain?
classification of diseases and injuries, supplementary classifications, appendices
What are the subdivisions of volume 1?
Used in both exclusion/inclusion notes to indicate that one of the modifiers from the list below must be present in order for statement to apply.
slanted brackets
This is used in volume 2 to enclose a code number that must be used with the code preceding it.
Typeface that is used for all codes and titles in volume 1.
This is used when documentation indicates a specific condition but there is no separate code for the condition.
This encloses a series of terms that are modified by the statement to the right or left.
This encloses synonyms, alternative words, abbreviations or explanatory phrases.
This is used when the diagnostic statement and medical record does not provide specific information that would permit classification to a specific code.
Typeface used for all exclusion notes.
squiggly mark
This indicates a footnote or instructional note.
This further defines or provides examples of a category or section.
This encloses supplementary words and does not affect the code.
This indicates conditions that are to be coded/listed elsewhere.
These are indented under main term and affects code selection
nonessential modifiers
Terms in parentheses that are nonessential
Mandatory instruction, indicates that the coder must refer to alternative term.
Follows terms to define and give further instructions.
Means unspecified
see also
Directs coder to look under another term if all information is not found under the first term
see category
Directs coder to consult specific category in volume 1.
Disease/syndrome named for a person.
Means "other"
chapter, section, category, subcategory, subclassfication
List the order in which codes are organized.
v codes, e codes
What are the two supplementary classifications to the ICD 9 system?
main terms
Terms listed in the alphabetic index in boldface type all the way to the left are known as
april 1, october 1
New ICD 9 codes can go into effect on which dates?
documentation, specific condition
Codes containing the abbreviation NOS are to be used when _____ doesn't provide enough information to point you to a ______
October 1, 2014
What is the scheduled date for implementation of ICD 10 in the U.S.?
ancient Greece
Notion of classification originated at the time of
London Bills of Mortality
This was the first documentation of the proportion of children who died before age six.
Which organization assumed responsibility for revising ICD every 10 years?
more specific, more codes, alphanumeric, up to 7 characters
What 4 changes were made with ICD 10?
Final Rule of the HIPAA Administrative Simplification Modifications
Implementation of ICD 10 was established in the
What are the five medical code sets under HIPAA?
Medicare Prescription Drug Improvement and Modernization Act
Which act included the possibility that code changes could occur twice a year?
The ICD 9 coordination and maintenance committee is composed of representatives from
All ICD 9 coding book must be updated
All coding software must be updated
October 1
New ICD 9 codes are effective
Number of chapters for ICD 9 Diseases and Injuries
These have 4 digits and provide more specificity of information regarding etiology, site, and manifestations.
chapter, section, category, subcategory
5 digit assignments and instructions appear at the beginning of a ______, _____, _____, or _____.
highest level of specificity
You must code to the ______.
subcategory, subclassification
3 digit codes are only used when there is no ______ or ______.
.8 codes are equivalent to
unspecified, other and unspecified
.9 codes are equivalent to _____ or _____.
This is a type of specific condition that is not otherwise classified to preceding fourth digits in same category.
This describes a condition that has not been described as specific enough to assign it to another 4th digit in same category.
v codes
Supplementary classification of factor influencing health status and contact with health services.
e codes
Supplementary classification of external causes of injury and poisoning.
index to diseases and injuries, table of drugs and chemicals, index to e codes
Three major sections of the alphabetic index (volume 2).
diseases, conditions, nouns, adjectives
Main terms in volume 2 index represent (4) _____.
anatomic site, cause, clinical type
Subterms in volume 2 index describe (3) _____.
hypertension, neoplasm
Which areas of disease in volume 2 are arranged in tables?
associated condition, present
For exclusion notes, codes under consideration cannot be assigned if the _______ specified in the exclusion note is _____.
Exclusion notes may indicate that a condition may have to be coded ____.
additional code, explain the condition
Exclusion notes may indicate that an ______ may be required to fully _____.
5th digit, additional coding instructions, definition of terms
ICD 9 Notes describe needed ______, provide ______, and provide _____.
underlying condition, manifestation
Mandatory multiple coding indicates the need for two codes. One for _____ and the other for _____.
underlying condition, manifestation
When multiple coding is needed, the first code is the _____ and the second code is the _____.
irrelevant information
Multiple codes should note be used to code ______.
once the cause is identified
Signs and symptoms that are characteristic of an illness are not coded _____.
not confirmed by physician
Conditions listed in diagnostic test reports should be avoided if _____.
groups of three digit categories
three digit code numbers
four digit code numbers
Terms indented directly under main terms.
carryover lines
These are indented two standard indentations from level of preceding line and used only when the complete entry cannot fit on a single line
main term, subterm
Subterms preceded by "with" or "without" are not listed in alpha order but appear immediately below ____ or appropriate _____ entries.
These notes list synonym or conditions similar enough to be classified to the same code.
These notes indicate that a particular condition is not assigned to the code to which the note applies.
code first underlying condition
This identifies a code for a condition that is a manifestation of an underlying disease and that a specific condition must be sequenced first.
use additional code
Indicates that another code may be needed to complete the condition.
code any causal condition first
Indicate that if a causal condition were present, it would be sequenced before the code.
This term should be interpreted as "and" or "or".
due to
Indicates that a causal relationship between two conditions exists.
Indicates that both elements in the title must be present in the diagnostic or procedural statement. Do not indicate cause/effect relationship, but may occur together frequently.
index, tabular list
The condition or procedure to be coded must first be located in the _____ and the code provided must then be verified in the _____.
residual codes
NEC and NOS codes are also known as ____.
specific code
NOS code should never be assigned when a ______ is available.
combination code
A single code to classify either two diagnoses, or a diagnosis with a secondary condition.
multiple codes
When no combination code is provided, _____ should be assigned as needed to fully code condition.
dual classification
The required assignment of two codes to provide information about both a manifestation and underlying disease.
Mandatory multiple coding is identified in index by use of second code in ____.
use additional code, code first underlying condition
Dual coding is indicated by _____ or _____.
inpatient, outpatient
Probable or rule out conditions may be coded on _____ side but not _____ side.
Probable or rule out cases related to _____ may never be coded.
physician documentation
When it comes to HIV, confirm only cases confirmed by ______.
symptoms, signs, abnormalities
For patients seen in an outpatient setting, only ____, ____, and ______ may be reported to the highest degree of certainty.
personal consequences, unconfirmed diagnoses
Incorrect reporting of epilepsy, AIDS, and MS can have serious _______ and therefore caution should be used in coding _____.
possible, not possible
Rule out indicates that a diagnosis is considered ______. Ruled out indicates that a diagnosis is ______.
provider clarification
If the physician indicates a borderline condition, the coder should ask for _____.
abnormal findings
With a borderline condition, if the disease is not clarified by provider, code for _____.
both codes, indentation level, acute
If a condition is described as acute and chronic, _____ are assigned, if they are at the same ______, with the code for the ____ condition listed first.
For acute and chronic conditions, if "acute" is following by "chronic" in parentheses, code only ____.
combination code
A _____ may be available for acute and chronic conditions.
impending or threatening condition
If an impending or threatening condition actually occurs, code _______.
impending, threatened, subterm, impending, threatened
If neither the threatened/impending condition nor a related condition occurred, the coder must answer whether: (1) the condition is indexed under ______ or _____; (2) and if there is a _____ for _____ or ____ under main term.
precursor condition, impending, threatened
When neither threatened or impending terms are indexed, ______ is coded. Code is not assigned for _____ or _____ condition.
late effect
A residual condition that remains after the termination of the acute phase of illness or injury.
residual condition, cause of late effect
Late effects require two codes: ____ and ___.
residual condition, cause of late effect
With late effects, _____ is sequenced first followed by ____.
e code
If a late effect is due to an injury, ____ is assigned.
cause of late effect
In the case of late effect, when the residual effect is not stated, ______ is used alone.
residual condition
In the case of late effect, when no late effect code is provided in ICD 9, but the condition is described as being a late effect, only _____ is coded.
history, complication of previous surgery
Conditions described as due to previous surgery are coded as ____ or _____ rather than late effects.
cause of late effect code
When the late effect code has been expanded at the fourth or fifth digit level to include the residual condition, only _____ code is assigned.
residual effects, current
The only time late effects are coded with a current illness is when a patient with _____ from earlier cerebrovascular disease is seen because of ______ cerebrovascular disease.