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28 terms

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.