Understanding Health Insurance - week 6

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)
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
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
are located in Tabular List, describe external causes of injury, poisoning, or other adverse reactions affecting a patient's health
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,
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
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
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
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
traumatic wound or some other damage to an organ
late effect
a residual effect or sequela of a previous acute illness, injury, or surgery
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
secondary malignancies are metastic and indicate that a primary cancer has spread to another part of the body
indicate that a primary cancer has spread
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.
new growths, tumors, in which cell reproduction is out of control
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
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
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
late effects of injury or illness
Tabular list (ICD-9-CM) coding conventions

bold type




code first underlying disease




fourth and fith digits


major topic heading

not otherwise specified (NOS)




use additional code

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
pertaining to death