International Classificatio of Diseases 9th Revision Clinical Modification
What is ICD-9 designed for?
The morbidity and mortality information, for statistical purposes and for data storage and retrieval
What are codes used to do....
Faciliate payment for medical services, Research the quality of healthcare facilities Study healthcare cost, Predict healsthcare trends and plan for future healthcare needs
to how many codes should each condition be coded?
To one as much as possible to ensure the validity and reliability of data
Is ICD-9 training vital to a coder?
yeas, to learn the tranforming of verbal or narrative description of diseases injuries conditions and procedures in to numeric designation.
What is volume 2?
The alphabetical Index for volume 1
Where and for what are volume 1 and 2 used for?
used in inpationt and outpatient settings to sbstantiate the reason for receiving medical services.
Volume 3 is used for what and where?
It is mainly used in Hospitals to code surgical therapudical and diognastic procedures....
Name the titles of the volumes....
Volume 1: Tabular List Volume 2: Diseases; Alphabetical Index Volume 3; Procedures, Tabular Lisat and Alphabetical Index, (for hospital use)
Is it ok to code from the Tabular only?
Never code from the tabular only, always double check for the code in the numerical index
What are the 2 divisions volume 1?
Classification of Diseases and Injury, Supplementary classifications
What is th Main part of ICD-9?
Classification of Disease
Define CHAPTER! *****
a main division in ICD-9
Define SECTION ****
a group of 3 digit categories that represents a group of conditions or related conditions
Define CATEGORY ****
a 3 digit category that represents a single condition or disease
Define SUBCATEGORY ****
it is a one digit after the decimal poin. a 4 digit code provides more info or specificity as compared to the 3 digit code in terms of the cause, site or menifestation of the condition
Do we always have to assign a 4th digit?
If available yes, and we must always code to the highest level of specifity based on the documentation in the mdical record
2 digits after the decimal point. A 5 digit code that adds even more specifity to a conditions description . Must assaign when available.
Do all codes have a 4th or 5th digit?***
No, but must be used when ever available
How many Appendices are in volume 1?**
it contains 5 appendices
Name the 5 appendices in volume 1....***
Morphology of Neoplasm, Glossory if mental disorder (Dleted in 2004) Classification of drugs by American Hospital Formulary Services, Industrial Accidents, and List of all 3 digit categories in th ICD-9 by chapter
Wat is BOLD print? ****
Main terms are identified by bold print and are flush with the left margin of each column
What are ESSENTIAL MODIFIERS?***
subterms under main terms are indented to the right begin with lower case letter and not bolded.
symbols , abbreviations, punctuations and notations.
Define CONNECTING WORDS.*****
relationship between the mainterm and subterm and an associated condition of etiology
Define NEC ****.
Not Elswhere Classified.....Used in Alphabetic Index and Tabular List
Not Otherwise Specified...used when info on hand does not permit a more specific code assignment
Brackets are ? ***
enclose synonyms, alternative wording or explanatory phrases and are found in the tabular list
Slanted Brackets are? *****
enclose the manifestation of the underlying condition......found in Alphabetic Index
Parentheses are ? ****
enclose supplementary words in on essential modofiers that may be present or absent in the statement of a disease or procedure without affecting code assignment
lokated in the tabular list after an incomplete term that needs one or more modifiers that follow in order to make the condition assignable to a given category
used in some publications to enclose a series of terms each of which is modified by the statement appearing at the right of the brace
they define or provide examples and may apply to the chapter, section or category
indicate terms that are to be coded elswhere
"AND" Means ...****
2 conditions are included in the code and both conditions must be present to report the code
explicite direction to look elswhere
"SEE ALSO" means.....****
directs the coder to reference another main term if all info being searched for cannot be located under the first main term entry
When do we use an additional code?****
it is mandatory when supporting physician documentation is lokated in the p/t record
Code FIrst Underlyin Disease.......****
not intended to indicate principal diagnosis
"Code is applicable, Any casual Condition"****
if no casual condition is present or documented then the code may be sequenced first
disease procedure or syndrome named for a person listed as main term in the Index under the main terms "Disease" or "Syndrome"
"Numbers" are ..........****
Arevic, Roman or Ordinal numbers that come before letters
as by and with immidiatly follow the main term to which they refer
main term may be followed by a series of terms in parentheses, presenc or absence of these parenthetic terms in the procedure description has no effect on the selection of the code listed for the main term
See, See also , See category.....
Cross reference words
combonation codes are
single 4 or 5 digit codes
3 types of hypertntion are........
malignant, benign and unspecified
type of Neoplasms are....
adnome, epethial, basal cell, papillory
certain terms are followed by notes that are used to define terms and give coding instructions
cannot be assigned as first listed diagnosis because they always follow another code