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Medical Assisting ch.18 Diagnostic Coding

Terms in this set (49)

- Locate the patient's diagnosis. This information may be found on the superbill (encounter form) or elsewhere in the patient's chart. If it is on the superbill, verify documentation in the medical chart.
- Locate the patient's diagnosis. This information may be found on the superbill (encounter form) or elsewhere in the patient's chart. If it is on the superbill, verify documentation in the medical chart.
- After coding the diagnosis of the condition requiring treatment, open the ICD-9 manual to the External Cause Alphabetic Index or, if necessary, use the Table of Drugs and Chemicals. Find the appropriate description in the ICD-9's Alphabetic Index, looking for the condition first, and then locate any indented subterms that make the condition more specific. Read all cross-references.
- Locate the code from the Alphabetic Index in the E code area of the ICD-9's Tabular List.
- Read all descriptive information to find the code that corresponds to how the patient's current condition came about. Choose the most specific code available. Check for the symbol that shows that a fourth and (possibly) a fifth digit are required; many E codes require these.
- Carefully record the diagnosis code(s) on the insurance claim and proofread the numbers.
- E codes are always secondary, so be sure that the primary diagnosis code is listed first. Check for instructions stating an additional code(s) is needed. If more than one code is needed, be sure instructions are followed and the codes are listed in the correct order