Step by Step ch. 10: Using ICD-9-CM
Terms in this set (21)
American Hospital Association
American Health Information Management Association
Centers for Medicare and Medicaid Services
National Center for Health Statistics
Section 1 of the Official Guidelines for Coding and Reporting
-structure of conventions
Section 2 of the Official Guidelines for Coding and Reporting
selection of principal diagnosis for non-outpatient (hospital) settings
Section 3 of the Official Guidelines for Coding and Reporting
reporting additional diagnoses in non-outpatient settings
Section 4 of the Official Guidelines for Coding and Reporting
for outpatient coding and reporting
Appendix 1 of the Official Guidelines for Coding and Reporting
includes Present on Admission Reporting Guidelines
8 steps to accurate coding
1) Identify the main terms
2) Locate the main term in the Alphabetical Index
3) Review any sub terms
4) Follow any cross-reference instructions
5) Verify codes in the Tabular
6) Refer to any instructional notations in the Tabular
7) Assign codes to the highest level of specificity
8) Code until all the elements have been identified
Should signs and symptoms receive an additional code if they are routinely associated with the coded disease?
Should signs and symptoms receive an additional code if they are not routinely associated with the coded disease?
"Use additional code"
found in the Tabular that are not part of the etiology/manifestation where a secondary code is useful to fully describe a condition
under certain code not specifically manifestation codes but may be due to an underlying cause
If the same condition is described as both acute and chronic, with separate subentries, which is sequenced first?
a single code used to classify:
-a diagnosis with an associated secondary process (manifestation)
-a diagnosis with an associated complication
Late effects codes
You report late effects codes when the acute phase of an illness or injury has passed but a residual remains.
An example is when scars (residual) remain after the burn (cause)
Is residual or late effects coded first
Where are late effects codes found?
In the index under the term "Late"
"impending" or "threatened"
-If it did occur, code as diagnosis
-if it did not occur, reference the Index for a subentry for "impending" or "threatened"