Coding with. Snayhil Rana

Transcription

1 Coding with ICD-9-CM CM Snayhil Rana

2 ICD-9-CM CM Index Pre-Test Introduction to ICD-9-CM Coding The Three Volumes of the ICD-9-CM ICD-9-CM Coding Conventions Other ICD-9-CM Sections ICD-9-CM for Claim generation Difficult Diagnosis Coding Situations

3 ICD-9-CM CM Introduction to ICD-9-CM Coding, explores the definition of and uses of diagnosis coding. The Three Volumes of the ICD-9-CM : explains the components and characteristics of the ICD-9-CM volumes. ICD-9-CM Coding Conventions : explains the terminology used in the ICD-9-CM manual. Other ICD-9-CM Sections : describes other sections of the ICD-9-CM. ICD-9-CM for Claim generation : explains how ICD-9- CM codes are used on claim forms. Difficult Diagnosis Coding Situations, reviews why certain conditions are more difficult to code.

4 Pre-Assessment Adobe Acrobat Document

5 ICD-9-CM CM Introduction to ICD-9-CM CM Coding

6 Introduction to ICD-9-CM Coding After completing this lesson, you should be able to: Identify the definition and uses of diagnosis coding. Identify CMS coding guidelines. Identify coding tips for inpatient, outpatient, and other specific coding situations.

7 Introduction to ICD-9-CM Coding Description of Diagnosis Coding Proper diagnosis coding involves using the ICD-9-CM volumes to identify the appropriate codes for items or services provided (as recorded in the patient record), and assigning those codes correctly on the medical claim forms. The diagnosis codes submitted on claim forms (and on other medical documentation) are generally used to determine coverage. The codes are also used by outside agencies or organizations to forecast health care needs, evaluate facilities and services, review costs, and conduct studies of trends in diseases over the years. Although getting paid is a very important issue for health care providers, a provider should never code for reimbursement purposes only. Coding solely for reimbursement can be considered fraud. Remember, you are required to maintain medical documentation to support the diagnoses reported.

8 Introduction to ICD-9-CM Coding History of Diagnosis Coding:

9 Introduction to ICD-9-CM Coding ICD-9 vs. ICD-9-CM The ICD-9 was originally intended to: Record morbidity and mortality information for statistical purposes. Index hospital records by diseases. Store and retrieve data.

10 Introduction to ICD-9-CM Coding ICD-9 vs. ICD-9-CM The Clinical Modification (CM) allowed the data to be used to: Classify morbidity data for reporting Compile and compare health care data Assist in evaluating the appropriateness and timeliness of medical care for review purposes Assist in planning health care delivery systems Establish patterns of patient care among health care providers Analyze payments for health care Conduct epidemiological and clinical research

11 Introduction to ICD-9-CM Coding Revisions to the ICD-9-CM: Revision for Volumes -1 and 2: A Federal committee discusses proposed changes to the ICD-9-CM each year. The Department of Health and Human Services (DHHS) has the responsibility of the maintenance of Volumes 1, 2, & 3. The changes take effect each year on October 1 and include: Additional new codes. Deletion of old ICD-9-CM codes. Revisions to descriptors. [ The updated ICD-9-CM codes are published in the Federal Register in April/May of each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in Table 6. After the ICD-9-CM codes are published in the Federal Register, CMS places the new, revised, and discontinued codes on CMS Website

12 Introduction to ICD-9-CM Coding Revisions to the ICD-9-CM: Revision for Volumes - 3: Volume 3 is revised annually by CMS. Publishers of the ICD-9-CM volumes use a variety of symbols or formatting conventions to identify changes in their manual from year to year.

13 Introduction to ICD-9-CM Coding Centers for Medicare & Medicaid Services (CMS) Coding and Reporting Guidelines: The coding and reporting requirements published in 1994, by CMS, had a large impact on diagnosis coding. They outlined basic steps that should be used to ensure correct coding. 1.) Use the ICD-9-CM codes that describe the patient's diagnosis, symptom, complaint, condition, or problem. 2.) Use the ICD-9-CM code that is chiefly responsible for the item or service provided. Continued..

14 Introduction to ICD-9-CM Coding Centers for Medicare & Medicaid Services (CMS) Coding and Reporting Guidelines: Continued.. 3.) Assign codes to the highest level of specificity. Use the fourth and fifth digits when indicated as necessary in your ICD-9-CM volumes. 4.) Do not code suspected diagnoses in the outpatient setting. Code only the diagnosis symptom, complaint, condition, or problem reported. Medical records, not claim forms, should reflect that the services were provided for Rule Out purpose. 5.) Code a chronic condition as often as applicable to the patient's treatment. Continued..

15 Introduction to ICD-9-CM Coding Centers for Medicare & Medicaid Services (CMS) Coding and Reporting Guidelines: Continued.. 6.) Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions which no longer exist).

16 Introduction to ICD-9-CM Coding Tricky Capsule : In an emergency situation, the coder should identify the acute condition(s) or symptomology for outpatient services. For inpatient services, the principal diagnosis is the reason, after study, which leads to the admission. Code the principal diagnosis and any other secondary diagnoses that were documented during the admission. For multiple injuries, always sequence the most severe injury first. Limit use of other and unspecified diagnosis codes to situations where there is no definitive information available, or there is no other specific code available.

17 Introduction to ICD-9-CM Coding Tricky Capsule : In an emergency situation, the coder should identify the acute condition(s) or symptomology for outpatient services. For inpatient services, the principal diagnosis is the reason, after study, which leads to the admission. Code the principal diagnosis and any other secondary diagnoses that were documented during the admission. For multiple injuries, always sequence the most severe injury first. For causes of infections, code them as secondary. Limit use of other and unspecified diagnosis codes to situations where there is no definitive information available, or there is no other specific code available. Continued..

18 Introduction to ICD-9-CM Coding Tricky Capsule : For causes of infections, code them as secondary. Distinguish between acute and chronic whenever the ICD-9-CM makes the distinction. For inpatient coding on a claim, code each medical condition identified in the medical record that coexisted at the time of admission and required or affected patient care or treatment. Revise billing charge tickets and forms annually to include up-to-date ICD-9-CM codes.

19 ICD-9-CM CM The Three Volumes of the ICD-9-CM CM

20 The Three Volumes of the ICD-9-CM After completing this lesson, you should be able to: Identify the components of the ICD-9-CM. Identify the characteristics of the ICD-9-CM. Identify specific terms or codes from the ICD-9-CM volumes, given sample descriptions. Use each volume of the ICD-9-CM.

21 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes: The ICD-9-CM is made up of three main volumes: Volume 1: Tabular List of Diseases & Injuries. Volume 2: Alphabetic Index of Diseases & Injuries. Volume 3: Tabular List and Alphabetic Index of Procedures. Volumes 1 and 2 contain symptoms and diagnosis codes that are used for physician or hospital/facility billing. Volume 3 contains codes for both surgical and non-surgical procedures that are used for hospital billing. FYI : In our process we generally use vol-1 and vol-2.

22 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-1: Volume 1: Tabular List of Diseases & Injuries Volume 1 is: a.) Arranged in numerical sequence ( ) b.) Divided into seventeen chapters Volume 1 contains: a.) Two supplementary classifications (V codes and E codes). b.) Appendices c.) Information related to coding V codes and E codes is covered in Lesson Four. Volume 1 are categorized by anatomical site (From Head to Toe).

23 The Three Volumes of the ICD-9-CM ICD-9-CM Codes: Codes in the ICD-9-CM are: a.) Made up of three, four, or five digits. b.) Either numeric or alphanumeric. c.) A decimal point always follows the third digit when a fourth or fifth digit is necessary. d.) Diagnosis codes are to be coded to their highest level of specificity. This means that when fourth or fifth digits are available, they must be used.

24 The Three Volumes of the ICD-9-CM ICD-9-CM Codes: "Other" codes : Codes titled "other" or "other specified" (usually with a fourth digit of 8 or fifth digit of 9 for diagnosis codes) are for use when the information in the medical record provides detail for which a specific code does not exist. "Unspecified" codes : Codes (usually with a fourth digit of 9 or fifth digit of 0 for diagnosis codes) titled "unspecified" are for use when the information in the medical record is insufficient to assign a more specific code.

25 The Three Volumes of the ICD-9-CM ICD-9-CM Codes: Decimal digits XXX.8 or XXX.9 are usually used to indicate "other specified" or "not otherwise specified" conditions. The unspecified fourth or fifth digits are residual subheadings. You should only use them when information that is more specific is not available or does not exist. You should not use these digits when it is not convenient to get more detailed information.

26 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-2: Volume 2: Alphabetic Index of Diseases & Injuries Volume 2 includes: 1.) Alphabetic Index of Diseases and Injuries. 2.) Table of Drugs and Chemicals 3.) Index of External Causes of Injuries and Poisonings Always begin the initial search for a code with Volume 2, but do not code directly from Volume 2. Coding from Volume 2 can lead to inaccurate codes because: 1.) Not all fifth digits are indicated 2.) Include, Exclude, and Notes are not included 3.) Reference Job Aid B pages 1 and 3 for additional information on Volume 2.

27 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-2 : Main Term What is a Main Term? Volume 2 is sequenced alphabetically by "main terms" which are key words from the medical records. The method of searching for a code in Volume 2 should always be by main terms which are based on the: Diagnosis Symptom Condition The method of searching for a code in Volume 2 should NOT be based on the anatomical site.

28 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-2 : Main Term What is a Main Term? Volume 2 is sequenced alphabetically by "main terms" which are key words from the medical records. The method of searching for a code in Volume 2 should always be by main terms which are based on the: Diagnosis Symptom Condition The method of searching for a code in Volume 2 should NOT be based on the anatomical site.

29 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-2 : Main Term What is a Main Term? In Volume 2, main terms are printed in bold. There are four distinct ways to look up a main term. They are: By the condition By the disease itself By the nouns describing the condition/disease By the adjectives describing the condition/disease

30 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-2 : Sub-Term What is a Sub-Term? A sub-term: Is indented and listed alphabetically under the main term. Further defines the main term. There may also be terms indented under sub-terms that define a condition in even greater detail. Example: Blindness (acquired) (congenital) (both eyes) [Main term] with deafness V [Sub-Term]

31 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-2 : Sub-Term What is a Sub-Term? Example: Blindness (acquired) (congenital) (both eyes) [Main term] with deafness V49.85 Note : Blindness is the main term and "with deafness", "blast", "Bright's", and "color" are subterms. "Acquired" and "blue provide further detail under the subterm "color".

32 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-3:Tabular List and Alphabetic Index of Procedures Volume 3 contains codes for procedures. Hospitals use it for billing. Volume 3 begins with an Alphabetical Index of procedure descriptors along with their three or four-digit code. It is modified annually by CMS and is organized such that: There are no alphanumeric category codes Procedures are identified by three- or four-digit numerical codes Chapters are organized by anatomy Non-surgical codes are generally maintained in the Miscellaneous Diagnostic and Therapeutic Procedures

33 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-3:Tabular List and Alphabetic Index of Procedures Sequencing of Volume-3 Procedures listed in Volume 3 have a hierarchical order. Step 1: Locate each term in the Alphabetic index. Step 2: Read and be guided by instructional notations in the alphabetic index. Step 3: Verify the code selected in the Tabular List. Step 4: Read and be guided by instructional notations in the Tabular List.

34 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-3:Tabular List and Alphabetic Index of Procedures Diagnosis Related Groups Reimbursement for Inpatient Prospective Payment System (IPPS) acute care hospitals are based on Medicare Severity DRGs (MS-DRGs). DRGs are used for inpatient acute care hospital services and are based on the following: Diagnoses Procedures Age Sex Discharge status/length of stay

35 The Three Volumes of the ICD-9-CM ICD-9-CM Volumes-3:Tabular List and Alphabetic Index of Procedures Diagnosis Related Groups : Incorrect diagnosis coding greatly affects DRG reimbursement because if diagnosis codes do not correlate with procedure codes on a claim, the claim may not be processed. Procedures performed on a patient must be in accordance with the patient's recorded problems or conditions.

36 The Three Volumes of the ICD-9-CM Tricky Capsule : Coming Soon - ICD-10 ICD-10-PCS is the proposed new procedure coding system that is being developed as a replacement for ICD-9-CM, Volume 3. ICD-10-CM is the proposed replacement for ICD-9-CM, Volumes 1 & 2. Proposed year for ICD-10-CM implementation is Current information related to ICD-10 development and implementation efforts can be found on the ICD-10-CM page on the CMS website.

37 ICD-9-CM CM ICD-9-CM CM Coding Conventions

38 ICD-9-CM Coding Conventation After completing this lesson, you should be able to: Identify the significance of the ICD-9-CM coding conventions the components of the ICD-9-CM. Identify correct and incorrect codes based on ICD-9-CM conventions and instructions.

39 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation: What are ICD-9-CM Coding Conventions? ICD-9-CM Coding Conventions are the abbreviations, punctuation, symbols, typefaces, and formatting methods used in the ICD-9-CM. Knowing these conventions will greatly enhance your ability to find the correct codes that match your search criteria.

40 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation There are two sources of ICD-9-CM coding conventions: ICD-9-CM Official Guidelines for Coding and Reporting. ICD-9-CM publisher-specific formatting conventions.

41 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline It is also very important that you familiarize yourself with the guidelines related to ICD-9-CM coding conventions that are found in Section 1.A of the ICD-9-CM Official Guidelines for Coding and Reporting.

42 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline Abbreviations : The official guidelines identify two key abbreviations that are used in the ICD-9-CM. a.) NEC (Not elsewhere classified) Used in Volumes 1 and 2 b.) NOS (Not otherwise specified) Used in Volume-1. Examples: If you have an ICD-9-CM manual you may wish to look up the following: For an NEC example, look up Difficult, delivery. For an NOS example, look up Unspecified endocrine disorder.

43 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline Punctuation : The three punctuation symbols listed in the official guidelines are brackets, parentheses, and colons.

44 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline Notes and Inclusion Terms Include Notes and Exclude Notes are found in Volume 1 under the codes and will help you select the correct code to use.

45 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline "Other" Codes and "Unspecified" Codes : "Other" codes are used when the medical records provide details for which a specific code doesn't exist. "Unspecified" codes are used when the medical record information is insufficient to assign a more specific code. Examples: Both other and unspecified other unspecified.

46 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline Etiology and Manifestation : Etiology refers to a primary or underlying condition. Manifestation refers to conditions that are due to the etiology. Certain conditions have both an underlying etiology and multiple body system manifestations that are due to the underlying etiology. The ICD-9-CM coding convention for these conditions requires that the underlying condition (the etiology) be sequenced first followed by the manifestation. Continued.

47 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline Etiology and Manifestation : Etiology codes have "use additional code" notes to indicate when manifestation codes are required and manifestation codes have "code first" notes to indicate when an etiology code is required. The words "in diseases classified elsewhere" are part of the code title for most manifestation codes. Examples: for examples of "use additional code" for examples of "code first"

48 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline "And", "With", "See", and "See Also " : And - Immediately follows the main term, not in alphabetical sequence. With - Means "and" or "or. See - Means that there is another main term that must be referenced. See Also - Means that there is another main term that may be referenced.

49 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Oficial Guideline Examples of Coding Conventions :

50 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Publisher specific conventions Publisher specific conventions Color coding conventions. Age category indicators Sex indicators Symbols to indicate new or revised codes Symbols to indicate when fourth or fifth digits are required Additional punctuation symbols or notes

51 ICD-9-CM Coding Conventation ICD-9-CM Coding Conventation : Publisher specific conventions Examples :

52 To be continued.