Chapter 6 Coding

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National Center for Health Statistics (NCHS)

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U.S. Department of HEALTH AND hUMAN sSERVICES AGENCIES RESPONSIBLE FOR OVERSEEING ALL CHANGES AND MODICFICATIONS TO THE icd-9-cm

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Advance Beneficiary Notice (ABN)

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acknowledges pateint responsibility for payment if MEDICARE DENIES CLAIM

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mortality

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death

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morbidity

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disease

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encoder

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automates the coding process using computerized or web based software

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Diagnostic Coding and Reporting Guidleines for Outpatient Services; Hospital Based and Physician Office

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developed by the federal government for use in reporting diagnoses for claims submission

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First-listed diagnoses

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is determined in accordance with ICD-9-CM coding coinventions as well ass general and disease specific coding guidelines

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outpatient

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a person treated in one of four settings; ambulatory surgery center, health care providers office, hospital clinic or hospital observation

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principal diagnoses

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the condition determined after study which resulted in the patients admission to the hospital

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secondary diagnoses

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comorbidities and complications

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comorbidity

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a concurretn condition that develops after outpatient care has been provided or during an inpatient admission

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qualified diagnoses

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a working diagnoses that is not yet proven or established

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Preadmission testing (PAT)

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routinely completed proir to an inpatient admission or outpatient surgery to fascilitate the patients treatmet

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Tabular List of Diseases (Volume1)

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conatains 17 chapters that classfiy diseases and injuries, two supplemental classifications and four appendices

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E codes

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located in the TabularList of Diseases, describe external casues of injuries, poisioning or other adverse reactions affecting a persons health

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V codes

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locate din the Tabular List of Diseases and are assigned to pateint encounters when circumstances other than a disease or injusr is present

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Morphology of Neoplasms (m codes)

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contains a reference to the Worlds Health Asscociation publication entitled International Classification of Diseases for Onclolgy

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morphology

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indicates the tissues of the type of neoplasm

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benign

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not cancerous

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malignant

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cancerous

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Classification of Drugs by AHCFS List

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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

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Classification of Industrial Accidents According to Agency

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based on employment injurt statistics adopted by the Tenth International Conference of Labor Staitics

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List of Three Digit Categories

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contains a breakdwon of three digit category codes organized beneath section headings

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Index to Diseases (Volume 2)

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contains alphabetical index of Diseases and Injuries, Tbale of Drugs and Chemicals to External Causes of Injury and Posioning

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Index to Procedures and Tabular List of Procedures (Volume 3)

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included in the hosptial version of commercial ICD-9-CM books, a combined alphabetical index and numerical listing of inpatient procedures

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main terms

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conditions; printed in bold type and followed by the code number

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nonessential modifiers

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supplemtary words located in paretheses after a main term

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subterms

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qualify rhe main term by listing alternate sites, etiology or cllincal staus

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essential modifiers

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same as subterms

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Codes in Slanted Brackets

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always listed as secondary codes bc they are manifestations (results)of other conditons

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eponyms

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diseases (or procedures) named for an individual (ex: pysician who originally discovered the disease, first pateint diagnosed with the disease)

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essential modifiers

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subterms that are indented below the mian term in alphabetical order (except for "with" and "without") The essential modifier clarifies the main term and must ne contained in the diagnostic statement for the code to be assigned

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coding conventions

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rules that apply to the assignmnet of ICD-9-CM codes

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NEC (not elswhere classifiable)

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identifies codes to be assigned when information needed to assign a mnore specific code cannot be located in the ICD-9-CM

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nonessential modifiers

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subterms that are enclosed in parentheses following main term

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notes

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contained in bpxes to define terms, clarify index entries and list choices for additional didgits

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SEE

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directs the coder to a more specific term under which the code can be found

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SEE ALSO

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refers the coder to an index entry that may provide additonal info to assign a code

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SEE ALSO CONDITION

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refers coder to the patients condition for code assignment

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SEE CATEGORY

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refers the coder directory to the Tabluar List of Diseases three digit code for code assginment

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major topic headings

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printed in bold uppercase letters and followed by a range of codes enclosed in parentheses

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categories

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printed in bold upper and lowercase type and are preceded by a three digit code

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subcategories

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indented and printed in the same fashion as the major category headings

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subclassification

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require the assingnment of a fifth digit, indicated by the presence of a section mark, a red dot or sme other symbol

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and

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used when two disorders are separted by the word "and" it is imterpreted as "and/or" and indiccates that either of the two disorders is asscicated with the category code

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bold type

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used for all category and subcategory codes and descriptions are printed in bold type

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braces

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enclose a series of terms, each of which modifies the statement mocated to the right of the brace

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brackets

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enclose synonyms, alternate wording or explanantory phrases

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code forst underlying disease

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apperas when the code referenced is to be sequenced as a secondary code, the code the title and the instructions are italicized

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colon

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used after an incomplete term and is followed by one or more modifiers (additonal terms)

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excludes

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note directs the coder to another location in the codebook for proper assignm,ent of the code

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format

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the way all additonal terms are indented below the term to which they are linked, and if a defintion or diseases requires more than one line that text is printed on the next line and further indetned

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fourth and fifth digits

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require the assignment of fourth and/or fifth digit indicated by an instrustional note located below the category or subcategory descritption

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includes

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note appears below a three digit category code description to further define, clarify or provide an example

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NOS

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the abbreviation for not otherwise specified and indicates that the code is unspecified, coders shoudl ask the prvoider for a more specific diagnosese b4 assigning the code

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notes

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define terms, clarify information and list choices fr fourth and fifth digits

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parentheses

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enclose supplementary wprds that may be present or absent in the diagnostic statement , without affecting assignment of the code number

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USE ADDITIONAL CODE

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indicates that a second code is to be reported to providemore info about the diagnosis

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with

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used when codes combine one disorder wit another, the providers diagnostic statement must clearly indicate that both conditions are present and that a relaitonship exist bt the two

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prinicpal procedure

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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 priincipla diagnoses

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secondary procedures

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additional procedures performed during the smae encounter as the prinicpal procedure

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OMIT CODE

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a term that identifies procedures or services that may be components of other procedures, means that the procedure or service is not coded

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CODE ALSO ANY SYNCHRONOUS PROCEDURES

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refers to operative procedures that are to be coded to completely classify a procedure

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neoplasms

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are new growths, or tumors in which cell production is out of control

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lesion

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any discountinuity tissues that may or may not be malignant

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Primary Malignancy

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the original tumor site; all malignant tumors are considered primary unless other wise documented as metastic or secondary

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seondary malignancy

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the tumor has metastisized (spread) to a secondary site, either adjacent to the primary siet or to a remote region of the body

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carcinoma (Ca) in situ

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a malignant tumor that is localized, circumscribed, encapsulated, and noninvasive (has not spread to deeper or adjacent tissues or organs)

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benign

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a noninvasive, nonsp[reading, nonmalignat tumor

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uncertain behavior

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it is not possible to predict subsequent morphology or behavior from the sumbitted specimen. in order to assgin a code from this column th pathology report must specifically indicate the "uncertain behavior" of the neoplasm

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unspecified nature

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a neoplasn id identified, but no further indication of the hidtology or nature of the tumor is reflected in the documneted diagnoses. assign a code from the column when the neoplasm was destroyed or removed and a tissue biopsy was performed and result pending

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metastic

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descriptive indicator that indicates a primary cancer has spread to another part of the body

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mestasized

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the spread of cancer from primary to secondary sites

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contiguous sites (overlapping sites)

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occur when the origin of the tumor (primary site) invloves two adjacent sites.

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re-excision

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occurs when the pathology repoet recommends that the surgeon perform a second excision to widen the margins of the orginal tumor site

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adverse effect or adverse reaction

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the appearance of a patholofic condition caused by ingestion or exposure to a chemical substance properly administered or taken

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poisonings

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occur as a result of an overdose, wrong substance administered or taken or intoxication

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late effect

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a residual effect or sequela of a private acute illness, injury, or surgery

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congenital anomalies

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disorders diagnosed in infants at birth (adults can also be diagnosed bc such disorders may have been previouly undetected)

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perinatal conditions

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occur before birth, during birth

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perinatal period

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the first 28 days of life

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indexing

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cataloging diseases and procedures by code number

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axis of classification

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organizing entities, diseases, and othe condtions according to etiology, anatomy, or severity

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latrongenic illness

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results from medical intervention (ex; adverse reaction to contrast material injected proior to a scan)

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sequelae

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(singular for sequela) are late effects of injury or illness

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injury

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a traumatic wound or some other damage to an organ

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complication

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a conditon that develops after outpatient care has been provided