chapter 7 coding medical conditions (diagnosis coding) understanding hospital billing and coding...

CHAPTER 7CHAPTER 7

CODING MEDICAL CONDITIONS CODING MEDICAL CONDITIONS (DIAGNOSIS CODING)(DIAGNOSIS CODING)

UNDERSTANDING HOSPITAL BILLING AND CODING

Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc.Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc.

22Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc.Copyright © 2011, 2006 by Saunders an imprint of Elsevier Inc.

CODINIG MEDICAL CONDITIONSCODINIG MEDICAL CONDITIONSDIAGNOSIS CODING DIAGNOSIS CODING

Hospital coding professionals Hospital coding professionals

Must master coding principles and applications to Must master coding principles and applications to accurately describe patient conditions, ensure accurately describe patient conditions, ensure compliance with coding guidelines, and obtain compliance with coding guidelines, and obtain proper reimbursement proper reimbursement

Hospital billing professionalsHospital billing professionals

Understanding of coding is critical to ensure Understanding of coding is critical to ensure compliance with billing guidelines and to obtain compliance with billing guidelines and to obtain accurate reimbursementaccurate reimbursement

HOSPITAL CODING AND BILLING PROFESSIONALSHOSPITAL CODING AND BILLING PROFESSIONALS


HISTORY AND PURPOSE HISTORY AND PURPOSE OF DIAGNOSIS CODINGOF DIAGNOSIS CODING

Evolution of diagnosis coding systems dates Evolution of diagnosis coding systems dates back to the 17th century, when systems were back to the 17th century, when systems were originally developed to track the number of originally developed to track the number of deaths in children.deaths in children.



Evolution of ICD to ICD-9-CM Evolution of ICD to ICD-9-CM International List of the Causes of Death International List of the Causes of Death

Revisions 1-5, 1938-1958 Revisions 1-5, 1938-1958 International Classification of Diseases International Classification of Diseases

Revisions 6-9, 1958-1978 Revisions 6-9, 1958-1978 International Classification of Diseases, 9th International Classification of Diseases, 9th

Revision, Clinical Modification, 1979 to Revision, Clinical Modification, 1979 to todaytoday



The International Classification of Diseases, 9th The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) was Revision, Clinical Modification (ICD-9-CM) was “clinically” modified to enhance the classification “clinically” modified to enhance the classification and collection of morbidity data and for indexing and collection of morbidity data and for indexing medical records.medical records.


HISTORY AND PURPOSE HISTORY AND PURPOSE OF DIAGNOSIS CODINGOF DIAGNOSIS CODINGICD-9-CM DATA CLASSIFICATIONSICD-9-CM DATA CLASSIFICATIONS

ICD-9-CM allows the collection of data regarding:ICD-9-CM allows the collection of data regarding:

Morbidity (patient illness or disease) Morbidity (patient illness or disease) Mortality (factors that contribute to death) Mortality (factors that contribute to death) Hospital procedures (significant proceduresHospital procedures (significant procedures performed in the hospital, such as surgery) performed in the hospital, such as surgery)



ICD-9-CM Coordination and Maintenance Committee ICD-9-CM Coordination and Maintenance Committee (Cooperating Parties)(Cooperating Parties) Maintenance and update of the ICD-9-CM is the Maintenance and update of the ICD-9-CM is the result of a collaborative effort of members of the result of a collaborative effort of members of the ICD-9-CM Coordination and Maintenance ICD-9-CM Coordination and Maintenance Committee that consists of representatives from Committee that consists of representatives from four organizations: four organizations:

National Center for Health Statistics (NCHS) National Center for Health Statistics (NCHS) Centers for Medicare and Medicaid Services (CMS)Centers for Medicare and Medicaid Services (CMS) American Hospital Association (AHA) and American Hospital Association (AHA) and American Health Information Management Association American Health Information Management Association (AHIMA) (AHIMA)


HISTORY AND PURPOSE HISTORY AND PURPOSE OFDIAGNOSIS CODINGOFDIAGNOSIS CODING

International Classification of Diseases, 10International Classification of Diseases, 10 thth Revision (ICD-10) Revision (ICD-10) In 1993 the World Health OrganizationIn 1993 the World Health Organization published the newest version of the published the newest version of the International Classification of Diseases, International Classification of Diseases, Tenth Revision (ICD-10). The ICD-10 is Tenth Revision (ICD-10). The ICD-10 is being used in some European countries and being used in some European countries and implementation, in the U.S., is set for 2013. implementation, in the U.S., is set for 2013.


PURPOSE OF DIAGNOSIS CODINGPURPOSE OF DIAGNOSIS CODING

Coding systems are designed to provide a Coding systems are designed to provide a standardized system for describing and standardized system for describing and classifying dataclassifying data

Coding classification systems provide an Coding classification systems provide an efficient method to collect, track, research, and efficient method to collect, track, research, and analyze specified data analyze specified data

Coding medical conditions (diagnosis) involves Coding medical conditions (diagnosis) involves assigning codes to written descriptions of the assigning codes to written descriptions of the patient’s signs, symptoms, illness, injury, patient’s signs, symptoms, illness, injury, disease, condition, or other reason for patient disease, condition, or other reason for patient care servicescare services



Utilization of Diagnosis Code DataUtilization of Diagnosis Code Data

Data collected through the ICD-9-CM coding Data collected through the ICD-9-CM coding systemsystem are utilized in a number of ways. are utilized in a number of ways. Various organizations and other entities such as Various organizations and other entities such as government agencies, research organizations, government agencies, research organizations, medical associations, and insurance companies medical associations, and insurance companies use data collected for:use data collected for: ResearchResearch EducationEducation AdministrationAdministration



ORGANIZATIONS UTILIZING ORGANIZATIONS UTILIZING DIAGNOSIS CODE DATADIAGNOSIS CODE DATA

Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC)(CDC)

Centers for Medicare and Medicaid Services Centers for Medicare and Medicaid Services (CMS)(CMS)



DIAGNOSIS CODING DEFINEDDIAGNOSIS CODING DEFINED

The definition of coding is the process of The definition of coding is the process of translating written descriptions of signs, translating written descriptions of signs, symptoms, illness injury, disease, and other symptoms, illness injury, disease, and other reasons for healthcare services from the reasons for healthcare services from the patient’s record into numeric or patient’s record into numeric or alphanumeric codesalphanumeric codes


DIAGNOSIS CODING DIAGNOSIS CODING RELATIONSHIPSRELATIONSHIPS

DOCUMENTATIONDOCUMENTATION MEDICAL NECESSITYMEDICAL NECESSITY CLAIM FORMS CLAIM FORMS REIMBURSEMENTREIMBURSEMENT


DIAGNOSIS CODING DIAGNOSIS CODING RELATIONSHIPS DOCUMENTATION RELATIONSHIPS DOCUMENTATION

Documentation is the term used to describe Documentation is the term used to describe information regarding the patient’s condition, information regarding the patient’s condition, treatment, and response to treatmenttreatment, and response to treatment

It is the coder’s responsibility assign code(s) It is the coder’s responsibility assign code(s) for conditions that are recorded in the for conditions that are recorded in the patient’s medical recordpatient’s medical record



DOCUMENTATION GOLDEN RULE IN CODINGDOCUMENTATION GOLDEN RULE IN CODING

““IF IT IS NOT IF IT IS NOT

DOCUMENTED, DO NOT DOCUMENTED, DO NOT

CODE IT”CODE IT”


GOOD CODING HABITS GOOD CODING HABITS

Develop good coding habits to ensure accurate Develop good coding habits to ensure accurate

and effective codingand effective coding DO NOT ASSUMEDO NOT ASSUME Identify all possible codes in the Index Identify all possible codes in the Index

(Volume II)(Volume II) NEVER EVERNEVER EVER code from the Index (Volume II) code from the Index (Volume II) Review each code in the Tabular List (Volume I)Review each code in the Tabular List (Volume I) Review all codes in the range Review all codes in the range WHEN IN DOUBT, askWHEN IN DOUBT, ask Never use an E code as the first listed conditionNever use an E code as the first listed condition


DIAGNOSIS CODING DIAGNOSIS CODING RELATIONSHIPSRELATIONSHIPSMEDICAL NECESSITYMEDICAL NECESSITY

Medical necessity is the term used to describe Medical necessity is the term used to describe services that are reasonable and medically services that are reasonable and medically necessary to address the patient’s medical necessary to address the patient’s medical condition.condition. Diagnosis codes explain the medical Diagnosis codes explain the medical necessity for services or items provided. necessity for services or items provided. Medical necessity is generally determined Medical necessity is generally determined based on standards of medical practice. based on standards of medical practice. Payer guidelines will vary by payer.Payer guidelines will vary by payer.



CLAIM FORMSCLAIM FORMS

Two claim forms used to submit charges for services rendered Two claim forms used to submit charges for services rendered to payers for reimbursement.to payers for reimbursement. CMS-1500 is used for submission of physician and outpatientCMS-1500 is used for submission of physician and outpatient services. ICD-9-CM codes describing the first listed condition and services. ICD-9-CM codes describing the first listed condition and other conditions are reported in block 21. other conditions are reported in block 21.Note: the first listed condition is the major most significant reason for Note: the first listed condition is the major most significant reason for why the patient is seeking healthcare services.why the patient is seeking healthcare services. CMS-1450 (UB-04) is used for submission of facility charges forCMS-1450 (UB-04) is used for submission of facility charges for services provided by a hospital or other facility. ICD-9-CM codes services provided by a hospital or other facility. ICD-9-CM codes describing the principal, admitting and other diagnoses are describing the principal, admitting and other diagnoses are reported in FL 67a-q 69, 70 and 72. reported in FL 67a-q 69, 70 and 72.



REIMBURSEMENTREIMBURSEMENT

Reimbursement is the term used to describe Reimbursement is the term used to describe payment from payers for services rendered.payment from payers for services rendered.

Claim forms are submitted to third-party payers Claim forms are submitted to third-party payers such as insurance companies, Medicare, and such as insurance companies, Medicare, and other government payers to obtain reimbursement other government payers to obtain reimbursement for services provided.for services provided.

Diagnosis codes are utilized on the claim form to Diagnosis codes are utilized on the claim form to explain why the services were provided.explain why the services were provided.


ICD-9-CM CONTENTICD-9-CM CONTENT

ICD-9-CM CONTAINS THREE VOLUMES: ICD-9-CM CONTAINS THREE VOLUMES: Volume IVolume I includes the tabular list of diseases, includes the tabular list of diseases,

two supplemental classifications, and two supplemental classifications, and appendices.appendices.

Volume IIVolume II consists of an alphabetic Index to consists of an alphabetic Index to diseases, three tables, and an alphabetic index diseases, three tables, and an alphabetic index to external causes of injury as outlinedto external causes of injury as outlined

Volume IIIVolume III contains an alphabetic and tabular contains an alphabetic and tabular listing of procedures listing of procedures


ICD-9-CM CONTENT ICD-9-CM CONTENT VOLUME I—THE TABULAR LIST VOLUME I—THE TABULAR LIST

Tabular List of DiseasesTabular List of Diseases Supplemental classificationSupplemental classification

Classification of Factors Influencing Heath Status and Classification of Factors Influencing Heath Status and Contact with Health Services (V01-V84)Contact with Health Services (V01-V84)

Classification of External Causes of Injury and Poisoning Classification of External Causes of Injury and Poisoning (E800-E999)(E800-E999)

AppendicesAppendices Morphology of NeoplasmsMorphology of Neoplasms Glossary of Mental DisordersGlossary of Mental Disorders Classification of Drugs by American Hospital FormularyClassification of Drugs by American Hospital Formulary Classification of Industrial Accidents According to AgencyClassification of Industrial Accidents According to Agency List of Three-Digit CategoriesList of Three-Digit Categories


ICD-9-CM CONTENT ICD-9-CM CONTENT VOLUME I—THE TABULAR LISTVOLUME I—THE TABULAR LIST

Tabular List of DiseasesTabular List of DiseasesThe tabular list is a numerical listing of diseases, and it The tabular list is a numerical listing of diseases, and it includes signs, symptoms, injury, illness, disease, or includes signs, symptoms, injury, illness, disease, or other reasons why the patient seeks health care. The other reasons why the patient seeks health care. The tabular list consists of 17 chapters that categorize tabular list consists of 17 chapters that categorize conditions by body system or type of condition. conditions by body system or type of condition. Examples:Examples: Chapter 1: Infectious and Parasitic Diseases, which are coded Chapter 1: Infectious and Parasitic Diseases, which are coded

utilizing code range of 001-149utilizing code range of 001-149 Chapter 2: Neoplasms code range 140-239Chapter 2: Neoplasms code range 140-239


ICD-9-CM CONTENTICD-9-CM CONTENT

VOLUME I—THE TABULAR LISTVOLUME I—THE TABULAR LIST

SUPPLEMENTAL CLASSIFICATIONSSUPPLEMENTAL CLASSIFICATIONS Classification of Factors Influencing Heath Status Classification of Factors Influencing Heath Status

and Contact with Health Services (V01-V84) and Contact with Health Services (V01-V84)

These codes are used to describe reasons patients seeks These codes are used to describe reasons patients seeks healthcare services that are other than a condition, sign, healthcare services that are other than a condition, sign, symptom, injury, illness, or disease. symptom, injury, illness, or disease.

Classification of External Causes of Injury andClassification of External Causes of Injury and Poisoning (E800-E999) Poisoning (E800-E999) These codes are used to describe external causes of injury, These codes are used to describe external causes of injury, such as auto accident, explosion, or a fall. such as auto accident, explosion, or a fall.


ICD-9-CM CONTENT ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX VOLUME II—ALPHABETIC INDEX

Alphabetic Index to DiseasesAlphabetic Index to Diseases TablesTables Alphabetic Index to External Causes of InjuryAlphabetic Index to External Causes of Injury


ICD-9-CM CONTENT ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEXVOLUME II—ALPHABETIC INDEX

Alphabetic Index to DiseasesAlphabetic Index to DiseasesContains an alphabetical listing of signs, Contains an alphabetical listing of signs, symptoms, conditions, injuries, illnesses, symptoms, conditions, injuries, illnesses, diseases and other reasons that patients diseases and other reasons that patients seek healthcare services.seek healthcare services.

Main terms are in bold print and subterms Main terms are in bold print and subterms that further define the condition are indented that further define the condition are indented below the main termbelow the main term


ICD-9-CM CONTENT ICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX VOLUME II—ALPHABETIC INDEX

TablesTablesThere are three tables in the index that are There are three tables in the index that are utilized to identify possible codes for review in utilized to identify possible codes for review in the tabular section.the tabular section.

1.1. Hypertension Table Hypertension Table

2.2. Neoplasm Table Neoplasm Table

3.3. Table of Drugs and Chemicals Table of Drugs and Chemicals


ICD-9-CM CONTENTICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEX TABLESVOLUME II—ALPHABETIC INDEX TABLES

1.1. Hypertension TableHypertension TableLists codes for malignant, benign, and unspecified Lists codes for malignant, benign, and unspecified hypertension and related conditionshypertension and related conditions

2.2. Neoplasm TableNeoplasm Table Lists codes for Neoplasm according to behavior: Lists codes for Neoplasm according to behavior: malignant, benign, or uncertain behavior, or malignant, benign, or uncertain behavior, or non-specifiednon-specified

3.3. Table of Drugs and ChemicalsTable of Drugs and Chemicals Lists codes for poisoning caused by ingestion of a Lists codes for poisoning caused by ingestion of a substance or chemical that is toxic and adverse substance or chemical that is toxic and adverse reactions from chemicals and substancesreactions from chemicals and substances


ICD-9-CM CONTENTICD-9-CM CONTENT VOLUME II—ALPHABETIC INDEXVOLUME II—ALPHABETIC INDEX

HYPERTENSION TERMSHYPERTENSION TERMS

HypertensionHypertension Essential hypertensionEssential hypertension Benign hypertensionBenign hypertension Malignant hypertensionMalignant hypertension Unspecified hypertensionUnspecified hypertension



NEOPLASM TERMSNEOPLASM TERMS

NeoplasmNeoplasm Benign neoplasmBenign neoplasm Malignant neoplasmMalignant neoplasm

Primary, Secondary, Carcinoma in situPrimary, Secondary, Carcinoma in situ

Metastasis, Metastasize, MetastaticMetastasis, Metastasize, Metastatic

Uncertain behaviorUncertain behavior UnspecifiedUnspecified



TABLE OF DRUGS AND CHEMICALSTABLE OF DRUGS AND CHEMICALS

POISONING versus ADVERSE EFFECT POISONING versus ADVERSE EFFECT Poisoning is a condition caused by the Poisoning is a condition caused by the

ingestion of a substance or chemical that is ingestion of a substance or chemical that is toxic or when a medication is taken that is not toxic or when a medication is taken that is not properly prescribed or administered.properly prescribed or administered.

Adverse effect is an unexpected condition that Adverse effect is an unexpected condition that occurs in reaction to a medication that is occurs in reaction to a medication that is properly prescribed and administered. properly prescribed and administered.




CODING POISONING versus ADVERSE EFFECT CODING POISONING versus ADVERSE EFFECT PoisoningPoisoning

1.1. Select a code from the poisoning column of the table Select a code from the poisoning column of the table of drug for each chemical or substanceof drug for each chemical or substance

2.2. Select code(s) that describe the patient’s condition Select code(s) that describe the patient’s condition

3.3. Select a code from one of the External Cause Select a code from one of the External Cause Columns for each chemical or substanceColumns for each chemical or substance




CODING POISONING versus ADVERSE EFFECT CODING POISONING versus ADVERSE EFFECT Adverse AffectAdverse Affect

1.1. Select code(s) that describe the patient’s condition Select code(s) that describe the patient’s condition

2.2. Select a code from the “Therapeutic Use” for each Select a code from the “Therapeutic Use” for each chemical or substance to describe the external causechemical or substance to describe the external cause


ICD-9-CM CONTENT ICD-9-CM CONTENT VOLUME III—PROCEDURES VOLUME III—PROCEDURES

Alphabetic Index to ProceduresAlphabetic Index to ProceduresContains an alphabetical listing of procedures Contains an alphabetical listing of procedures and services. Main terms are in bold print and and services. Main terms are in bold print and subterms that further define procedure or subterms that further define procedure or service are indented below.service are indented below.

Tabular List of Procedures Tabular List of Procedures Contains a numerical listing of procedures Contains a numerical listing of procedures and services.and services.


ICD-9-CM CONVENTIONSICD-9-CM CONVENTIONS

Convention is a term used to describe the Convention is a term used to describe the special terms, punctuation marks, special terms, punctuation marks, abbreviations, or symbols used as abbreviations, or symbols used as shorthand in a coding system to efficiently shorthand in a coding system to efficiently communicate special instructions to the communicate special instructions to the codercoder


ICD-9-CM OFFICIAL CONVENTIONSICD-9-CM OFFICIAL CONVENTIONS

ICD-9-CM Official Abbreviations and ICD-9-CM Official Abbreviations and SymbolsSymbols

ICD-9-CM Official Instructional NotesICD-9-CM Official Instructional Notes

ICD-9-CM Official Other ConventionsICD-9-CM Official Other Conventions

ICD-9-CM Convention Variations ICD-9-CM Convention Variations


ICD-9-CM OFFICIAL ABBREVIATIONS ICD-9-CM OFFICIAL ABBREVIATIONS AND SYMBOLSAND SYMBOLS

NECNEC Not elsewhere classifiableNot elsewhere classifiable NOSNOS Not otherwise specifiedNot otherwise specified BracketsBrackets [ ] [ ] Slanted bracketsSlanted brackets [ ][ ] ParenthesesParentheses ( ) ( ) ColonColon : : Brace Brace } } Section mark Section mark §§


ICD-9-CM OFFICIAL ICD-9-CM OFFICIAL INSTRUCTIONAL NOTESINSTRUCTIONAL NOTES

IncludesIncludes ExcludesExcludes Use additional code Use additional code Code first underlying disease Code first underlying disease Code, if applicable, any causal condition first Code, if applicable, any causal condition first AndAnd WithWith See, See also, See category, See conditionSee, See also, See category, See condition


ICD-9-CM OFFICIAL ICD-9-CM OFFICIAL OTHER CONVENTIONSOTHER CONVENTIONS

Boldface Boldface typetype

Used in the alphabetic index to highlight main Used in the alphabetic index to highlight main terms to help the coder find main conditions terms to help the coder find main conditions identified in the patient recordidentified in the patient record

ItalicizedItalicized typetypeUsed in the tabular list to indicate conditions Used in the tabular list to indicate conditions that are excluded in a range and to indicate that are excluded in a range and to indicate codes that should not be used as a primary codes that should not be used as a primary diagnosisdiagnosis


ICD-9-CM CONVENTION ICD-9-CM CONVENTION VARIATIONSVARIATIONS

Age-specificAge-specific American Hospital Association (AHA) coding clinic American Hospital Association (AHA) coding clinic Complication Complication Definitions Definitions Gender-specific Gender-specific Medicare code edits (MCEs)Medicare code edits (MCEs) Medicare secondary payer (MSP)Medicare secondary payer (MSP) New code New code Nonspecific diagnosis Nonspecific diagnosis Primary/secondary diagnosis Primary/secondary diagnosis Revised code Revised code Use additional codeUse additional code


STEPS TO CODING DIAGNOSIS STEPS TO CODING DIAGNOSIS UTILIZING ICD-9-CM VOLUMES I UTILIZING ICD-9-CM VOLUMES I

AND IIAND II

Step 1:Step 1: Read the Record. Read the Record. Identify the main term for each condition treated and Identify the main term for each condition treated and those that affect treatment.those that affect treatment.

Step 2:Step 2: Refer to ICD-9-CM Volume II Alphabetic Index. Refer to ICD-9-CM Volume II Alphabetic Index. Look up main term and identify all possible codes.Look up main term and identify all possible codes.

Step 3:Step 3: Refer to ICD-9-CM Volume I Tabular List. Refer to ICD-9-CM Volume I Tabular List.Review each code and select the code that most Review each code and select the code that most adequately describes the condition recorded in the adequately describes the condition recorded in the record. record.


STEPS TO CODING DIAGNOSIS STEPS TO CODING DIAGNOSIS UTILIZING ICD-9-CM VOLUMES I UTILIZING ICD-9-CM VOLUMES I

AND IIAND II Step 4:Step 4: Sequence ICD-9-CM Codes Sequence ICD-9-CM Codes

Sequencing is a term used to describe the process of Sequencing is a term used to describe the process of listing codes in an order that accurately describes the listing codes in an order that accurately describes the conditions treated and those that affect treatment. conditions treated and those that affect treatment. The UB-04 requires a combination the following The UB-04 requires a combination the following based on the type of service (Outpatient or Inpatient):based on the type of service (Outpatient or Inpatient): Principal Diagnosis Principal Diagnosis Other Diagnosis Other Diagnosis Admitting Diagnosis Admitting Diagnosis Patient Reason Diagnosis Patient Reason Diagnosis External Cause of Injury External Cause of Injury


ICD-9-CM OFFICIAL GUIDELINESICD-9-CM OFFICIAL GUIDELINES

The ICD-9-CM Official Guidelines for Coding and Reporting The ICD-9-CM Official Guidelines for Coding and Reporting provides coders with critical information on how to code and provides coders with critical information on how to code and report various clinical circumstances. The guidelines are report various clinical circumstances. The guidelines are broken down into the following sections: broken down into the following sections: Section ISection I - ICD-9-CM Conventions, General Coding - ICD-9-CM Conventions, General Coding Guidelines, and Chapter Specific GuidelinesGuidelines, and Chapter Specific Guidelines Section IISection II - Selection of Principal Diagnosis for Inpatient, - Selection of Principal Diagnosis for Inpatient, Short-Term, Acute Care Hospital RecordsShort-Term, Acute Care Hospital Records Section IIISection III - Reporting Additional Diagnoses for Inpatient, - Reporting Additional Diagnoses for Inpatient, Short-Term, Acute Care Hospital Records Short-Term, Acute Care Hospital Records Section IV Section IV -- Diagnostic Coding and Report Guidelines for Diagnostic Coding and Report Guidelines for Outpatient Services Outpatient Services

chapter 7 coding medical conditions (diagnosis coding) understanding hospital billing and coding...

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