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Chapter 5

Unit 4 Presentation

ICD-9-CM Hospital Inpatient, Outpatient, and Physician Office Coding

Shatondra Surulere, MBA, RHIA, CCS

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Inpatient Coding

Settings Reimbursement systems Indexes and data entry Coding guidelines and rules of

coding

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Sequencing of Diagnoses

Uniform Hospital Discharge Data Set (UHDDS) Principal diagnosis Additional diagnoses Principal procedure Other significant procedures

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Inpatient Health Care Settings

Acute care facilities (hospitals) Behavioral health care facilities Hospice inpatient care Long-term care

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Acute Care Facility (ACF)

Range of services Ancillary services Single hospital versus multi-hospital

system Bed size (bed count) Short term versus long term

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Hospital Categories

Critical access General Long-term acute care (LTAC) Specialty Behavioral health care

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Hospital Patients

Inpatients Newborn patients Sub-acute care

patients

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Patient Coding Guidelines

Sequencing Principal diagnosis Other (additional) diagnoses

Complications Comorbidities

Principal procedure Significant other procedures

(secondary)

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Codes for Symptoms, Signs and Ill-defined Conditions

Codes from Chapter 16 are not reported as the principal diagnosis when a related definitive diagnosis has been established

Chest Pain vs. Myocardial Infarction Short of Breath vs. Emphysema

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Two or More interrelated Conditions that meet Definition of Principal Diagnosis

When two or more interrelated conditions potentially meet the definition of principal diagnosis, either condition can be sequenced first (unless the ICD-9 book indicates otherwise).

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Two or More Diagnoses that equally Meet Definition of Principal Diagnosis

Circumstances of admission Diagnostic work up and/or therapy

provided Alphabetic index tabular list or

coding guidelines

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Two or More Comparative or Contrasting Conditions

When you have two or more comparative or contrasting diagnoses they are coded as confirmed diagnoses.

Sequence them according to coding rules. Either can be first.

Patient has chest pain, shortness or breath and doctor documents “acute asthma or acute pneumonia” you code both .

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Symptoms Followed by Contrasting/Comparative Diagnosis

When a symptom is followed by contrasting/comparative diagnosis, the symptom code is sequenced first. Contrasting and comparative diagnoses are coded as secondary codes.

Overflow incontinence (symptom), Rule Out neurogenic bladder, rule out urinary stones

Code 788.38 incontinence and all rule out diagnoses.

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Original Treatment Plan not Carried Out

Patient was supposed to have surgery for salpingo-oophorectomy for cystic ovaries and after anesthesia the patient’s blood pressure drops and surgery is cancelled. Still code the cystic ovaries as principal.

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Complications of Surgery and Other Medical Care

When patients is admitted for complications of previous surgery or other medical care the complication is sequenced first.

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Uncertain Diagnosis

Probable Suspected Likely Questionably Possible Still to be ruled outCode the condition as if it

existed!!!!!

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Reviewing the Patient Record

Assumption coding Physician query

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Other Key Terms

Optimizing reimbursement Permitted

Maximizing reimbursement Not permitted

Consolidated bill

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Principal Diagnosis for Admission Following Observation Care

Admission following observation, principal diagnosis is medical condition that led to hospital admission

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Principal Diagnosis for Admission Following Observation Care

Admission following post-operative observation, principal diagnosis is: Complication of outpatient surgery If no complication, then reason for

outpatient surgery If another condition unrelated to

surgery, assign unrelated condition

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Chapter 6

ICD-9-CM Outpatientand Physician Office Coding

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Outpatient Care (Ambulatory Care)

Primary care Point of first

contact Primary care

provider

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Hospital Outpatient Services

Ambulatory patients (outpatients)

Ambulatory surgery patients

Emergency care patients

Observation patients

Freestanding Ambulatory Care Facilities

Ambulatory surgical center

Cardiovascular center

Clinical laboratory Imaging center Industrial health

clinic Infusion center Neighborhood health

center

Pain management center

Physician office Primary care center Public health

department Radiology center Rehabilitation

facility

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Other Ambulatory Care Facilities

Staff model health maintenance organization

Student health center

Urgent care center

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Hospital-Based Departments

Ambulatory surgery Outpatient department Emergency department Partial hospitalization program

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Hospital-Owned Facilities

Hospital-owned physician practice

Satellite clinics

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Outpatient Coding and Reporting Guidelines

Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office) Selection of first-listed diagnosis ICD-9-CM Tabular List of Diseases

(001.0 through V89) Accurate reporting of ICD-9-CM codes Always code to greatest degree of

accuracy and completeness

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Outpatient Coding Guidelines

Reason for encounter (001.0–999.9) Reporting signs and symptoms Factors Influencing Health Status

and Contact with Health Services (V codes)

Level of detail in coding Sequencing diagnoses

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Outpatient Coding Guidelines

Reporting qualified diagnoses (e.g., suspected pneumonia; questionable)

Reporting chronic diseases Reporting coexisting conditions Encounter for diagnostic services

(continued)

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Outpatient Coding Guidelines

Encounter for therapeutic services Encounter for preoperative

evaluations Ambulatory surgery Routine outpatient prenatal visits

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Outpatient Diagnostic Tests

Determining first-listed diagnosis (e.g., due to signs and/or symptoms)

Instruction to determine reason for test Information unavailable from physician Incidental findings Always code to greatest degree of

accuracy and completeness

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Outpatient Diagnostic Tests

Unrelated/Coexisting conditions Tests ordered in absence of signs

and/or symptoms If order communicated via

telephone, both treating provider and testing facility must document the call

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Routine Laboratory and Radiology Encounters

In the absence of any signs, symptoms, or associated diagnosis, assign: V72.5 for radiology exam V72.6 for laboratory exam

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Outpatient Surgery

Code reason for surgery as first-listed diagnosis Even if surgery is cancelled due to

contraindication

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Observation Stay

When admitted for observation of a medical condition, code as first-listed diagnosis

When admitted after outpatient surgery, code for reason for surgery as first-listed diagnosis and complication as secondary

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