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CODING WITH ICD-9-CM IN LONG TERM · PDF filecoding with icd-9-cm in long term care mary ann p. leonard, rhia, ... on icd-10-cm) purpose of icd-9-cm ... instructional notes includes:

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  • CODING WITH

    ICD-9-CM IN

    LONG TERM CARE

    Mary Ann P. Leonard, RHIA, CRM, RAC-CT

    Health Information Professionals

    [email protected]

    610-291-9210

  • HISTORY OF ICD-9-CM

    Published the revised U.S. version of the

    International Classification of Disease, 9th edition,

    Clinical Modifications (ICD-9-CM)

    1/1/79 use mandated for all health care systems

    Revisions published by the American Hospital

    Association every 6 months (now focusing on ICD-

    10-CM)

    Interpretations published by the American Hospital

    Association quarterly (Coding Clinic) (now focusing

    on ICD-10-CM)

  • PURPOSE OF ICD-9-CM

    To classify morbidity and mortality information for

    statistical purposes

    To index health care record (information) by

    diagnosis and procedure

    Not utilized as a nomenclature (naming of disease)

  • CODING MANUAL FORMAT

    Diagnostic Index

    Divided into alphabetic and tabular (numeric)

    sections

    Divided into 17 chapters

    Contains 6 appendices

    Diagnostic codes consist of 3 digits to the left of

    the decimal point and 0 - 2 digits to the right of

    the decimal point (XXX.XX)

  • CODING MANUAL FORMAT

    Procedural Index

    Divided into alphabetic and tabular (numeric)

    sections

    Procedure codes consist of 2 digits to the left of

    the decimal point and 1 - 2 digits to the right of

    the decimal point (XX.XX)

    Procedure codes are NOT used in long term care

  • CONVENTIONS AND TERMS cont

    OTHER CONVENTIONS

    TYPEFACE

    BOLD Used for all codes and titles in the

    Tabular List

    ITALICS Used for all exclusions notes

    and to identify those rubrics which are not

    to be used for primary tabulation of disease

  • TABLES

    Hypertension Table

    Neoplasm Table

    Table of Drugs and Chemicals

  • CONVENTIONS AND TERMS

    MAIN TERMS

    identifies the disease condition

    always in bold print

    arranged alphabetically in the Index by

    diagnosis, condition, problem, etc.

    anatomical sites will refer to a condition

  • CONVENTIONS AND TERMS

    SUBTERMS

    terms listed after the Main Term

    in alphabetical order or numerical order

    will have anatomical sites

  • CONVENTIONS AND TERMS cont.

    MODIFYING TERMS

    listed in parentheses ( ) after the Main term

    or subterm

    descriptive terms that do not have to be

    present for coding

  • CONVENTIONS AND TERMS cont

    CATEGORY CODE

    Three digit code that starts the sequence

    there are codes that are only three digits

    but the number of these is limited (@ 100)

    Sample: Multiple Sclerosis 340

    Depression 311

    Parkinsons Disease 342

  • CONVENTIONS AND TERMS cont

    NEC (Not Elsewhere Classifiable)

    used when a more specific category has

    not been provided in the Manual

    to be avoided if possible

  • CONVENTIONS AND TERMS cont

    NOS (Not Otherwise Specified)

    identifies a lack of more specific

    information

    to be avoided if possible

  • CONVENTIONS AND TERMS cont

    CROSS REFERENCE

    see, see also, see category

    direction to look elsewhere for information

    must be followed

  • CONVENTIONS AND TERMS cont

    NOTES

    informational

    used to define terms and coding instructions

    identifies 5th digits

    italicized print

    SAMPLE: Note - Complicated includes traumatic amputation with delayed healing, delayed treatment, foreign body, or major infection

  • CONVENTIONS AND TERMS cont

    PUNCTUATION

    [ ] Brackets are used to enclose synonyms,

    alternative wordings, or explanatory phrase

  • CONVENTIONS AND TERMS cont

    ( ) Parentheses used to enclose

    supplementary wording which may be present

    or absent in the statement of the disease or

    procedure without affecting the code number

    to which it is assigned

  • CONVENTIONS AND TERMS cont

    : Colons are used in the Tabular List after an incomplete term which needs one

    or more of the modifiers which follow in

    order to make the it assignable to a given

    category

  • CONVENTIONS AND TERMS cont

    { } Braces are used to enclose a series of

    terms, each of which is modified by the

    statement appearing at the right of the brace

  • CONVENTIONS AND TERMS cont

    SYMBOLS

    The lozenge symbol printed in the

    left margin preceding the disease code

    denotes a fourth digit rubric unique to ICD-

    9-CM

  • CONVENTIONS AND TERMS cont

    The section mark symbol preceding

    a code denotes the placement of

    applicable subdivisions in that code at the

    top of the page

  • CONVENTIONS AND TERMS cont

    INSTRUCTIONAL NOTES

    INCLUDES:

    This note appears immediately under a

    two or three digit title to further define, or

    give example of the contents of the

    category

  • CONVENTIONS AND TERMS cont

    EXCLUDES

    Terms following the word excludes

    are to be coded elsewhere as

    indicated in each case

  • CONVENTIONS AND TERMS cont

    The word AND should be interpreted to mean either and or or when it appears in a title.

    < 2011 Official Guidelines A.7>

    Example:

    198.5 - Secondary Malignant Neoplasm, Bone and Bone Marrow

  • CONVENTIONS AND TERMS cont

    Omit Code

    When Used in the Alphabetic Index

    Instructs coder that No Code is to be Assigned.

    Omit code is a medical term that should not be coded

    as a diagnosis.

    Example: Metaplasia cervix omit code

  • CONVENTIONS AND TERMS cont

    See condition

    Guides the Coder to refer to Main Term rather

    than the Anatomical Site or Adjectives

    Describing the Disease.

    Examples: Cerebral see condition

    Diffuse see condition

  • CONVENTIONS AND TERMS cont

    Use additional code, if desired

    Instruction is placed in the Tabular List in

    those categories where the user may wish to

    add further information (by using an additional

    code) to give a more complete picture of the

    diagnosis or procedure

  • CONVENTIONS AND TERMS cont

    Code first underlying disease

    Instruction is used in those codes not

    intended to be used as a principle diagnosis,

    or not to be sequenced before the underlying

    disease

  • CONVENTIONS AND TERMS cont

    Acute and Chronic Conditions

    If the same condition is described as both acute and chronic, and exist as separate entries at the same indentation level in the Alphabetic Index, code as separate entries

    If the same condition is described as both acute and chronic but is identified in the Alphabetic Index (and Tabular) as a Combined Code, (one code to represent both conditions) use the one code

  • CONVENTIONS AND TERMS cont

    Multiple coding should not be used when the

    classification provides a combination code which

    addresses all of the elements

  • CONVENTIONS AND TERMS cont

    Late Effect

    A late effect is a residual condition after the acute

    phase of an illness or injury has passed

    There is no time limit on when a late effect code

    can be used

  • CONVENTIONS AND TERMS cont

    Late effects requires two codes:

    The residual condition

    The cause of the late effect

    The residual effect is sequenced first followed by

    the cause of the late effect unless identified

    otherwise in the Tabular Index

  • CONVENTIONS AND TERMS cont

    Uncertain diagnosis/diagnoses

    In acute care, those diagnoses identified as

    questionable, possible, ?, suspected, likely, rule

    out, etc. are coded as though the condition has

    been substantiated

    In long term care, uncertain diagnoses are NOT

    to be coded

  • CONVENTIONS AND TERMS cont

    Syndromes

    Follow the Alphabetic Index guidance when

    coding syndromes. In the absence of index

    guidance, assign codes for the documented

    manifestations of the syndrome.

  • CONVENTIONS AND TERMS cont

    Documentation of complication of care

    Code assignment is based on the providers

    documentation of the relationship between the condition

    and the care or procedure. The guidelines extends to any

    complications of care, regardless of the chapter the code

    is located in. It is important to note that not all conditions

    that occur during or following medical care or surgery is

    classified as complications. There must be a cause-and-

    effect relationship between the acre provided and the

    condition, and an indication in the documentation that it is

    a complication. Query the provider for clarification, if the

    complication is not clearly documented.

  • STEPS IN CODING

    Locate the main term in the Alphabetic Index

    under the disease or condition NEVER

    RELY SOLELY ON THE ALPHABETIC

    INDEX TO CODE

    Select the appropriate code

    Refer to the Tabular Index (numeric listing)

    Read the information provided in the Tabular

    Check for the 4th and 5th digits

    Assign the appropriate code

  • USE OF V CODES

    V codes identify encounters with the health care system for diagnostic, monitoring, or other types of interactions

    Some of the cate

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