Basics of Diagnostic Coding

Basics of Diagnostic Coding History of Medical Coding o o o o o o o Medical coding began as medical classification in 17 th-century England League of nations established in 1920 o International List of Diseases In 1946, the International Commission of the World Health Organization (WHO) established codes o Called Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD) Edition currently in use in the United States is the ICD-10-CM o Significantly different format from that of ICD-9-CM Original purpose of medical coding was to collect statistical data United States is the only country in the world that uses coding for health insurance reimbursement purposes All components of the encounter are used to determine charges and to generate an insurance claim What is Diagnostic Coding? o o o o Translation or transformation of written descriptions of diseases, illnesses, or injuries into numeric or alphanumeric codes Accurate use of ICD-10-CM manual is essential for accurate translation of medical record’s diagnostic statement into alphanumeric codes When you use ICD-10-CM, you choose a standardized alphanumeric code for the diagnostic statement Table 12-1 Kinn’s Book page 213 General Equivalence Mappings (GEMs) o o o The Centers for Medicare and Medicaid Services (CMS) has developed code maps to assist in the changeover from ICD-9-CM to ICD-10-CM Purpose is to create a useful, practical, code-to-code translation reference dictionary for both code sets Can increase efficiency in ICD-10-CM Structure and Format of the ICD-10-CM o o o Has a Tabular List and Alphabetic Index Each year the CMS reviews the ICD-10-CM coding manual and an update is posted on October 1st CMS prepares Official Guidelines for Coding and Reporting to be used with the ICD-10-CM codes, in addition to instructions on how to report the codes on insurance claims The Alphabetic Index o Consists of an alphabetic list of diagnostic terms and related codes and includes: o Main terms o Nonessential modifiers o Essential modifiers o Subterms Supplementary Sections of the Alphabetic Index o o Table o Table o o of Neoplasms Lists neoplasms by anatomic location of Drugs and Chemicals Presents a classification of drugs and other chemical substances Used to identify poisonings and external causes of adverse effects Tabular List o o o o Divided into 21 chapters Each chapter is subdivided into categories In each chapter, all of the 3-character category codes begin with the alphabetic letter assigned to that chapter Each chapter has a different-colored border strip Conventions Used in the Tabular List o o o o o o o o o o o Abbreviations Punctuation Symbols Instructional notations Related entities Placeholder character o ICD-10-CM uses the dummy placeholder X in two different ways o As the 5th character in certain 6-character codes o To fill empty character space Codes with 7 characters o 7th character typically provides specificity about the coded condition o A: initial encounter o D: subsequent encounter o S: sequela Table page 217 Includes notes o Used to clarify when conditions are included within a particular chapter Excludes notes o Excludes 1: clear “NOT CODED HERE” message o Excludes 2: means “not included here” Code first o Code first notes appear under “manifestation” codes Indicates that the underlying condition must be sequenced first, before manifestation code Use additional code o Use additional code notes indicate the order in which the codes are arranged: etiology code first, followed by manifestation code Cross reference notes o Instruct the coder to check elsewhere in the index before assigning a code o See o See also o See category Relational terms o And o With o Due to o o o o Coding Guidelines o Guidelines are organized into four sections: o Section I: Conventions, General Coding Guidelines, and Chapter Specific Guidelines o Section II: Selection of Principal Diagnosis o Section III: Reporting Additional Diagnosis o Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services Preparing for Medical Coding o Extracting diagnostic statements o Must analyze the patient’s health record and abstract the diagnostic statement documented in the various reports o Sources of diagnostic statements include: o Encounter form o Treatment notes o Discharge summary o Operative report o Radiology, pathology, and laboratory reports Encounter Form o o o Can be viewed in EHR Most commonly used to obtain the list of medical services rendered and the treating diagnosis when the total charges are calculated Vital that the form used by the medical practice be reviewed annually History and Physical (H&P) Examination o o o H&P are the starting point of the patient’s narrative medical evaluation H&P begin with a statement in the patient’s own words that describes the reason for seeking medical attention Chief complaint (CC) Treatment or Progress Notes o o o Treatment notes are the second most common medical document from which diagnostic statements can be extracted Most commonly used format is SOAP Diagnostic statement can most often be found in the assessment section Discharge Summary o o Used primarily for extracting diagnostic information for patients who were hospitalized, rather than those seen in a provider’s office Main elements o Patient’s admission date o Date of discharge o H&P findings o Clinical course during hospitalization o Health condition on discharge o Discharge diagnosis o Aftercare plan Operative Report o o Used for patients who underwent surgery as an outpatient or inpatient Includes preliminary diagnosis and procedure, final diagnosis and procedure, and detailed description of operative procedure from start to finish Radiology, Laboratory, and Pathology Reports o o Used to support/establish diagnostic statement Any findings from these reports must be documented in treatment notes in the health record Steps in ICD-10-CM Coding 1. 2. 3. 4. 5. 6. 7. Determine the correct diagnosis from the diagnostic statement Use the main term to look up the diagnosis in the Alphabetic Index Look up the “see” term in the Alphabetic Index Review the essential modifiers under the main term Choose the correct essential modifier based on the diagnostic statement Look up code in the Tabular List Check for any coding guidelines, conventions, inclusion or exclusion notes, or an additional character symbol 8. Assign the final ICD-10-CM code Using the Alphabetic Index o After you have abstracted the diagnostic statement and identified main terms, start searching for the best code (or code range) in the Alphabetic Index Using the Tabular List o Once you have identified at least the first three characters of the code in the Alphabetic Index, turn to the Tabular List Encoder Software o o o o Tool commonly used by coders to assist in medical coding Performs computer-aided coding to assign the most accurate code possible Coder types a few key words into a Search box and software finds the most likely matches in the Alphabetic Index Can increase for a wide variety of medical causes Understanding Coding Guidelines o o All ICD-10-CM coding manuals have comprehensive instructional notations and conventions Must always refer to and thoroughly review the conventions, instructional notations, code definitions, and other guidelines in the Alphabetic Index and Tabular List in the current year’s version of the ICD-10-CM Coding of Signs and Symptoms o o o Signs and symptoms are coded only if the provider has not yet reached a final diagnosis Subjective findings include patient’s CC Objective findings are any measurable indicators found during physical examination Coding the Etiology and Manifestation o o o Etiology o Underlying cause or origin of disease Manifestation o Signs and symptoms of the disease Etiology code is always listed first Multiple Coding o o Some conditions require more than one code “Use additional code” means use another code in conjunction with one selected o o “Code first” means if more than one code is used, code with notation “Code first” should be first or primary diagnosis “Code, if applicable, any casual condition” not indicates that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable Sequela (Late Effects) Codes o o Sequelae are the lingering effects produced by a health condition after the acute phase of an illness or injury has ended Coding of sequelae generally requires two codes sequenced in the following order: original condition is sequenced first; the sequela code sequenced second Coding Impending or Threatened Conditions: Rules o Chart page 225 Coding Complications of Care o o Generally requires additional procedures or services, but often complication is not mentioned a part of the diagnostic statement, which results in reduced reimbursement Two criteria must be met: o Cause-and-effect relationship o Documentation must indicate that the condition is complication Coding Infectious and Parasitic Diseases o Multiple codes are usually needed for infectious or parasitic diseases o First code identifies disease or condition (e.g., bacterial infection) o Second code identifies organism causing disease (e.g., streptococcal bacteria) Coding Organism-Caused Diseases o Two-step process of coding organism-caused disease begins with site of the condition o Can use “Use additional code” to identify infectious agent Coding of HIV Infection and AIDS o Key is whether the patient has symptoms o Human immunodeficiency virus (HIV) o o o This indicates only that the virus is present Acquired immunodeficiency syndrome (AIDS) o AIDS is a syndrome; a syndrome is defined as a “group of symptoms occurring together” AIDS is manifestation(s) of and/or symptoms that can occur as a result of HIV infection Selection and Sequencing of HIV Codes 1. 2. 3. 4. Patient admitted of HIV-related condition Patient with HIV admitted for unrelated condition HIV infection in pregnancy, childbirth, and the puerperium Encounters for testing for HIV Terms Defining Malignant Neoplasm Sites o o o Primary o Identifies originating anatomic site of neoplasm Secondary o Identifies sites to which primary neoplasm has metastasized (spread) Ca in situ o Carcinoma in situ is defined as absence of invasion of surrounding tissues Benign, Uncertain Behavior, and Unspecified Nature Neoplasms o o o Benign o The growth is noncancerous, nonmalignant, and has not invaded adjacent structures or spread to distant sites Uncertain behavior o Pathologist is unable to determine whether neoplasm is benign or malignant Unspecified nature o Neither behavior nor histologic type of neoplasm is specified in diagnostic statement Instructional Notes o o o In situ is used only when diagnostic statement contains that exact phrase Unspecified is used only when no pathology study has been done and neoplasm is still described with a term such as “tumor” or “growth” Uncertain is used only when neoplasm’s behavior is not malignant, the tumor is not in situ, or behavior is unpredictable Six Steps for Coding Neoplasms 1. Using the Table of Neoplasms, determine site of neoplasm and select the row in the table in which it appears 2. Determine whether the neoplasm is malignant or benign 3. If neoplasm is benign, select the column in the table that best defines its behavior: Uncertain Behavior or Unspecified Nature 4. If the neoplasm is malignant, determine the table column that best fits its behavior: Malignant Primary, Malignant Secondary, or Ca in situ 5. Link the appropriate columns to the appropriate row 6. Check the code in the Tabular List to make sure it complies with guidelines, conventions, and instructional notations in the Tabular List Coding for Diabetes Mellitus o o o o Diabetes is classified as type 1 or type 2 Diabetes mellitus codes are combination codes o Include type of diabetes mellitus, body systems affected, and the complications affecting that body system If insulin is documented in the health record, a second code is required Gestational diabetes can cause complications in a pregnancy o Codes for gestational diabetes are in subcategory O24.4 Coding for Myocardial Infarction o o o o As acute if it is documented as such in diagnostic statement or has a stated duration of 8 weeks or less As chronic if its is so stated in diagnostic statement or if symptoms persist after 8 weeks If MI is specified as “Old” or “Healed” without any current symptoms, it should be coded using I21 Code underlying condition or symptoms only if underlying condition is not known Coding for Hypertensive Disease o o o o High blood pressure is defined as hypertension If diagnostic statement does not contain term hypertension or high blood pressure, condition is coded as elevated blood pressure, not hypertension Mention of hypertension is diagnostic statement does not mean that a combination code for hypertensive heart disease should be used If cause-and-effect relationship exists between hypertension and heart disease, it should be clearly documented in clinical record or diagnostic statement Coding for Chronic Kidney Disease o o ICD-10-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension and hypertensive chronic kidney disease If a patient has hypertensive chronic kidney disease and acute renal failure, and additional code for acute renal failure is required Coding for Atherosclerotic Cardiovascular Disease o o ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris When you use a combination code, you do not need to use an additional code for angina pectoris Coding for Skin Ulcers o o Codes from category L89 (pressure ulcer) are combination codes that identify the site of the ulcer and the stage of the ulcer Unspecified and unstageable codes are used for pressure ulcers in which the stage cannot be clinically determined Coding for Complications of Pregnancy, Childbirth, and Puerperium o o o o Coding for the obstetric patient is challenging o Antepartum o Meaning pregnancy (applies as soon as pregnancy test result is positive) o Childbirth o Meaning delivery o Peripartum o Period from the last month of pregnancy to 5 months postpartum o Postpartum o The puerperium period (6 weeks after delivery) 7th character for fetus identification o Where applicable, a 7th character is assigned for certain categories to identify the fetus for which the complication code applies o Assign the 7th character “0” o For single gestations o When the documentation in the record is insufficient to determine whether the fetus is affected Outcome of delivery and liveborn infant codes o When a delivery occurs, the principal diagnosis should correspond to the main circumstances or complication of the delivery Newborn coding o When you code the birth episode in a newborn’s health record, assign a code from the category Z38 as the principal diagnosis Coding for Injuries o o o Assign separate codes for each injury unless a combination code is provided Code for the most serious injury is sequenced first Superficial injuries are not coded when they are associated with more severe injuries on the same site Coding for Traumatic Fractures o o o Fractures of specified sites are coded individually by site in accordance with the level of detail furnished by health record Fracture not indicated as open or closed should be coded as closed Fracture not indicated as displaced or not displaced should be coded as displaced Coding for Burns and Corrosions o o o Code each burn separately unless specific combination codes are given in Tabular List Most burn codes are found in Chapter 19 ICD-10-CM makes a distinction between burns and corrosions o Corrosions are caused by chemicals; thermal burns are caused by a heat source Coding for Drug Toxicity o Chapter 19 also includes coding for: o Poisoning o Adverse effect o Underdosing o Toxic effect Coding for External Causes of Morbidity o o o o In the ICD-9-CM, External causes of morbidity were coded with E codes E codes are not included in ICD-10-CM Instead, ICD-10-CM has added chapter 20: external causes of morbidity These codes capture how the injury or health condition happened, the intent, the place where event occurred, the activity of the patient at the time of the even, and the person’s status Place of Occurrence Guideline o Codes from category Y92 (place of occurrence of the external cause) are secondary code o Only used once, at the initial encounter o No 7th character is used in Y92 codes Activity Codes o o Codes from category Y93 (activity codes) are used to define the activity the patient was involved in at the time of injury or when health condition developed A code from category Y93 can be used with external cause Y99 and intent codes if identifying the activity provides additional information about the event Coding for Health Status and Contact with Health Services o In ICD-10-CM, chapter 21 (Factors Influencing Health Status and Contact with Health Services) replaces V codes used in the ICD-9-CM o Describes circumstances or encounters with a healthcare provider when no current illness or injury exists Maximizing Third-Party Reimbursement o o o o o o Most important thing to remember is to code diagnosis to the highest level of specificity Use current year ICD-10-CM manual Code accurately from documented information Be sure diagnosis corresponds to symptoms Review data entry Know the insurance carrier’s rules Providers and Accurate Coding o o o o Detailed documentation in the patient’s health record can help coders to code to the highest specificity Providers should be trained in how to document appropriately Staff meetings to review third-party reimbursements should be held regularly Medical assistant should stress to providers the high value of detail documentation Ethical Standards of Medical Coding o o o o o Understand what ethical coding standards mean Stand your ground Say something Keep in communication with the office manager Review notes from other health providers Closing Comments o o o Be responsible and knowledgeable to ensure that no fraud takes place in coding and claims submission process Adhere to ethical standards, assigning and reporting only codes clearly supported by concise documentation in patient’s chary Maintain and continually enhance coding skills and keep informed of changes in codes, guidelines and regulations