Transcript 4 - Walla Walla Community College

4
Diagnostic Coding: Introduction
to ICD-9-CM and ICD-10-CM
Lecture 2
4.4 The Tabular List
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• The Tabular List:
– Diseases and injuries are organized into chapters
according to etiology or body system
– Supplementary codes and appendices cover other
special situations
– Each chapter is divided into sections with titles
that indicate the types of related diseases or
conditions they cover
4.4 The Tabular List (Continued)
• Category—three-digit code that covers a
single disease or related condition
• Subcategory—four-digit subdivision of a
category
• Subclassification—five-digit subdivision of a
subcategory
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4.4 The Tabular List (Continued)
• NOS (not otherwise specified)—indicates the
code to use when no information is available
for assigning the illness or condition a more
specific code
• Unspecified—incompletely described
condition that must be coded with an
unspecified ICD code
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4.4 The Tabular List (Continued)
• Ten conventions are used in the Tabular List:
1.
2.
3.
4.
5.
Fifth-digit requirement symbol
Includes and excludes notes
Colons in notes
Parentheses around supplementary terms
Brackets around supplementary synonyms,
alternative wording, or explanations
6. Braces to group related terms
7. Lozenge for nonWHO codes
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4.4 The Tabular List (Continued)
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• Ten conventions are used in the Tabular List
(continued):
8. The abbreviation NOS to indicate the code to use when a
condition is not completely described, and the
abbreviation NEC for the code to use when the diagnosis
does not match any other available code
9. Bullet (●) for new codes or entries, single triangle (►) or
facing triangles (►◄) for new or revised descriptions
10. Phrases for multiple code requirements: codes that are
not used as primary appear in italics and are usually
followed by an instruction to code first underlying
disease or use an additional code
4.5 Tabular List of Chapters
• The Chapters of the Tabular List:
– Infectious and Parasitic Diseases—Codes 001–139
– Neoplasms—Codes 140–239
– Endocrine, Nutritional, and Metabolic Diseases, and
Immunity Disorders—Codes 240–279
– Diseases of the Blood and Blood-Forming Organs—
Codes 280–289
– Mental Disorders—Codes 290–319
– Diseases of the Nervous System and Sense Organs—
Codes 320–389
– Diseases of the Circulatory System—Codes 390–459
– Diseases of the Respiratory System—Codes 460–519
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4.5 Tabular List of Chapters (Continued)
• The Chapters of the Tabular List (Continued):
– Diseases of the Digestive System—Codes 520–579
– Diseases of the Genitourinary System—Codes 580–
629
– Complications of Pregnancy, Childbirth, and the
Puerperium—Codes 630–677
– Diseases of the Skin and Subcutaneous Tissue—Codes
680–709
– Diseases of the Musculoskeletal System and
Connective Tissue—Codes 710–739
– Congenital Anomalies—Codes 740–759
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4.5 Tabular List of Chapters (Continued)
• The Chapters of the Tabular List (Continued):
– Certain Conditions Originating in the Perinatal
Period—Codes 760–779
– Symptoms, Signs, and Ill-Defined Conditions—
Codes 780–799
– Injury and Poisoning—Codes 800–999
4.6 V Codes and E Codes
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• V Code—alphanumeric ICD code that identifies
factors influencing health status and encounters
not due to illness or injury
– Use for healthy patients to receive routine service, for
therapeutic encounters, for a problem that is not
currently affecting the patient’s condition, and for
preoperative evaluations
• E Code—alphanumeric ICD code for an external
cause of injury or poisoning
– Never used as primary codes
4.6 V Codes and E Codes (Continued)
• Adverse effect—patient’s unintentional,
harmful reaction to a proper dosage of a drug
• Table of Drugs and Chemicals—reference
listing of drugs and chemicals in the ICD-9-CM
Alphabetic Index
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4.7 Coding Steps
• The correct process for assigning accurate
diagnosis codes has five steps:
Step 1 – Review complete medical documentation
Step 2 – Abstract the medical conditions from the
visit documentation
Step 3 – Identify the main term for each condition
Step 4 – Locate the main terms in the Alphabetic
Index
Step 5 – Verify the code in the Tabular List
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4.7 Coding Steps (Continued)
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• Chief complaint (CC)—patient’s description of
the symptoms or reasons for seeking medical
care
• Primary diagnosis—represents the patient’s
major illness or condition for an encounter
• Coexisting condition—additional illness that
either affects the primary illness or is also
treated during an encounter